NURSING NURSING

ASSESSMENT RATIONALE PLANNING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
Short Term: Independent:
Subjective: Risk for electrolyte  Monitor the vital 
“I was vomiting imbalance signs every hour Goal met.
yesterday char” as related to After 4 hours of
verbalized by the insuficient fluid nursing  Instruct the patient to
volume as intervention the
patient eat foods rich in
evidenced by
patient will be able vitamins and
involuntary
Objective: gastric to achieve the ff. minerals
contents goals:  Advice the patient to
 V/S expulsion increase fluid intake
RR- 24 rpm 1. Determine  Elevate the legs of
HR- 114 bpm factors that the patient above the
BP- 88/34 mm Hg aggravate the level of the heart
condition
 Hct 33% Dependent:
2. Compare the  Administer IV fluids
 Sings of latter condition to at prescribed rates
hypotension the present  Give anti-emetic
noted drugs at prescribed
 Fatigue signs 3. Attain the vital dosage by the
noted signs at least in physician.
the normal range;
RR from 24 cpm to Collaborative:
20cpm; HR from
 Consult with dietitian
114 bpm to at
or nutritionist for
least 100 bpm;
specific foods to eat
and BP from
 Collaborate the
88/34mmHg to at
medical technologist
least 90/60mmHg
for lab testing
 Consult the physician
for any lab results
alteration