Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective data: Risk for deficient Fluid After 8 hours of nursing  Monitor vital signs for  Low blood pressure level After 8 hours of nursing
“ Sa nakalipas na Volume related to blood intervention the client changes (orthostatic put the patient at risk intervention the client
tatlong araw kulay itim volume loss secondary will be able to: hypotension). for hypotensive was be able to:
ang dumi ko sa at hindi to gastrointestinal  Maintain fluid volume episodes that leads to  Maintain fluid volume
ko magawa ang dati bleeding as evidenced by as evidenced by shock. at a functional level as
kong mga gawain black sticky and normal blood pressure  Review laboratory data evidenced by normal
dahil sa pagkahilo at malodorous stool, level, absence of (e.g., Hb/Hct, BUN/Cr, blood pressure level,
panghihina ng aking dizziness, facial pallor  To evaluate body’s
dizziness, restlessness electrolytes). absence of dizziness,
katawan” as verbalized and orthostatic response to fluid loss
and facial pallor. restlessness and facial
by the client. hypotension. and to determine
pallor.
replacement needs.
 Monitor I&O balance,
being aware of altered
intake or output.  To ensure accurate
Objective Data: picture of fluid status.
 Dizziness  Start IV therapy as
 Orthostatic prescribed.
hypotension  To replace the fluid and
 Restlessness electrolytes lost from GI
 Facial pallor  Encourage oral fluid bleeding.
 Rapid and weak intake if able (up to 2.5
peripheral pulses L/day).  Promote better blood
 Black stool circulation around the
 Vital Signs was taken  Administer blood body.
as follows: transfusion as
BP: 120/80 (supine) prescribed.  To increase the
HR: 110 (supine) hemoglobin level and
BP: 90/60 (standing) treat hypovolemia
HR: thready (standing) related to GI bleeding.
RR: 20/min
Temp: 98 F