ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

INTERVENTION
Subjective: Deficient Fluid After 2° of Monitor and -Tachycardia, After 2° of
“Kanina pa ako Volume Nursing record vital signs dypnea, or Nursing
dumudumi ng related Interventions, q 2° or as often hypotension Interventions,
malambot na to active fluid the patient fluid as necessary until may indicate the goal was
malambot” as volume loss. and blood stable. fluid volume met as the
verbalized by volume will deficit or patient’s fluid
the patient increase on its electrolyte and blood
level according imbalance volume increase
to its 1st up to normal as
Objective: appearance. evidenced by
( + ) sunken Measure intake - Low urine stable vital
eyeballs. and output q 1°. output and signs.
( + ) poor skin Record and high specific
turgor. report significant gravity
Pain scale of changes. Include indicates
8/10 urine, and stools. hyovolemia.
V/S as follow:

Assess skin -To check for

turgor and oral dehydration.
mucous
membranes q
2°.

Give oral/mouth -To avoid

care dehydrating
mucous
membranes

Don’t allow -To avoid

patient to sit or orthostatic
stand up quickly hypotension
as and possible
long as syncope.
circulation is
compromise

Administer and -To prevent

monitor further fluid
medications as loss.
ordered.
Acute Gastroenteritis is a catchall term for infection or irritation of the digestive tract, particularly the
stomach and intestine. It is frequently referred to as the stomach or intestinal flu, although the influenza
virus is not associated with this illness. Major symptoms include nausea and vomiting, diarrhea, and
abdominal cramps. These symptoms are sometimes also accompanied by fever and overall weakness.
Acute Gastroenteritis typically lasts about three days. Adults usually recover without problem, but
children, the elderly, and anyone with an underlying disease are more vulnerable to complications such
as dehydration.

Common symptoms:

 Low grade fever to 100 F (37.7 C)

 Nausea with or without vomiting

 Mild-to-moderate diarrhea

 Crampy painful abdominal bloating (The cramps may come in cycles, increasing in severity until
a loose bowel movement occurs and the pain resolves somewhat.)

More serious symptoms of acute gastroenteritis:

 Blood in vomit or stool (Blood in vomit or stool is never normal and the affected individual
should call or a visit a health care practitioner.)

 Vomiting more than 48 hours

 Fever higher than 101 F (40 C)

 Swollen abdomen or abdominal pain

 Dehydration - weakness, lightheadedness, decreased urination, dry skin, dry mouth and lack of
sweat and tears are characteristic signs and symptoms.