Nursing

Assessment Inference Planning Interventions Rationale Evaluation

Diagnosis
Subjective Data: Risk for Deficient Fluid Volume (also Date: October 18, 2021 Independent: Date: October 19, 2021
- vomited 10 times deficient fluid known as Fluid Volume Deficit Time: 12:30 pm Time 12:30 pm
- undocumented fever volume related (FVD), hypovolemia) is a state Shift 7am - 3pm  Assess the client’s  A loss of interstitial Shift: 7am - 3pm
- abdominal pain to excessive or condition where the fluid skin turgor and fluid causes the
- loose bowel losses through output exceeds the fluid intake. Short Term Goal: mucous loss of skin turgor. Actual Evaluation:
movement diarrhea and Risk factors for deficient fluid After 24 hours of membranes for After 24 hours of
vomiting. volume are as follows: nursing intervention, signs rendering nursing
Objective Data: vomiting, diarrhea, GI patient will report of dehydration. intervention, the patient
- sunken eyeballs suctioning, sweating, decreased adequate fluid volume reported adequate fluid
- weak and pale intake, nausea, inability to gain as evidenced by good  Assess the volume  Vomiting is volume as evidenced by
appearance access to fluids, adrenal skin turgor, stable vital and frequency of associated with good skin turgor, stable
- soft abdomen insufficiency, osmotic diuresis, signs,and absence of vomiting. fluid loss. vital signs,and absence
- poor skin turgor hemorrhage, coma, third-space orthostasis. of orthostasis.
- nausea fluid shifts, burns, ascites, and  Assess the  Gastroenteritis is
PR: 139 bpm liver dysfunction. Fluid volume consistency and associated with an
RR: 28 cpm deficit may be an acute or number of bowel increased
T: 38 C/axilla chronic condition managed in movements. frequency of very
Wt: 11kg the hospital, outpatient center, loose or watery
or home setting. bowel movements.
The inflammation
in the large
intestine limits the
colon’s ability to
absorb water,
leading to fluid
volume deficit.

 Monitor and assess  Usually, the pulse

client’s PR and is weak and may be
temperature. irregular
if electrolyte
imbalance also
occurs. Also, fever
that occurs with
gastroenteritis

Dependent:
 Give:  These drugs will
- Ranitidine 25mg IV
every 8hrs
- Metroclopromide
15mg SIV now, then
every 8hrs for vomiting
 Give:  It helps replenish
- Bacillus clausii
nebule, 1 nebule BID
- Zinc Syrup 2.5 mL
OD
 Administer:  Controls fever,
- Paracetamol
125mg/5 mL (5mL
every 4hrs RTC)
- Paracetamol
100mg IV every 4hrs
increases fluid loss
through
perspiration and
increased
respiration.
reduce vomiting
and the risk for
fluid volume
deficit.
and support the
normal flora of the
gut. Additionally, it
is considered a
probiotic which are
indications for
chronic diarrhea
and certain vitamin
malabsoption
disorders. Zinc also
treat diarrheal
episodes.
reducing insensible
loss. Fever that
occurs with
gastroenteritis
increases fluid loss
through
perspiration and
increased
respiration.
 D5IMB; 500mL x  For maintenanace
14 hrs of fluid and
electrolytes
especially to
patients who need
calories and
hydration..

Collaborative:

 Facilitate fecalysis.  A culture is a test

Submit for client’s to detect which
stool for culture. causative
organisms cause an
infection.

 Facilitate typhidot.  The only way to

know for sure if an
illness is typhoid
fever or
paratyphoid fever
is to have a sample
of blood or stool
(poop) tested for
Salmonella Typhi
or Salmonella
Paratyphi.