Nursing Diagnosis:

Risk for Fluid Volume Deficit related to vomiting, loss of appetite, nausea and watery stool.

Acute Pain related to inflammation.

 PLANNING
NURSING
ASSESSMENT OBJECTIVE IMPLEMENTATION EVALUAT
DIAGNOSIS INTERVENTION RATIONALE
OF CARE

Subjective Cues: After 2 hours of After the 8 h

Risk for Fluid nursing nursing
The patient Volume Deficit intervention the intervention,
verbalized that he: related to patient will be patient met h
vomiting, loss of able to: when he wa
appetite, nausea to:
- Felt mild and watery stool. - At 8:00 am, I
- Inspect - Indicators
discomfort - Show inspected the
mucous of
around the signs of patient’s mucous - Show
membranes; adequacy
umbilicus hydratio membrane, of hy
assess skin of
- Had an n assessed skin and,
turgor and peripheral
abdominal turgor and - When
capillary circulation
pain in the - Maintai capillary refill. maint
refill. and cellular
RLQ n adequ
hydration.
- Loss of adequate fluid
appetite fluid - I monitored the balan
- Decreasing
- Nausea balance patients I & O by havin
- Monitor I&O; output of
- Vomiting as noting the moist
note concentrate
evidence patients urine muco
urine color d urine
by moist color and memb
and with
Objective Cues: mucous concentration good
concentration, increasing
membra and specific turgor
Vital Signs: specific specific
nes, gravity every 2 adequ
Temperature: 39C gravity. gravity
good hours starting at urinar
suggests de
skin 8:00 am. outpu
hydration
turgor
and need
and
for
adequate
increased
urinary fluids.
output.

- Auscultate - Indicators - I auscultated and

and document of return of documented the
bowel sounds. peristalsis, patients bowel
Note passing readiness sounds.
of flatus, to begin
bowel oral intake.
movement. Note: This
may not
occur in the
hospital if
patient has
had a
laparoscopi
c procedure
and been
discharged
in less than
24 hr.

-  Reduces
- Provide clear - I encouraged the
risk of
liquids in patients to take
gastric
small amounts small amounts of
irritation
when oral clear liquid when
and
intake is oral intake is
vomiting to
resumed, and resumed.
minimize
progress diet fluid loss.
as tolerated.
- I administered
- The
- Administer IV IV fluids and
peritoneum
 Fluids and reacts to electrolytes per
electrolytes irritation an doctors order.
d infection
by
producing
large
amounts of
intestinal
fluid,
possibly
reducing
the
circulating 
blood
volume,
resulting in
dehydratio
n  and
relative
electrolyte
imbalances
.

- Cathartics - I never
- Never and enemas administered
administer may cathartics or
cathartics or rupture the enemas to the
enemas. appendix. patient.
 PLANNING
NURSING
ASSESSMENT OBJECTIVE IMPLEMENTATION EVALUAT
DIAGNOSIS INTERVENTION RATIONALE
OF CARE

Subjective Cues: After 2 hours of After 4 ho

Acute Pain nursing nursing inter
The patient related to intervention the the patient w
verbalized that he: inflammation. patient will be to meet th
able to: when he:
 - Felt mild Useful in monitoring - At 8am, I
effectiveness of
discomfort - Assess pain, medication, assessed the
around the - Pain is location and progression of healing. patients pain, it’s - Verba
umbilicus relieved. severity. Changes in location and that
- Had an
characteristics of pain
severity by reliev
may indicate
abdominal - Relax, developing abscess or asking the from
pain in the able to peritonitis, requiring patient to rate - And
RLQ rest prompt medical
the pain from 0- he w
evaluation and
- Loss of intervention. 10, wherein 0 is to re
appetite the lowest and relax.
To lessen the pain.
- Nausea Gravity localizes 10 is the highest.
- Vomiting inflammatory exudate
into the lower
abdomen or pelvis,
relieving abdominal
Objective Cues: tension, which is - I encouraged the
- Keep at rest in accentuated by a patient to keep at
Vital Signs: supine position.
semi-Fowler’s rest in a semi-
Temperature: 39C position. Promotes fowler’s
normalization of organ position.
function (stimulates
peristalsis and passing
of flatus, reducing
abdominal discomfort).

Decreases discomfort
of early intestinal
peristalsis, gastric
irritation, and vomiting. - I also
encouraged the
- Encourage patient to do
Relief of pain facilitates
early cooperation with other early
ambulation. therapeutic ambulation.
interventions
(ambulation,
pulmonary toilet).
 - I encouraged the
- Keep NPO and patient to keep
maintain NG NPO and
suction maintained NG
initially. suction initially
at 9 am.

- I administered
- Administer analgesics as
analgesics as ordered by the
indicated. physician.