PHINMA University of Pangasinan

College of Health Sciences

Patient’s Initials: Ms. T. A Age & Gender: Female, 32 Name of Student: Mae Louise G. Aritcheta
Birthday: January 21, 1991 Address: Villasis, Pangasinan Level/block: Level 2, Block 22
Date of Confinement:February 20, 2022 Clinical Instructor: Ma’am Kathrina Luiza Menor , Ma’am
Maria Rowena Via Lucena, Ma’am Arlene Dacanay, Ma’am Violeta C. Gutierrez

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective:
Deficient Fluid After a 4 hours of INDEPENDENT: 1. A decrease in circulating After a 4 hours of
“ Nurse, I feel Nauseous and Volume (also known Nursing Intervention, blood volume can cause Nursing Intervention,
Thirsty” as stated by the as Fluid Volume the Patient will be 1. Monitor and hypotension and the Patient has:
Mother Deficit (FVD), able to: document vital signs, tachycardia. Alteration in
hypovolemia) is a especially BP and HR. HR is a compensatory 1. Demonstrated
state or condition LONG TERM: mechanism to maintain lifestyle changes to
Objective: where the fluid 2. Monitor active fluid cardiac output. Usually, the
1. Demonstrates avoid progression of
VS are taken as follows: output exceeds the loss from wound pulse is weak and irregular
lifestyle changes to dehydration
fluid intake. It occurs drainage, if electrolyte
BP: 110/70 mmHg when the body loses avoid progression of imbalance also occurs.
tubes, diarrhea,
RR: 18bpm both water dehydration bleeding, and vomiting; Hypotension is evident in 2. Patient verbalized
PR: 80bpm and electrolytes fro maintain accurate input hypovolemia. awareness of causative
Fundal Height: 41cm m the ECF in similar 2. Patient verbalizes and output record. factors and behaviors
proportions. awareness of 2. Fluid loss from wound essential to correct fluid
Common sources of causative factors and 3. Urge the patient to drainage, diarrhea, deficit.
fluid loss are the behaviors essential drink the prescribed bleeding, and vomiting
gastrointestinal to correct fluid amount of fluid. cause decreased fluid 3. Patient explained
tract, polyuria, and deficit. volume and can lead to measures that can be
NURSING DIAGNOSIS increased 4.Assess skin turgor and dehydration. taken to treat or
Deficient Fluid Volume as perspiration. 3. Patient explains oral mucous prevent fluid volume
evidenced by Nausea and measures that can membranes for signs of 3.Oral fluid replacement is loss.
Vomiting be taken to treat or dehydration. indicated for mild fluid
prevent fluid volume deficit and is a cost- 4. Patient described
loss. 5.Note the presence of effective method for symptoms that indicate
nausea, vomiting, and replacement treatment. the need to consult with
fever.
4. Patient describes health care provider.
symptoms that 4.Signs of dehydration are
6. Monitor BP and HR also detected through the
indicate the need to for orthostatic changes skin.
consult with health
care provider. 5.These factors influence
intake, fluid needs, and
route of replacement.

6.A common manifestation

of fluid loss is postural
hypotension. It is
manifested by a 20-mm Hg
drop in systolic BP and a 10
mm Hg drop in diastolic BP.