NCP

Assessment Explanation Of The Problem Objective Intervention Rationale Evaluation

Subjective: STO: Dx STO:
Deficient FluidVolume Within 30 minutes to 1. Monitor and record 1. Febrile states Within 30 minutes
Related to nausea , one hour of effective vital signs. Especially decrease body to 1 hour of
Objective: dysuria,and fever, nursing interventions: the temperature. fluids by effective nursing
Nausea evidenced by decreased  Patient X will perspiration and interventions the
Fever urine output . verbalizes increased patients X
Dysuria awareness of 2. Record intake respiration. This is verbalized
Reference: causative factors and output. known as insensible awareness of
Doenges, M., Moorhouse, and behaviors water loss. causative factors
M., & Murr, A., (2012). essential to correct 3. Note presence of and behaviors
Nurse’s Pocket Guide p. fluid deficit. nausea, vomiting 2. To determine fluid essential to correct
Diagnosis: 413-417 and fever. balance . fluid deficit.
Risk for deficient fluid
volume related to LTO:
fever and nausea. . Tx 3. These factors Within 8 hours of
1. Weigh daily with influence intake, effective nursing
same scale, and fluid needs, and interventions,
preferably at the route of patient
LTO: same time of day. replacement. maintained fluid
Within 8 hours of volume at a
effective nursing 1. Weight is the best functional level as
interventions: assessment data evidenced by
2. Monitor active fluid for possible fluid individually
loss from vomiting; volume imbalance. adequate urinary
maintain accurate An increased in 2 output with normal
input and output lbs a week is specific gravity,
record. consider normal. stable vital signs,
 Patient X will 2. Fluid loss from moist mucous
Maintain fluid volume 3. Maintain IV fluid vomiting cause membranes, good
at a functional level as replacement as decreased fluid skin turgor, and
evidenced by ordered to volume and can prompt capillary
individually adequate maintain. lead to refill.
urinary output with EDX dehydration. GOAL MET.
normal specific gravity, 1. Emphasize
stable vital signs, moist importance of oral 3. Dehydrated
mucous membranes, hygiene. patients may be
good skin turgor, and weak and unable
prompt capillary refill. to meet prescribed
intake
2. Encourage patient independently.
to increase fluid
Intake.
1. Fluid deficit can
3.encourage to eat cause a dry, sticky
foods with high fluid mouth. Attention to
content such as mouth care
watermelon and promotes interest in
grapes. drinking and
reduces discomfort
of dry mucous
membranes.

2. To replace fluid
lost and prevent
dehydration.

3. For hydration.