Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective: Risk for deficient Short Term: INDEPENDENT: INDEPENDENT: Short term: After 30
-Patient become fluid volume related After 4 hours minutes of nursing
febrile and has to active fluid of nursing - List interventions that -A patient must intervention the
episodes of vomiting volume loss intervention can be used to prevent understand the mother will be able to:
and loose stools. the patient or reduce future significance of
will be able to: instances of drinking extra fluids -Declares
-Suddenly noticed dehydration. during spells of awareness of
that their child -Declares diarrhea, fever, or the factors
becomes bluish and awareness of other conditions that that are
is struggling for air. the factors cause fluid shortage. causing the
that are fluid deficit
-Have vomited most causing the -Teach family members -An accurate and the
of the food ingested fluid deficit how to monitor output measurement of activities that
during lunch and the at home and assign fluid intake and are required
activities that them the responsibility outflow is a key sign to correct it.
are required of tracking both intake of a patient's fluid
to correct it. and output. condition. -Describes
methods to
-Describes -Determine the age- -Individuals who are treat or
methods to related effects really young or prevent fluid
treat or elderly are most volume loss.
prevent fluid affected by fluid
volume loss. volume deficiency Long term:
and have the least After 8 hours
Long Term: ability to of nursing
After 8 hours communicate their intervention
of nursing needs. Elderly the child will
intervention persons, for be able to:
the child will example, may have a
be able to: reduced thirst -Maintain a
response and/or be functional
-Maintain a ignorant of their fluid volume
functional water requirements. as evidenced

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 fluid volume Infants, small by adequate
as evidenced children, and urine
by adequate nonverbal production
urine individuals are with a normal
production DEPENDENT: unable to specific
with a normal - Encourage the patient communicate their gravity, moist
specific to consume the thirst. mucosal
gravity, moist recommended amount membranes,
mucosal of fluid. normal skin
membranes, turgor, and
normal skin rapid capillary
turgor, and refill.
rapid capillary DEPENDENT:
refill. -Oral fluid
replacement is
advised for modest
fluid deficiency and
is a cost-effective
method of fluid
replacement. Seniors
experience lessened
thirst and may
require regular
reminders to drink.
-Provide precautions Fluid replacement
against electrolyte loss can be facilitated by
that is excessive (e.g., being inventive in
resting the GI tract, the fluid source
administering selection process
antipyretics as ordered (e.g., flavored
by the physician.) gelatin, frozen juice
bars, sports drink).
As needed, oral
hydration solutions

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 (e.g., Rehydralyte)
may be considered.

- Diarrheal fluid
losses should be
treated concurrently,
as indicated, with
antidiarrheal
medications.
Antipyretics can help
to alleviate fever and
fluid loss associated
with diaphoresis.

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