Assessment Nursing (Rationale) Desired Outcome Nursing Justification Evaluation

Cues Diagnosis Pathophysiologic / Schematic Diagram Intervention

Subjective:
Deficient Fluid Predisposing Precipitating After 8 hours of nursing Independent: Independent: SHORT TERM
“Halin pa gid sang Volume related to intervention the patient GOALS
vomiting as Factor Factor
kagina akon na suka, and family will be able: The patient will have
Nurse. Kaluya na gid evidenced by delay  64 YO HYPOTENSIVE Assess skin turgor and dry skin and mucous After 8 hours of
ka akon na in skin turgor.  FEMALE DEHYDRATED 1. To maintain BP mucous membranes for signs membranes. Tenting of nursing
and skin turgor of dehydration. the skin will occur. The intervention, client
pamatyag".
within the normal tongue may have was able to:
range. longitudinal furrows.
Patient was weak and Definition: 1. Maintain BP
lethargic. within acceptable
HEALTH PROBLEMS 2. To demonstrates
Decreased lifestyle changes to Assess vital signs, especially A BP drop of more than range with V/S
intravascular, avoid progression noting BP and HR for 15 mm Hg when bp: 120/80 and
Delayed in skin interstitial and/or of dehydration. orthostatic changes. changing from supine to skin turgor of
Turgor was noted (6 sitting position, with a 2secs. GOAL
intracellular fluid.
seconds). concurrent elevation of MET.
This refers to
Adrenal glands not functioning due to After 3 days of nursing 15 beats per min in HR,
dehydration, indicates reduced 2. Demonstrate
autoimmune reasons intervention the patient
water loss alone circulating fluids. change of lifestyle
without change in and family will be able:
to avoid
sodium. Cortisol (hydrocortisone, cortisone dehydration by
acetatem prednisone, or dexmethasone) 1. To maintain and Encourage oral fluids as the As sodium loss verbalizing that
Objective: Patient is optimize overall
nonsmoker Reference: very low or absent. patient tolerates. increases, extracellular she needs to have
NANDA health status. fluid volume decreases. a healthy diet and
International, These interventions are maintain a healthy
Tried drinking alcohol
Nursing Glucocorticoid deficiency 2. To have adequate necessary to prevent lifestyle. GOAL
in her high school
Diagnoses, fluid and fluid volume deficit MET
years.
electrolyte because the kidneys are
Eleventh Edition
balance as unable to conserve LONG TERM
Patient had loss weight
Insulin sensitivity and disturbances in evidenced by sodium. GOALS:
according to her
husband carbohydrate, fat, and protein metabolism MIO. After 3 days of
nursing care, was
able to:
01/31/2023
Dependent: Dependent:
Vital signs 1. Maintain and
4:00 pm Hypoglycemia, decreased liver glycogen, Administer parenteral fluids Normal saline is infused optimize
BP: 80/60 weakness, trauma and circulatory failure as prescribed. Anticipate the initially to restore fluid overall health
HR: 106bpm need for an intravenous (IV) volume. Treatment are status as
fluid challenge with needed because of the evidenced by
RR: 24cpm
Deficient Fluid Volume related to immediate infusion of fluids high mortality with improvement
T: 36.0 C for patients with abnormal Addisonian crisis. in the V/S.
vomiting as evidenced by delay in skin
O2 sat: 98% vital signs. GOAL MET
turgor.
8:00 pm 2. Adequate
BP: 100/60 Source: Administer replacement Cortisone and prednisone fluid and
HR: 112bpm Nettina, Sandra M. (2003) Lippincott’s medications as prescribed or replace cortisol deficits, electrolyte
RR: 24cpm pocket manual of nursing practice. 2nd indicated: oral cortisone which will promote balance as
T: 36.1 C edition. (Cortone), hydrocortisone sodium resorption. evidenced by
O2 sat: 98% (Cortef), prednisone, or Fludrocortisone is a improvement
fludrocortisone (Florinef). mineralocorticoid for in MIO.
patients who require GOAL MET
Laboratories
aldosterone replacement
1/31/2023 to promote sodium and
WBC Count water replacement.
13.90 Acute adrenal
x10^9(elevated) insufficiency is a
Potassium medical emergency
5.9 mmol/L requiring immediate
(elevated) fluid and corticosteroid
ESR administration. If treated
55 mmol/L (elevated) for adrenal crisis, the
CRP patient requires IV
hydrocortisone initially;
16 mg/L (elevated)
usually by the second
TSH day, administration can
30 mIU/L (elevated) be converted to an oral
Cortisol form of replacement.
5mcg/dL (low)
ACTH
7 pg/mL (low) Collaborative:
Instruct the patient to inquire Collaborative:
a dietician with regards to
ingesting salt additives in Sweating increases
conditions of excess heat or sodium loss. A dietician
humidity. will help the patient with
regards to a healthy diet.