ASSESSMENT NURSING DIAGNOSIS GOAL AND OBJECTIVE INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Risk for deficient fluid Short Term: INDEPENDENT: The goal was met as
“Na uuhaw ako, last kung volume related to After 10mins of nursing - Assessed patient’s - To monitor for other evidenced by assessing the
inom ay nung umaga naka inadequate fluid intake as interventions. The client condition signs and symptoms patient’s vital signs, fluid
3 baso lang ako pero di ko evidenced by poor skin will verbalize intake increased, and
pa maubos.” As verbalized turgor understanding of drinking - Assessed vital signs (BP, - Hypotension, moist skin and pink lips.
by the patient water in maintaining body pulse, temperature, tachycardia, and fever can The patient’s weight is
fluid. respiratory, oxygen level). indicate a response to or measured and maintained.
“Ayaw kung uminom After 15 minutes of effect of fluid loss No signs of dehydration
walang ka lasa lasa, tiyaka providing nursing
wala din akong gana” as intervention, the client will - Assessed likes and - To promote hydration
verbalized by the patient increase her fluid intake to dislikes, to provide
increase her body fluids. favorite fluids
OBJECTIVE:
(+) thirst Long term: - Monitored intake and - Provides information
(+) decreased skin turgor – After 72 hours of proving output about overall fluid
3 seconds nursing interventions. balance, as well as
(+) dry lips The patient will maintain guidelines for fluid
(+) dry skin adequate fluid volume as replacement.
(+) weakness evidenced by good skin
turgor, moist skin, pink - Observed for excessively - Indicates fluid loss or
VS was taken as follows: lips, no signs of dry skin and decreased resultant of dehydration
BP: 140/70 mmHg dehydration, and balanced skin turgor.
PR: 89 intake and output.
RR: 16 - Encouraged fluid intake - For hydration and to
TEMP: 36.6 C increase fluid intake
SPO2: 95%
- Weight daily - Change in weight can
provide information on
fluid balance and
adequacy of fluid volume
replacement

CABFIT, SHANNON D. BSN 3-02