Assessment Nursing (Rationale) Desired Nursing Intervention Justification Evaluation

Cues Diagnosis Pathophysiologic / Outcome

Name of Student: Mary Claire Joy Pescadero Schematic Diagram
Subjective: Risk for fluid Predisposing Factor: NURSING
After 8 hours ofCARE PLANInterventions:
Independent After 8 hours of
Patient verbalized, volume deficit Age: 45 years old Nursing Intervention, 1. Assess and document 1. This will serve as baseline Nursing
“sagay lang ko suka related to Gender: Male the patient and vital signs and weight of the data for assessment. Intervention, the
Section andnurse
nga suka Group number: 4C Group
excessive 5
fluid significant other will patient. patient and
asta sa gapangluya losses secondary Precipitating Factor: be able to: significant other was
Name of CI: Myka Billones Canlas RN, MN 2. Weight changes are an
nako” to nausea, Environmental stressors 2. Ensure that daily able to:
vomiting and Lifestyle Short Term Goal: weights are taken at the effective indicator of fluid
Area of Exposure: TDHI Medical Surgical volume.
diarrhea Suffered a cervical spine A. Establish fluid same time each day A. The patient was
fracture and phrenic nerve balance within the able to establish
injury 7 years ago. normal range 3. Ensure fluid intake 3. This helps ensure that fluid balance within
Objective: Definition: within the recommended the patient receives the normal range by
Restlesness At risk for Systemic immune response volume. appropriate amounts of having adequate
Guarding sign experiencing primarily against the GI tract fluids, keeping him properly fluid intake by 1 liter
Facial grimace vascular, cellular (unclear mechanism, hydrated and eliminating per day. Goal Met.
Tenderness over or intracellular mediated by cytokine release the risk for excessive fluid
McBurney's point dehydration B. Adhere to intake which may cause B. The patient was
and neutrophil inflammation)
is elicited, as is interventions aimed congestion later on able to follow
rebound Inflammation of the GI tract to help maintain interventions given
tenderness in the acceptable fluid 4. Maintain oral 4. Colon is placed at rest for by the nurse such as
right lower Source/Reference balance restrictions, bed rest; avoid healing and to decrease
Inflammatory cytokines drinking fluids. Goal
quadrant. Nurse’s Pocket exertion. intestinal fluid losses.
destroy the mucosa epithelial Met
Guide. Edition 11 cells of the GI tract wall
MIO of: by Marilynn Long Term Goal: Dependent Interventions:
causing apoptosis and
Intake: Doenges, Mary C. Display intake and 1. Administer parenteral 1. Maintenance of bowel
ulceration. C. The patient was
Parenteral: 2500 cc Frances output near balance, fluids as indicated. rest requires alternative able to able to
Output: 1200 cc Moorhouse and Transporter proteins good skin turgor, fluid replacement to correct display intake and
Alice Murr responsible for Na+ moist mucous losses and anemia. Note: output near balance
V/s: reabsorption gradually membranes, palpable Fluids containing sodium which is 30 cc per
T- 36.0 ‘C disappear from the peripheral pulses, may be restricted in hour, has stable
P- 75 bpm epithelium. stable weight and presence of regional weight. Goal Met.
R- 20 cpm vital signs, and enteritis.
BP- 145/80 mmHg More sodium (and thus electrolytes within
water) is retained in the GI normal range.
tract lumen. 2. Administer prescribed 2. Anti-inflammatory drugs,
medications. including corticosteroids
Strength : Diarrhea and oral 5 aminosalicylates
Good family — initially used to reduce
support S/S: the inflammation such as
Willing to adhere Methylprednisolone and