Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Deficient Short Term: Independent Short Term:

Fluid At the end At the end of
Objective: Volume of 6 hours Assess vital signs, These changes 6 hours
- Poor related to Nursing noting low blood in vital signs are Nursing
skin active fluid Intervention pressure-severe associated with Interventions
turgor volume loss , the patient hypotension, fluid volume , the patient
- Sunken as will be able rapid heart beat, loss/ are able to:
eyeballs evidenced to: and thready hypovolemia.
- 3-4 by episodes peripheral
episode of loose • Maintain pulses. Replenished
s of stools and fluid volume (a number fluid loss,
loose vomiting at a Observe/ higher than 1.25 maintain
stools functional measure urinary is associated urine specific
- 5 Definition: level as output with gravity within
episode Deficient evidenced (hourly/24-hr dehydration normal
s of Fluid by totals)Note the with usual range range, no
vomitin Volume individually color (may be being 1.010- more
g adequate dark greenish 1.025). episodes of
- 129.6 (Diagnostic urinary brown because loose stools
sodium Division: output with of concentration) and
level Food/Fluid] normal and specific vomiting.
specific gravity
Definition: gravity,
Decreased stable vital Note complaints
intravascular signs, moist and physical
, interstitial, mucous signs associated
and/or membranes, with dehydration
intracellular good skin (e.g., scanty,
fluid, these turgor and concentrated
refers to prompt urine; lack of
dehydration, capillary tears when
water loss refill, crying [infant,
alone resolution child); dry, sticky
without a of edema. mucous
change in membranes: lack
sodium. of sweating;
delayed capillary
refill; poor skin
turgor;
confusion;
sleepiness;
lethargy; muscle
weakness;
dizziness or
headedness;
headache).
 To reduce
pressure on
fragile skin and
Change position tissue
frequently

Bath every other

day; provide
optimal skin care To prevent
with emollients injury from
dryness
Provide frequent
oral as well as
eye care Too rapid a
correction of
Observe for fluid deficit may
sudden or compromise the
marked elevation cardiopulmonar
of blood y system,
pressure, causing fluid
restlessness, overload and
moist cough, edema,
dyspnea, basilar especially if
crackles, and colloids are used
frothy sputum. in initial fluid
resuscitation.

(dark urine
Instruct the equates with
client/SO(s) in concentration
how to monitor and
the color of urine dehydration) or
how to measure
and record I&O
(may include
weighing or
counting diapers
in
infant/toddler).

Dependent

Stop fluid loss

(e.g., administer
medication to
stop vomiting/
diarrhea, fever).
Administer fluids
and electrolytes
(e.g., blood,
isotonic so- dium
chloride solution,
lactated Ringer's
solution,
albumin,
fresh frozen
plasma, dextran,
and heptastich).
This prevents
Establish 24-hr peaks and
fluid valleys in fluid
replacement level.
needs and routes
to be used

Collaborative

Maintain
accurate input
and output (I&O)
and weigh daily
Monitor urine
specific gravity.