STUDENT NAME: ROTATION: AREA:

YR LEVEL AND SEC: DATE: CLINICAL INSTRUCTOR:

PROBLEM: Dehydration due to frequent urination and vomiting during pregnancy.

DIAGNOSIS:

PRIORITIZATION: HIGH PRIORITY, as it cause major discomfort and could also be a sign of a more serious condition
DATE:

ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION

 DIAGNOSIS

● SUBJECTIVE: ● The patient ● SHORT TERM INDEPENDENT - After 3 hours of

experiencing nursing
symptoms of - Check the - signs and interventions, the
sign and symptoms are
pregnancy patient’s mother
- Complaining symptoms the body's
- After 3 hours of verbalized the
of vomiting ● Dehydration of the ways of letting
nursing decrease level of
four times per due to frequent patient if a person know
interventions, the discomfort.
day, feeling urination and anything that not
dizzy and vomiting during patient will show has everything is
weak. pregnancy as the decrease of changed. running
evidenced by level of smoothly.
weak discomfort.
- She states she appearance,
is nauseated, and - Changes in BP
especially in experiencing - Monitor and HR can
the morning, dizziness and and indicate
smells fatigue. document hypovolemia,
sensitivity, vital signs, electrolyte
have frequent especially imbalances, or
urination and blood compensation
sometimes pressure mechanisms.
feel burning and heart Irregular pulse
sensation rate. and weak
while pulse may
urinating. suggest
● LONG TERM electrolyte
imbalances
and
hypovolemia.
- After 1 day of
- After 1 day of nursing
nursing - Skin turgor intervention, the
patient maintain
 ● OBJECTIVE intervention, the and mucous fluid volume, as
patient will membrane evidenced by
maintain fluid moisture adequate urinary
volume at a provide output, stable
- Appears to be
functional level, as valuable vital signs, moist
bothered and
evidenced by - Assess skin indicators of mucous
does not
adequate urinary turgor and hydration membrane and
make eye
output, stable vital oral status. good skin turgor.
contact.
signs, moist mucous Decreased skin
- Shows mucous membranes turgor and dry
weakness in membranes and for signs of mucous
appearance. good skin turgor. dehydratio membranes
n. are signs of
- Vital signs dehydration.
include:

- Reminding and
encouraging
BP: 110/70 individuals
may help them
PR: 78/Min to remember
the need to
TEMPERATURE:
continue
36.8’C. RR: 20/min,
drinking fluids
FHT:108 bpm; even if they do
Weight:58 kgs. not feel they
are thirsty.

- Encourages
or reminds
patient of
the need
for oral
 intake.

- Severely
dehydrated
DEPENDENT patients or
patients
unable to take
- Give oral hydration
prescribed may require IV
medication hydration to
by the maintain
doctor to appropriate
ease the hydration level
discomfort. as required by
the attending
- Administer
physician.
intravenous
hydration if
needed.
COLLABORATIVE

- Discuss
with
physician
about
medical
considerati
ons for pain
and
discomfort.