ZANIKA TAMAYAO

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTION RATIONAL EXPECTED OUTCOME

PROBLEM

SUBJECTIVE: Fluid volume deficit STO: Dx: STO (Goal met if):
“My child only drinks (FVD) or hypovolemic Within 8 hours of 1.Assess vital signs 1.Hypotension, Within 8 hours of effective
little amount of water is a state or condition effective nursing tachycardia, fever can nursing interventions, the
and still he has sweat where the fluid output indicate response to or
interventions, the patient and SO will
response”, as exceeds the fluid effect of fluid loss
verbalized by the patient and SO will be verbalize awareness of
intake. It occurs when
parent able to: causative factors and
the body loses both
a) Verbalize 2.Observe for excessively 2.This indicates the level of behaviors essential to
water and electrolytes
OBJECTIVE: awareness of dry skin, decreased skin client’s hydration correct fluid deficit. The SO
from the ECF in similar
✔ Limited fluid causative factors turgor, mucous
proportions. Common will be able to explain in his
intake (500mL and behaviors membranes
sources of fluid loss are own understanding the
a day) essential to
the gastrointestinal significance of nutrition to
✔ Nails are pale correct fluid 3.Monitor intake and 3.Provides information
tract, polyuria, and
✔ Thirst output, estimate insensible about overall fluid his child recovery and
increased deficit.
✔ Dry mucous fluid losses. Measure urine balance, as well as overall health as well as he
perspiration. Risk b) Explain
membrane specific gravity. guidelines for fluid
factors for FVD are as understanding on will be able to enumerate
✔ Oliguria with replacement
follows: vomiting, the significance of signs of insufficient intake
500mL a day
diarrhea, GI nutrition to the of nutrients. Lips and skin
NURSING Tx:
suctioning, sweating, patient recovery
INTERVENTION: 1.Measure body weight 1.Provide assessment for will appear moist and SO
decreased intake, and overall everyday fluid balance verbalize increase fluid
nausea, inability to health.
Risk for deficient fluid
c) Enumerate signs intake of his child as
volume related to gain access to fluids, 2.Monitor urine color and 2.Urine dark in color with
of insufficient specific gravity an increased specific restricted.
decrease urine adrenal insufficiency, intake of nutrients. gravity may mark an
output osmotic diuresis, d) Appear with moist increased urine
hemorrhage, coma, lips and skin. concentration and
third-space fluid shifts, e) Increase fluid volume deficit
burns, ascites, and intake as restrict. LTO (goal met if):
liver dysfunction. Fluid 3.Administer appropriate 3.Administer After 12 to 24 hours of
volume deficit may be medication as ordered antidiarrheals, antipyretics effective nursing
LTO: to reduce fluid loss
an acute or chronic interventions, the patient
Edx:
condition managed in Within 12 to 24 hours of demonstrated clinical signs
1.Observe for changes in 1.Dehydration can cause
the hospital, effective nursing the client’s mental status fatigue, restlessness of adequate hydration
outpatient center, or
interventions, the prior to discharge. He no
home setting.
patient will: 2.Educate parent about 2.Providing a rationale longer appears pale.
a) Demonstrate importance of promotes compliance
appropriate fluid and and helps prevent issues
SOURCE: clinical signs of
food intake
Wayne G. (2020) Fluid adequate
Volume Deficit hydration prior to
3.Educate parent about 3.Provides knowledge and
(Dehydration) Nursing discharge.
sign and symptoms of these allows parent to be
Care Plan Retrieved b) No longer appear
dehydration and proactive, recognizes
from pale.
conditions that increase states of fluid loss early
https://nurseslabs.com the likelihood of and when to contact
/deficient-fluid- becoming dehydrated; healthcare provider
volume/ include excessive
sweating, vomiting, fever
 BERNADETTE PADAGAS

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING RATIONALE EVALUATION

PROBLEM INTERVENTION
Subjective: The patient is experiencing STO: Dx: STO (Goal met)
“Nagngato ti hyperthermia due to 1. Monitored 1. To assist in
gurigor na”, as dehydration. Within 4 hours of vital signs. creating an After 4 hours of
verbalized by effective nursing accurate diagnosis effective nursing
the mother. Hyperthermia defines as the intervention, the and monitor intervention, the
core body temperature patient and SO will effectiveness of patient and SO was
Objective: above the normal diurnal be able to: medical treatment. able to maintain
range due to failure of
✔ Skin warm core temperature
thermoregulation.
to touch a. Maintain 2. Fluid loss can within normal range
✔ Flushed skin core temperature 2. Monitored the be a reason for of 36.5oC as well as
Hyperthermia is an
✔ Pale within normal range input and output of dehydration. demonstrated
abnormally high body
conjuctivae of 36.5oC the patient. Dehydration can behaviour to
temperature caused by a monitor and
✔ Dried lips b. Demonstrate also lead to a loss of
failure of the heat- promote
✔ V/S taken behaviour to monitor strength and
regulating mechanisms of and promote normothermia.
as follows: stamina. It's a main
the body to deal with the normothermia
T: 38.9 cause of heat
heat coming from the
PR: 90 exhaustion.
environment. Hyperthermia LTO (Goal met)
RR: 30
may transpire more quickly LTO: 3. Noted the 3. The body
in persons who have After 12-16 hours of
NURSING endocrine-related Within 12-16 hours presence or attempts to effective nursing
DIAGNOSIS: problems; use alcohol; or of effective nursing absence of increase heat loss intervention, the
Hyperthermia take diuretics; intervention, the sweating. by evaporation, patient was free of
related to anticholinergics; or patient will: conduction. seizure activity and
dehydration as phototoxic agents. Evaporation is have stable
evidenced by a.Be free of seizure decreased by temperature within
increased activity environmental normal range.
temperature of Source: a. Stable factors of high
38.9degrees https://nurseslabs.com/ temperature within humidity and high
Celsius hyperthermia/ normal range. ambient
temperature,
as well as body
factors producing
loss of ability to
sweat.

Tx:
1. Promoted 1. To facilitate
surface cooling by the body in cooling
means of tepid down and to
sponge bath provide comfort.

2. Medication
2. Administered will help to stimulate
prescribed the hypothalamus
medications. and normalize body
temperature and to
 facilitate fast
recovery.

3. To regulate
3. Removed the temperature of
excessive clothing, the environment
blankets and and to make
adjusted room patient more
temperature. comfortable.

Edx:
1. Encouraged 1. If the patient
mother to increase is dehydrated or
the child fluid intake. diaphoretic, fluid
loss contributes to
fever.

2. Educated 2. Providing
mother about the health teachings to
signs and symptoms could help client
of hyperthermia. cope with disease
condition and could
help prevent further
complications of
hyperthermia.

3. Educated the 3. Children are

guardian on hyper and active of
frequent rest periods the time.
and let patient pace
activity