NORTHERN LUZON ADVENTIST COLLEGE

Artacho, Sison, Pangasinan, PHILIPPINES

A SEVENTH-DAY ADVENTIST INSTITUTION
School of Nursing

www.nlac.edu.ph

Name: Joshua Carmelo I. Aquino

Year Level: II
Section: A
Problem: Risk for Deficient Fluid Volume

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

SUBJECTIVE: Risk for deficient After 2 days of -Monitor vital signs -Changes in BP and GOAL MET
“Madalas akong fluid volume nursing HR can indicate
mahilo at madals related to bleeding intervention, the hypovolemia and After 2 days of
din akong duguin” from a ruptured patient will be able tachycardia. nursing
as verbalized by the ectopic pregnancy to maintain Irregular pulse and interventions, the
patient. adequate fluid weak pulse may patient was able to:
volume as suggest electrolyte
OBJECTIVE: evidenced by: imbalances and -maintain adequate
BP – 110/80 mmhg hypovolemia fluid volume
PR – 85 bpm -moist mucous -have normal vital
RR – 18 cpm membranes -Prepare for blood -To increase blood signs
SPO2 – 97% -skin not dry and transfusion as volume -skin is not dry,
T – 37.0 °C has good mobility required. have good mobility
and turgor and turgor
-adequate urinary -Assess color and -Monitoring urine -adequate urinary
output amount of urine output helps assess output
-capillary refill renal function and -capillary refill is
 NORTHERN LUZON ADVENTIST COLLEGE
Artacho, Sison, Pangasinan, PHILIPPINES
A SEVENTH-DAY ADVENTIST INSTITUTION
School of Nursing

www.nlac.edu.ph

within 2 seconds adequacy of fluid less than 2 seconds

replacement. As
fluid volume deficit
develops, body
fluid losses exceed
fluid intake through
excessive urination
or polyuria,
diarrhea, vomiting,
or other
mechanisms

-Assess skin turgor, -To assess signs of

mucous dehydration and
membranes, and adequacy of
capillary refill hydration

-Monitor fluid -Monitoring fluid

intake and output intake and output
helps evaluate fluid
balance and
adequacy of dietary
fluid intake