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Final NCP
Final NCP
Subjective: Palagi ako naiihi as verbalized by the patient. Objective: Dry skin Generalized body weakness Restless Anxious Irritable
Diagnosis
Fluid Volume Deficit r/t active fluid loss (increased urine output)
Planning
Short Term: Patient will maintain urine output >30 ml/hr Patient will demonstrate elastic skin turgor and moist, pink mucous membranes. Long Term: Patient will have adequate fluid balance
Intervention
Monitor Vital signs Weigh patient daily.
Rationale
Evaluation
Patient will maintain urine output >30 ml/hr Patient will demonstrate elastic skin turgor and moist, pink mucous membranes.
Changes in weight can provide information on fluid balance and the adequacy of volume replacement. 1lb = 2.2kg
Measure and record urine output hourly; report urine output less than 30ml for 2 consecutive hours.
Fluid volume deficit reduces glomerular filtration and renal blood flow causing oliguria. The patient in DKA may also be undergoing osmotic diuresis and have excessive outputs.
Poor turgor, dry membranes and excessive thirst are all signs of dehydration.
Encouraged food and fluids high in sodium. Dependent: Administer medication as ordered. PNSS