NURSING DIAGNOSIS

ANALYSIS

GOAL AND OBJECTIVES

INTERVENTION

RATIONALE

EVALUATION

Risk for deficient fluid volume related to inadequate fluid intake as evidence by poor skin turgor.

SUBJECTIVE: Nauuhaw ako. Basa palagi ang tae ko. Masakit palagi ang tiyan ko yung lower part.

Deficient Fluid Volume is decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.

After 8 hours of nursing interventions, the patient will be able to maintain adequate fluid volume as evidenced by good skin turgor and balance intake and output.

INDEPENDENT:

Monitor intake and output, character, and amount of stools; estimate insensible fluid losses. Measure urine specific gravity and observe for oliguria.

Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement.

After 8 hours of nursing interventions, the patient will had been able to maintain adequate fluid volume as evidenced by good skin turgor and balance intake and output.

Nurses Pocket Guide p.90 Marilynn E. Doenges ,Mary Frances Moorhouse, Alice C. Murr

OBEJCTIVES: After 10 mins of nursing intervention, the client will verbalize understanding of drinking water in maintaining our body

Assess vital signs (BP, pulse, temperature).

Hypotension (including postural), tachycardia, fever can indicate response to or effect of fluid loss.

Objective Cues: Thirst Skin turgor Weakness After 15 mins of nursing intervention, the client will increase her fluid intake.

Observe for excessively dry skin and mucous membranes, decreased skin t turgor, slowed capillary refill.

Indicates excessive fluid loss or resultant of dehydration.

VS taken as follows: Temperature:37.9

Indicator of overall fluid and nutritional status Colon is placed at rest for healing and to decrease intestinal fluid losses.

Weigh daily. Pulse rate:79 BP: 130/90 Respiratory rate: 19 Maintain oral restrictions, bed rest and avoidance of exertion.