Assessment

Diagnosis

Subjective:
Nasusuka at
nauuhaw ako palagi
(I always feel
naseous and
thirsty) , as
verbalized by the
patient

Fluid Volume Deficit

related to loss of
fluids secondary to
nausea, vomiting

Objectives:
Poor skin turgor
Chapped and dry
lips
VS as taken

Inference

Blockage of lumen
of appendix

mucus produced by
mucous appendix
suffer dam

Increased
intraluminal
pressure

Inflammation
T 36.8
P 103
R 17
BP 80/50

Planning

Intervention

After 8 hours or
nursing
intervention, the
patient will be able
to maintain body
fluid balance by
having:
Normal BP
Normal pulse
rate
Do not complain
of thirst
Balance between
intake and
output

Independent:
Record intake
and output

Monitor skin
turgor

Observe for dry

mucous
membranes

Edema and
ulceration

Pain in the
epigastrium
radiating to the
lower right
abdomen

Give fluid little

by little but
often, as
appropriate
Monitor urine
output
Per hour and
shift

Rationale

To serve as a
basis to monitor
the balance of
fluids in the body
that are needed
for daily
metabolism
To find out the
less interstitial
fluid / loss can
lead to loss of
skin elasticity.
A dry mucous
membrane is an
indication of
dehydration
To minimize loss
of fluids

Reduced amount
of urine and its
concentration
indicate reduced
fluid in the body.

Evaluation
After 8 hours of
nursing
intervention, goal
met.
Patients BP and
pulse rate are in
normal range (BP
110/80 P-89);
The output is
balanced with
the patients
fluid intake in 24
hours
The patient does
not complain of
thirst.

Pain
stimulus/irritant is
sent to enteric
plexuses

Nausea and
vomiting
Are induced

Dependent:
Establish IV
access and
replace GI
losses,
volume/volume

Loss of body fluid

Give antiemetics
as ordered
Dehydration

To restore fluids
and electrolytes
lost via IV since
oral intake is
limited due to
nausea and
vomiting

To reduce
vomiting