Date/shift Assessment 5-9-11/ 7-3

Nursing diagnosis

Objective of care

Nursing intervention

Evaluatioin After 7 hours of nursing care, the goal is partially met as manifested by:  Feeling of Thirst not noted as client verbalized  moist mucous membrane noted.

Subjective: mag-sige man Risk forDefecient Fluid Volume ko ug suka nya uhaw related to akong pamati Vomiting. Objective:  On diet  Sunken noted  Dry  Thirsty  Fatigue Skin and Eyeballs General liquid

mucous membrane.

After 7 hours of  Evaluate nursing care, the capillary refill, patient will reduce skin turgor and feeling of thirst status of and moist mucous mucous membranes. membrane. > Provides information about general circulating volume and level of hydaration.  Monitor Intake and Ouput > direct indicators of hydration/organ perfusion and function. Provide guidelines for replacement.  Provide fresh water and oral fluids preferred by client, provide prescribed diet; >Distributing the intake over the entire 24 hour period preferred beverages increases the

likelihood that the client will maintain the prescribed oral intake. Collaborative:  Provide oral replacement therapy as ordered with a glucoseelectrolyte solution when client has acute diarrhea or nausea or vomiting. Provide small, frequent quantities of slightly chilled solutions. >Maintenance of oral intake stabilizes the ability of the intestines to digest and absorb nutrients; glucose-electrolyte solutions increase net fluid absorption while correcting deficient fluid volume.