NURSING DIAGNOSIS: Risk for Fluid and Electrolyte Imbalance________________________________________________________________________
DEFINING CHARACTERISTICS
SUBJECTIVE CUES:
“Gamay raman akong imnon nga
tubig”
OBJECTIVE CUES:
 W/ ISA @ left hand
 Awake
 Dark yellow colored urine
 Low urine output of 50 ml
 Slightly dry skin
 Weakness noted
 V/S taken:
Temp – 36.1 degree Celsius
PR – 85 bpm
RR – 20 cpm
BP – 110/80 mmHg
Reference: Nurses Pocket Guide 8th Edition by M.Doenges, M.F.Moorhouse, A.Geissler-Murr
SCIENTIFIC BASIS
Deficient fluid volume is a state
or condition where the fluid
output exceeds the fluid intake. It
happens when water
electrolytes are lost as they exist
in normal body fluids. Common
sources of fluid loss are the
gastrointestinal tract, polyuria,
and increased perspiration
EXPECTED OUTCOME
SHORT-TERM OBJECTIVE:
After 8 hours of patient-nursing
intervention at Ward X Pedia, the
patient will be normovolemic as
evidenced of by urine output
greater than 50 mL/hr and
normal skin turgor.
LONG TERM GOAL:
After 3 days of nursing exposure
at Ward X Pedia, the patient will
be able to explain measures that
can be taken to treat or prevent
fluid volume loss & demonstrates
lifestyle changes to avoid
progression of dehydration.
NURSING INTERVENTION
INDEPENDENT:
1. Checked ISA for patency
2. Assessed pt. color and amount
of urine
3. Assessed skin turgor
4. Monitored V/S
5. Noted presence of vomiting,
fever, and nausea
DEPENDENT/ COLLABORATIVE:
1. Encouraged pt. to consume at
least 5-6 glasses of water
2. Emphasized importance of oral
hygiene
RATIONALE
- To prevent blood clotting
- To record if there is any
changes in the urine of the pt. if
fluid deficit
- To record if pt. shows any signs
of dehydration
- Alterations of the pt. vital signs
can be an evident of hypovolemia
- Factors the influence fluid needs
and route replacement
- To avoid dehydration
- To prevent mouth dryness and
lip cracks
NURSING DIAGNOSIS: Acute Pain_______________________________________________________________________________________
DEFINING CHARACTERISTICS SCIENTIFIC BASIS EXPECTED OUTCOME NURSING INTERVENTION RATIONALE
SUBJECTIVE CUES: Acute pain is an unpleasant SHORT-TERM OBJECTIVE: INDEPENDENT:
“Sakitan ko gamay ubos nga part sensory and emotional After 8 hours of patient-nursing 1. Monitored V/S - Alterations may indicate signs
sakong boku-boku basta experience arising from actual intervention at Ward X Pedia, the of infection
magsuka nako” or potential tissue damage or patient will be able to report pain 2. Provided a condusive - To promote nonpharmacological
described in terms of such is relieved or controlled, with environment pain management
damage; sudden or slow onset the pain scale of 2/10 from 5/10
of any intensity from mild to - Indicates need for or
3. Performed an assessment
OBJECTIVE CUES: severe with an anticipated effectiveness of interventions and
of pain to include location,
 w/ ISA @ left hand or predictable end and a may signal development or
characteristics ,onset/
 Awake duration of less than 6 months resolution of complication
duration, frequency, quality,
 w/ pain score of 5/10 LONG TERM GOAL:
severity, grimacing
 Facial grimace noted After 3 days of nursing exposure
 Guarded behavior on the pain at Ward X Pedia, the patient will
DEPENDENT/ COLLABORATIVE:
site noted be able verbalize understanding - To distract attention and reduce
1. Encouraged pt. some
 V/S taken: of the condition, methods that tension
relaxation and diversional
Temp – 36.2 degree Celsius provide relief, and demonstrate
techniques
PR – 120 bpm use of relaxation skills - To lessen the severity of the
2. Advised pt. to have resting
RR – 23 cpm condition
periods
BP – 110/80 mmHg

Reference: Nurses Pocket Guide 8th Edition by M.Doenges, M.F.Moorhouse, A.Geissler-Murr

NURSING DIAGNOSIS: Disturbed Sleep Pattern__________________________________________________________________________
DEFINING CHARACTERISTICS
SUBJECTIVE CUES:
“Tag 3-4 hours ra akong tulog
since makamata man ko basta
mag check ang nurse sa akoa”
OBJECTIVE CUES:
 w/ ISA @ left hand
 Awake
 Restlessness noted
 Slightly dark under eye circle
noted
 V/S taken:
Temp – 36.1 degree Celsius
PR – 100 bpm
RR – 20 cpm
BP – 100/70 mmHg
Reference: Nurses Pocket Guide 8th Edition by M.Doenges, M.F.Moorhouse, A.Geissler-Murr
SCIENTIFIC BASIS
Disturbed sleep related to
lifestyle disruptions as evidence
by reports of difficulty falling and
remaining asleep, agitation,
dozing during the day, and mood
alterations
EXPECTED OUTCOME
SHORT-TERM OBJECTIVE:
After 8 hours of patient-nursing
intervention at Ward X Pedia, the
patient will state ways or methods
to improve sleep and comfort
measures
LONG TERM GOAL:
After 3 days of nursing exposure
at Ward X Pedia, the patient will
be able to report improvements in
quality of sleep pattern
NURSING INTERVENTION RATIONALE
INDEPENDENT:
1. Provided quiet environment - To let the pt. undisturbed
2. Provide comfort measure such - To soothe and relaxes the pt.
as back rub
3. Advised pt. to limit intake of - Caffeine inhibits sleep pattern
caffeine and chocolate
4. Arranged care to provide - To promote wellness
uninterrupted sleep
5. Straightened bed sheet or - To avoid discomfort
change pillow linens