Assessment
Nursing
Diagnosis
Analysis
Planning
Subjective:
“Naka 10 suka na
cya sa bahay,
naka 3 dumi din
cya, medyo basa
at mabaho.” as
verbalized by the
mother
Deficient Fluid
Volume related
to nausea,
vomiting, and
diarrhea as
evidenced by
decreased urine
output,
skin/tongue
turgor, dry
mucous
membranes
The nursing
diagnosis is
fluid volume
deficit related
to loose
stools and
vomiting is a
priority
problem
because the
patient is at
risk for
hypovolemic
shock due to
current
condition,
thus the need
for hydration
is a priority.
After 12
hours of
nursing
intervention,
no
hypovolemic
shock and
no signs of
dehydration
will be
noted.
Objective:
On admission
2x Loose stools
1x Vomiting
(+) Anorexia
(+) decrease fluid
intake
(+) dry lips
Rationale
Intervention
■
Assess patient's
condition
●
To monitor for
other signs and
symptoms
■
Assess likes and
dislikes, provide
favorite fluids
●
To promote
hydration
■
Weight patient daily
●
Changes in weight
can provide
information in fluid
balance and the
adequacy of fluid
volume
replacement
●
For hydration
■
Encourage increase
fluid intake providing
appealing liquids
●
For hydration
■
Encourage to eat foods
with high fluid content,
such as watermelon,
grapes
●
■
Encourage to eat
banana, rice, apple,
toast
To prevent
diarrhea, for stool
formation
●
■
Encourage to avoid
food that cause
dehydration such as
coffee, tea
Ensure accurate intake
and output monitoring
To prevent further
dehydration
●
Accurate records
are critical in
assessing the
patient’s fluid
■
Evaluation
After 12 hours
of nursing
intervention,
no
hypovolemic
shock was
noted and that
the mucosa of
the patient
was moist,
indicating no
signs of
dehydration.
balance
■
Maintain on IVF
hydration
■
Ensure proper IVF
regulation
■
Antibiotics given as
ordered
■
Vitamins given as
ordered
●
Initial goal is to
correct circulatory
volume
deficit.Isotonic
saline will rapidly
expand
extracellular fluid
volume. The
secondary goal,
correction of water
deficit, is usually
accomplished by a
hypotonic solution
●
To ensure that
there is adequate
hydration
●
To aid in
preventing
infection
●
To aid in the
general health of
the patient