Date and
Time
Cues
January
25, Subjective:
2023 – 8:00 “Sige ra syag suka jud
dam, gamayng inom tubig
A.M
or mukaon iyaha ra
ginasuka.”
-As stated by the watcher
Objective:
 (+) dry mucous
membrane
 (+) slightly sunken
fontanels
 vaguely weak in
appearance
Need
P
H
Y
S
I
O
L
O
G
I
C
A
L
N
E
E
D
S
Nursing Diagnosis
Deficient Fluid
Volume related to
post prandial
vomiting as
evidenced by dry
mucous membrane
and sunken eyeballs
Rationale: Deficient
Fluid Volume (also
known as Fluid
Volume Deficit (FVD),
hypovolemia) is a
state or condition
where the fluid
output exceeds the
fluid intake. It occurs
when the body loses
both water and
electrolytes from the
ECF in similar
proportions.
Reference:
NANDA, 15th edition
Planning
Short Term:
After 8hrs of continuous
nursing care and proper
health teachings the
patient will manifest:
 Decrease risk for
complications of Fluid
volume deficit
 Significant others will
have the proper
knowledge regarding
the disease.
 Significant others will
know the proper
intervention of the
problem.
Long Term:
After 2 days of
continuous nursing care
and proper health
teachings the client will
maintain fluid volume at
functional level as
evidenced by:
 Normalized Bowel
Movement
 Moist mucous
membrane and good
skin turgor.
Nursing Intervention
Evaluation
Independent:
Short Term Goal:
Collaborative:
 IVF administered as
ordered. Maintained at
proper regulation
Rationale: Agressive fluid
replacement may be
required to correct fluid
volume deficit
GOAL SUCCESSFULLY
MET
After 2hrs of continuous
nursing care and proper
health teachings the
patient manifested:
 Decreased risk for
complications of Fluid
volume deficit
 Significant others
acquired proper
knowledge regarding
the disease.
 Significant others
understand the
intervention of the
problem.
Long Term:
Still on further
Evaluation.