Assessment Nursing Diagnosis Inference Plan of Care Interventions Rationale Evaluation

NURSING PLAN OF
ASSESSMENT INFERENCE INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS CARE
Subjective: Fluid Volume Rapid propulsion of  Monitor vital signs  To assess for stable vital
“Ayoko po ng Deficit related to intestinal contents signs
pagkain at inumin active fluid through the small After 4 hours of
kasi isusuka ko po volume loss bowels may lead to a nursing  Encourage alternating  Bedrest is maintained to After 4 hours of
at tae ako ng tae” serious fluid volume interventions, activity with rest decrease metabolic nursing
as verbalized by the deficit. The body would the patient will demands interventions, the
patient want to expel the remain hydrated patient remain
foreign objective as and will begin to  Monitor intake and output.  Will determine if output hydrated and
Objective: much as possible thus drink fluids Be sure to document time of exceeds input. began to drink
VS: it doesn’t undergo its each voiding fluids
T – 37 C “normal” speed, with
 Assess level of  Will determine degree of
PR – 112bpm that, the digestive
consciousness, skin turgor, hydration and adequacy of
RR – 25bpm system organs are not interventions.
mucous membranes, skin
able to absorb the
color and temperature,
(+) poor skin turgor excess fluids that are
capillary refill, eyes, and
(+) diarrhea usually absorbed by
fontanels
the body.  Less invasive than IV fluids.
Provides for replacement of
 Provide oral fluid and
electrolyte replacement essential fluids and
solution if able to tolerate. electrolytes
 Use of IV replacement is
based on the degree of
 Provide and maintain IV dehydration, ongoing losses,
therapy as ordered insensible water losses and
electrolyte results
NURSING
ASSESSMENT INFERENCE PLAN OF CARE INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Imbalanced Adequate nutrition is  Monitor vital signs every  To assess for stable
“Ayoko po ng Nutrition: Less essential to meet the 4 hours vital signs
pagkain at inumin than body body’s demands. After 8 hours of
kasi isusuka ko po requirements Several diseases can nursing interventions,  Encourage alternating  Bedrest is maintained After 8 hours of nursing
at tae ako ng tae” related to greatly affect the the patient will be activity with rest to decrease metabolic interventions, the
as verbalized by the insufficient intake nutritional status of an able to increase demands patient will be able to
patient and excessive individual, this intake and achieve increase intake and
output (vomiting) includes the absence of  Monitor the patients’  In order to monitor achieve the absence of
Objective: gastrointestinal vomiting weight patient’s response vomiting
VS: malabsorption, burns,
T – 37 C cancer; physical  Monitor fluid status:  This will help in
PR – 112bpm factors (e.g., activity Intake & output, the initiating nursing
RR – 25bpm intolerance, pain, number of vomiting, actions and
substance abuse); amount and frequency. subsequent treatment
(+) poor skin turgor social factors (e.g.,
economic status,  Provide a diverse diet  This will stimulate the
financial constraint); according to patient’s appetite of the client
psychological factors needs.
(e.g., dementia,  Eating small, frequent
depression, grieving)  Consider six small meals lessens the
nutrient-dense meals feeling of fullness and
instead of three larger decreases the
meals daily to lessen the stimulus to vomit
feeling of fullness.
ASSESSMENT NURSING INFERENCE PLAN OF CARE INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Risk for Describes a person  Monitor vital signs  To assess for stable
“Ayoko po ng complications of experiencing or at vital signs
pagkain at inumin hypovolemia/shoc high risk to experience After 4 hours of After 4 hours of nursing
kasi isusuka ko po k inadequate cellular nursing interventions,  Promote rest  This helps decrease interventions, the
at tae ako ng tae” oxygenation and the hypovolemic tissue demands for patient did not show
as verbalized by the inability to excrete episodes will be oxygen any hypovolemic
patient waste products of managed and episodes thus it is
metabolism secondary minimized  Monitor fluid status:  Early detection of managed and
Objective: to decreased fluid input and output fluid deficit enables minimized
VS: volume (e.g., from interventions to
T – 37 C bleeding, plasma loss, prevent shock
PR – 112bpm prolonged vomiting, or
 Monitor for signs and  The compensatory
RR – 25bpm diarrhea)
symptoms of shock response to
decreased circulatory
(+) cold clammy
volume aims to
increase oxygen
delivery through i
creased heart and
respiratory rates and
decreased peripheral
circulation
 If shock occurs, place
client in the supine  This position
position unless increases blood
contraindicated return to the heart
 Administer oxygen as
ordered.

Assessment Nursing Diagnosis Inference Plan of Care Interventions Rationale Evaluation

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NURSING PLAN OF

ASSESSMENT INFERENCE INTERVENTIONS RATIONALE EVALUATION

ASSESSMENT NURSING INFERENCE PLAN OF CARE INTERVENTIONS RATIONALE EVALUATION

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