Assessment/ Cues Nursing Diagnosis Background Knowledge Goal and Objectives Nursing Interventions and Rationale Evaluation

NURSING BACKGROUND GOAL AND NURSING EVALUATION
ASSESSMENT/ DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTIONS

AND RATIONALE
CUES
Subjective: Deficient Fluid Deficient Fluid NOC: Hydration NIC: Hypovolemia Goal met.
Volume related Volume (also known Management
Objective: to decreased as Fluid Volume Goal: Achieved After rendering
fluid intake as Deficit (FVD), vitals signs within the nursing
Patient is admitted evidenced by hypovolemia) is a normal limits and interventions, the
with 5-day history increased state or condition displayed signs of goal was met as
of continuous capillary refill where the fluid hydration. evidenced by:
fever. time, vomiting, output exceeds the
fever and fluid intake. It occurs Objectives:After 8
Patient is reduced tea- when the body loses hours of nursing
conscious but colored urine both water and interventions, the
slightly confused. output. electrolytes from the client will be able
ECF in similar to:
She became more proportions.
unwell a day after Common sources of A. Verbalize A.1 Provide necessary The client was
admission with fluid loss are the understandin information about the able to
recurrent bouts of gastrointestinal tract, g of patient’s condition understand her
vomiting, polyuria, and causative including the signs and current situation
abdominal pain increased factors and symptoms of their and the possible
and reduced tea- perspiration. Risk purpose of condition that will require complications
colored urine factors for deficient individual immediate attention. that may arise
output. fluid volume are as therapeutic Enhances patient’s from it. She also
follows: vomiting, interventions cooperation that leads to verbalized
Oxygen was diarrhea, GI and better patient outcomes. understanding of
administered via suctioning, sweating, medication the individual
face mask at decreased intake, interventions.
15L/miin. nausea, inability to
gain access to fluids,
Vital Signs: adrenal insufficiency,
BP: 100/80 osmotic diuresis, B. Maintain B.1 Monitor vital signs
mmHg hemorrhage, coma, fluid volume noting BP, temperature The client
T: 38.5C third-space fluid at a and HR. maintained
PR: 148 bpm shifts, burns, ascites, functional Alteration in HR is a adequate
RR: 32 bpm and liver dysfunction level. compensatory mechanism fluid volume as
which are some of to maintain cardiac evidenced by
Chart Data: the manifestations of output. Usually, the pulse stabilized vital
WBC: 15,000 dengue hemorrhagic is weak and irregular if signs, balanced
cells/mm3 fever. Fluid volume electrolyte imbalance also intake and
RBC: 4.0 million deficit may be an occurs. output-
cells/mcl acute or chronic individually
Hgb: 10.8 g/dl condition managed in B.2 Assess skin turgor and adequate urinary
Capillary Refill: the hospital, oral mucous membranes output within
4-5 seconds outpatient center, or and capillary refill for normal gravity,
home setting. signs of dehydration. hydrated
Signs of dehydration are appearance,
also detected through the good skin turgor
skin. The skin of elderly and
patients loses elasticity; oral mucous
hence skin turgor should membrane, less
be assessed over the than
sternum or on the inner 2 seconds
thighs. Longitudinal capillary
furrows may be noted refill time.
around the tongue.
B.3 Assess color and

amount of urine. Report
urine output less than 30
ml/hr for two (2)
consecutive hours.
Normal urine output is
considered normal, not
less than 30ml/hour.
Concentrated urine
denotes fluid deficit.
B.4. Provide oral

replacement therapy or
administer fluids and
electrolytes as ordered.
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.
C. Shows no
signs of The client
dehydration. C.1 Regulate/monitor showed no signs
oxygen administered via of dehydration as
face mask. To ensure that evidenced by lab
oxygenation is optimised values within
at pulmonary and cellular normal range,
level. relieved vomiting
and confusion.
C.2 Monitor for the The client also
existence of factors showed signs of
causing deficient fluid increased energy
volume (e.g. level and
gastrointestinal losses, improved
vomiting, difficulty concentration.
maintaining oral intake).
Early identification of risk
factors and early
intervention can decrease
the occurrence and
severity of complications
from deficient fluid
volume.
C.3 Monitor for

neurologic and
neuromuscular
manifestations that
indicate dehydration. (e.g.,
muscle weakness,
lethargy, altered level of
consciousness).
Dehydration negatively
affects mental and muscle
performance which can
lead to slower reaction
times, increased fatigue
and poor concentration.
C.4 Obtain and monitor

laboratory data (e.g.,
hemoglobin/hematocrit
(Hgb/Hct), BUN,
electrolytes, urine
osmolality/specific
gravity. Indicators of
adequacy of hydration
and also to evaluate
body’s response to fluid
loss and determine need
of replacement.
C.5 Change position

frequently . To improve
circulation in the body
which prevents lethargy
and decrease in energy
level. Client
D. Demonstrate participated in
behaviors or D.1 Teach and counsel the activities that
lifestyle client how to promote and promotes the
changes maintain hydration by maintenance of
essential to monitoring and reporting adequate fluid
maintain areas of breakdown in volume,
hydration. terms of skin integrity, verbalized
ensuring frequent examples of
positioning and weight water-rich foods
shifts, and maintaining and fluids and its
adequate nutrition. importance in
Deficient fluid volume improving her
decreases tissue health.
oxygenation, which makes
the skin more vulnerable
to breakdown. Moreover,
frequent positioning
would help in order to
avoid postural
hypotension.
D.2 Provide health

teaching about
importance of
hydrating and its
benefits and provide
list of fluids and water-
rich foods and make
them available
throughout the day.
Assist/remind the
client to drink.
Getting enough water
not only prevents
dehydration it also
supports maintaining
normal
blood pressure. It is also
helpful in improving the
patients
mood and bootskin
health and regulates
body temperature.

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NURSING BACKGROUND GOAL AND NURSING EVALUATION

ASSESSMENT/ DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTIONS

B.3 Assess color and

B.4. Provide oral

C.3 Monitor for

C.4 Obtain and monitor

C.5 Change position

D.2 Provide health

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