The nursing assessment identified the client was experiencing low blood pressure, altered serum sodium levels, and symptoms of weakness and fatigue due to diarrhea-related fluid loss. The nursing diagnosis was deficient fluid volume. Goals were for the client to maintain normal fluid balance as evidenced by adequate urinary output, normal vital signs, and moist tissues. Nursing interventions included monitoring for underlying causes, assessing nutrition status and vital signs to determine fluid deficit severity, and providing fluid replenishment. The evaluation found the client achieved fluid balance goals after nursing interventions.
The nursing assessment identified the client was experiencing low blood pressure, altered serum sodium levels, and symptoms of weakness and fatigue due to diarrhea-related fluid loss. The nursing diagnosis was deficient fluid volume. Goals were for the client to maintain normal fluid balance as evidenced by adequate urinary output, normal vital signs, and moist tissues. Nursing interventions included monitoring for underlying causes, assessing nutrition status and vital signs to determine fluid deficit severity, and providing fluid replenishment. The evaluation found the client achieved fluid balance goals after nursing interventions.
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The nursing assessment identified the client was experiencing low blood pressure, altered serum sodium levels, and symptoms of weakness and fatigue due to diarrhea-related fluid loss. The nursing diagnosis was deficient fluid volume. Goals were for the client to maintain normal fluid balance as evidenced by adequate urinary output, normal vital signs, and moist tissues. Nursing interventions included monitoring for underlying causes, assessing nutrition status and vital signs to determine fluid deficit severity, and providing fluid replenishment. The evaluation found the client achieved fluid balance goals after nursing interventions.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online from Scribd
ASSESSMEN NURSING ANALYSIS GOALS AND NURSING RATIONALE EVALUATION
T DIAGNOSIS OBJECTIVES INTERVENTIONS
Goal: Subjective: Deficient After the nursing After the “Bigla akong fluid volume interventions, the nursing nanghina related to client will be able interventions, bago ako diarrhea to maintain fluid the client was dalhin sa volume at a able to ospital. Akala functional level maintain fluid ko as evidenced by volume at a matutuluyan individually functional na ako.” The adequate urinary level as client output with evidenced by verbalized. normal individually specific gravity, adequate Objective: stable vital signs, urinary output Low blood moist mucous with normal pressure: membranes, specific - 90/60 good skin turgor, gravity, stable mmHg and prompt vital signs, Altered capillary refill. moist mucous Serum • Note possible • To determine membranes, sodium: Objectives: conditions/ process the underlying good skin - low: 1. Assess that may lead to cause of the turgor, and 136.00 causative/ deficits disorder prompt mmol/L precipitating capillary refill. factors • Determine effects • Very young and of age extremely elderly individuals are quickly affected by fluid volume deficit, and are least able to express need
• Evaluate nutritional • To determine
status, noting current the current of intake, weight status of the changes, problems client with oral intake, use of supplement/tube feedings
• Assess vital signs • To provide
2. Evaluate baseline data with degree of fluid regards to the deficit current status of the client. • Note change in usual mentation/ behavior/ • These signs functional abilities indicate sufficient dehydration to
"Nagtatae Siya 4 Days Na" As Verbalized by The Mother. Inatake of Causative Agents Irritation of The Stomach Inflammation of The Stomach Increase GI Motility Diarrrhea