Assessment Nursing Analysis Planning Intervention Rationale Evaluation

Diagnosis

Subjective: Deficient Fluid The nursing After 12 ■ Assess patient's ● To monitor for After 12 hours
“Naka 10 suka na Volume related diagnosis is hours of condition other signs and of nursing
cya sa bahay, to nausea, nursing symptoms intervention,
naka 3 dumi din vomiting, and fluid volume
deficit related intervention, no
cya, medyo basa diarrhea as ■ Assess likes and ● To promote
no hypovolemic
at mabaho.” as evidenced by to loose dislikes, provide hydration
verbalized by the decreased urine hypovolemic favorite fluids shock was
stools and shock and noted and that
mother output,
skin/tongue
vomiting is a no signs of ■ Weight patient daily ● Changes in weight the mucosa of
Objective: turgor, dry priority dehydration can provide the patient was
On admission mucous problem will be information in fluid moist,
2x Loose stools membranes because the noted. balance and the indicating no
1x Vomiting patient is at adequacy of fluid signs of
(+) Anorexia volume dehydration.
(+) decrease fluid risk for replacement
intake hypovolemic
(+) dry lips shock due to ● For hydration
current ■ Encourage increase
fluid intake providing
condition, appealing liquids
thus the need ● For hydration
for hydration ■ Encourage to eat foods
is a priority. with high fluid content,
such as watermelon,
grapes
● To prevent
■ Encourage to eat diarrhea, for stool
banana, rice, apple, formation
toast
● To prevent further
■ Encourage to avoid dehydration
food that cause
dehydration such as
coffee, tea ● Accurate records
■ Ensure accurate intake are critical in
and output monitoring assessing the
patient’s fluid
 balance

■ Maintain on IVF ● Initial goal is to

hydration 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
■ Ensure proper IVF there is adequate
regulation hydration

● To aid in
■ Antibiotics given as preventing
ordered infection

■ Vitamins given as ● To aid in the

ordered general health of
the patient