NURSING GOAL AND

ANALYSIS INTERVENTION RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES

Risk for deficient Deficient Fluid After 8 hours INDEPENDENT:

fluid volume Volume is decrease of nursing
related to d intravascular, interventions, the ♦ ♦ ♦
inadequate fluid patient will maintain Monitor intake and Provides information After nursing
interstitial, and/or
intake as evidence adequate fluid volume output, character, about overall fluid interventions the
intracellular fluid. and amount balance, renal function, client has a baseline
by poor skin turgor. as evidenced by good
This refers to skin turgor and balance of stools; estimate and bowel disease data for further
SUBJECTIVE: dehydration, water intake and output. insensible fluid losses. control, as well as assessment and
 Nauuhaw loss alone without Measure urine guidelines for fluid measurement.
ako. change in sodium. OBEJCTIVES: specific gravity and replacement.
1. After 10 observe for oliguria.
 Basa palagi mins of
ang tae ko. Nurses Pocket nursing ♦ ♦  ♦
Guide p.90 intervention  Assess vital signs (BP, Hypotension (including After nursing
 Masakit Marilynn E. , the client pulse, temperature). postural), tachycardia, interventions the
palagi ang Doenges ,Mary will fever can indicate client will has a data
abdomens Frances verbalize response to or effect about her vital signs.
ko yung Moorhouse, Alice C. understandi of fluid loss.
lower part. Murr ng of
drinking ♦  ♦ ♦
water in Observe for  Indicates excessive fluid After nursing
Objective Cues: maintaining excessively dry skin loss or resultant of interventions the
 thirst our body and mucous dehydration. client
membranes, Fluid intake shall
 decreased decreased skin t increase her fluid
skin turgor 2. After 15 turgor, slowed intake and have a
 mins of capillary refill. moist skin.
 weakness nursing
intervention ♦ ♦ ♦
, the client Weigh daily. Indicator of overall fluid After nursing
will increase and nutritional status interventions the
VS taken as follows: her fluid client
intake. Weight is measured.
Temperature:37.9
♦  ♦ ♦
Pulse rate:79 Maintain oral Colon is placed at rest for After nursing
restrictions, bed rest healing and to decrease interventions the
BP: 130/90 and avoidance intestinal fluid losses. client
of exertion. Shall maintain bed
Respiratory rate: 19 rest and avoid
exertion of effort