JO HEINRICK AZUELO BSN 3B MCN 74

Nursing Diagnosis: Risk for Fluid Volume Deficit as evidenced by vomiting and watery stool

Assessment Cues: Planning Implementation Evaluation

Subjective:
Complaints of burning Long term objective: Patient should be able
sensation of the chest Ascertain whether the to demonstrate steps to
and nausea and Patient demonstrates patient has any related avoid dehydration.
vomiting and watery lifestyle changes to heart problem before
stool a day prior to avoid progression of initiating parenteral Patient should be able
admission dehydration. therapy. to have an adequate
amount of fluid intake
Identify the possible
Objective: cause of the fluid
disturbance or
observed imbalance.
manifestations of fluid
depletion. Monitor active fluid loss
from wound drainage,
The patient is tubes, diarrhea,
conscious and coherent bleeding, and vomiting;
but the vital signs maintain accurate input
support the nurse’s and output record.
initial assessment
which are, T= 37.8͒ PR= Urge the patient to
110, BP=80/60, O2 drink prescribed
saturation=94%. amount of fluid.

Plan daily activities.

Short term objective Administer antiemetic Patient should be

medications as ordered normovolemic as
 Patient shows evidenced by systolic
awareness of causative Encourage increase BP 90 mm Hg or
factors and behaviors fluid intake of 1.5 to 2.5 greater, absence of
essential to correct fluid liters/24 hour plus 200 orthostasis, HR 60 to
deficit. ml for each loose stool 100 beats per minute,
in adults unless urine output greater
contraindicated. than 30 ml per hour,
and normal skin turgor.
Monitor Vital Signs

Offer a variety of fluids

and water-rich foods,
and make them
available throughout
the day, if the client is
able to take oral fluids.
Assist/remind the client
to drink, as needed.
Determine individual
fluid needs and
establish replacement
over 24 hr to increase
the client’s daily fluid
intake.

Note the client’s level of

consciousness and
mentation to evaluate
JO HEINRICK AZUELO BSN 3B MCN 74
the ability to express
needs.

Nursing Diagnosis: Diarrhea as evidenced by vomiting and watery stool

Assessment Cues: Planning Implementation Evaluation

Subjective:
Complaints of burning Long term objective: Reestablish and
sensation of the chest Weigh patient daily and maintain normal pattern
and nausea and Patient maintains good note decreased weight. of bowel functioning.
vomiting and watery skin turgor and weight
stool a day prior to at usual level. Demonstrate
admission Avoid using appropriate behavior to
Patient states relief medications that slow assist with resolution of
from cramping and less peristalsis. If an causative factors (e.g.,
Objective: or no diarrhea infectious process is proper food preparation
occurring, such as or avoidance of irritating
observed Clostridium difficile foods).
manifestations of fluid infection or food
depletion. poisoning, medication
to slow down peristalsis
The patient is should generally not be
conscious and coherent given.
but the vital signs
support the nurse’s Monitor active fluid loss
initial assessment from wound drainage,
which are, T= 37.8͒ PR= tubes, diarrhea,
110, BP=80/60, O2 bleeding, and vomiting;
saturation=94%. maintain accurate input
and output record.

Urge the patient to

drink prescribed
amount of fluid.

Plan daily activities.

Short term objective Give antidiarrheal drugs Verbalize

as ordered. understanding of
 Patient consumes at causative factors and
least 1500-2000 mL of Initiate dietary alteration rationale for
clear liquids within 24 treatment regimen.
hours period. Monitor Vital Signs

Patient reports less Encourage fluids 1.5 to

diarrhea within 36 2 L/24 hr plus 200 mL
hours. for each loose stool in
adults unless
contraindicated;
consider nutritional
support.

Assess for the

presence of postural
hypotension,
tachycardia, skin
hydration/turgor, and
JO HEINRICK AZUELO BSN 3B MCN 74
condition of mucous
membranes indicating
dehydration.

Nursing Diagnosis: Readiness for enhanced nutrition

Assessment Cues: Planning Implementation Evaluation

Subjective:
Reports of experiencing Long term objective:
same conditions Review client’s
(nausea, vomiting and Patient should be free knowledge of current Patient has expressed
watery stool) after of signs of malnutrition. nutritional needs and a beneficial eating
eating processed meat ways client is meeting pattern and maintains
and a bowl of salad these needs. BMI appropriate for age
with fatty dressing
Assess eating patterns
and food and fluid
Objective: choices in relation to
any health risk factors
Patient is an elderly 70 and health goals.
years old
Verify that age-related
and developmental
needs are met.

Assess how client

perceives food, food
preparation, and the act
of eating to determine
client’s feelings and
emotions regarding
food and self-image.

Encourage client’s
beneficial eating
patterns/habits (e.g.,
con- trolling portion
size, eating regular
meals, reducing high-
fat or fast-food intake,
following specific
dietary program, drink-
ing water and healthy
beverages).

Short term objective

Provide bibliotherapy Demonstrates
Patient should be able and help client/SO(s) /verbalizes together
to Demonstrate identify and evaluate with SO the importance
behaviors to attain or resources they can of nutrition.
maintain appropriate access on their own.
weight. Demonstrates eating
Encourage variety and behavior to attain
moderation in dietary appropriate weight and
plan to decrease bodily needs
boredom and
JO HEINRICK AZUELO BSN 3B MCN 74
encourage client in
efforts to make healthy
choices about eating
and food.

Discuss use of
nutritional supplements,
over-the-counter and
herbal products.
Confusion may exist
regarding the need for
and use of these
products in a balanced
dietary regimen.

Consult with, or refer to,

dietitian, or physician,
as indicated.

Provide health
teachings on nutrition.

Reference:
Doenges, M.E., Moorhouse, M.F., Murr, A.C.(n.d.) Nurses Pocket Guide Diagnoses, Prioritized
Interventions, and Rationales 15th edition,.