ASSESSMENT DIAGNOSIS PLANNIG INTERVENTION
SUBJECTIVE: Fluid volume deficit Short Term Goal:
“I hate water and don’t related to inadequate After 1-2 hours of
drink it much.” As oral fluid intake performing appropriate
verbalized by the patient. as evidenced by dry nursing intervention/s,
mucous membranes, lips, the patient will be able to:  Monitored color
OBJECTIVE: skin and poor skin turgor.
 Dry mucous  Establish good
membrane hydration habit.
 Poor skin turgor  Verbalize
 Dry skin understanding of
 Dry lips causative factors and
therapeutic regimen.
V/S taken as follows:
T: 36.4
PR: 160 Long Term Goal:
RR: 26 After 8hrs of performing
BP: 100/80 appropriate nursing
intervention/s, the
patient will be able to:
 Demonstrate
improved fluid
balanced,
adequate urine
output, stable vital
signs, moist
mucous membrane
and good skin
turgor.
EVALUATION
 Monitored vital signs, Short Term Goal:
capillary refill and the After 1-2 hours of
status of the mucous performing appropriate
membranes. nursing intervention/s,
the patient WAS able to:
and amount of
urine. Report urine  Establish good
hydration habit.
output less than 30
 Verbalize
ml/hr for 2
understanding of
consecutive hours. causative factors and
 Assessed the results of therapeutic regimen.
the test function
electrolyte / kidney.
 Assess alteration in
mentation/sensoriu Long Term Goal:
m (confusion, After 6-8hrs of performing
agitation, slowed appropriate nursing
responses) intervention/s, the
patient WAS able to:
 Demonstrate
 Obtained nutritional
improved fluid
history, included
balanced,
SO/caregiver in adequate urine
assessment. output, stable vital
 Determined etiological signs, moist
factors for reduced mucous membrane
oral fluid intake and good skin
 Monitored attitudes turgor.
towards oral fluid
intake
 Encouraged patient
with the importance of
adequate fluid intake.
 Encouraged patient
to drink prescribed
amount of fluid
 Encouraged patient
participation in
recording oral fluid
intake using daily log
 Provided
companionship during
mealtime.
 Discouraged beverages
that are caffeinated or
carbonated
 Administered IV fluids
as prescribed
 Administered
supplemental
medication
(potassium, sodium,
magnesium) as
prescribed
ASSESSMENT DIAGNOSIS PLANNIG INTERVENTION EVALUATION
SUBJECTIVE: Constipation related to Short Term Goal: Short Term Goal:
“I defecate once or twice inadequate fluid intake as After 1-2 hours of  Determined stool After 1-2 hours of
a week only.” As evidenced by absence of performing appropriate color, consistency, performing appropriate
verbalized by the patient. stool. nursing intervention/s, frequency and nursing intervention/s,
the patient will be able to: amount the patient WAS able to:
OBJECTIVE:  Establish good  Auscultated bowel  Establish good
 Weak in appearance hydration habit. sounds hydration habit.
 Absence of bowel  Verbalize  Encouraged increased  Verbalize
sounds understanding of fluid intake of 2500 – understanding of
 Dry mucous causative factors and 3000 ml/day within causative factors and
membrane therapeutic regimen. cardiac tolerance. therapeutic regimen.
 Poor skin turgor
 Dry skin Long Term Goal:  Recommended Long Term Goal:
 Dry lips After 8hrs of performing Avoiding gas- forming After 8hrs of performing
 Pale conjuctiva appropriate nursing foods such as nuts, appropriate nursing
intervention/s, the patient peas and spicy foods. intervention/s, the patient
V/S taken as follows: will be able to:  Instruct client on a WAS able to:
T: 36.4  Establish normal high-fiber diet, as  establish normal
PR: 160 patterns of bowel appropriate. patterns of bowel
RR: 26 functioning  Discuss use of stool functioning
BP: 100/80 softeners, mild
stimulants, bulk
forming laxatives or
enemas as indicated.