DOLORES WELLBEING

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Fluid Volume Short Term: Independent: Short term:
weakness and Deficiency After 48 hrs of Get specimen for Analyzing the After 48 hrs of
unable to tolerate related to nursing analysis of sodium urine provides us nursing
fluid intake hypertonic intervention and levels such as urine details about the intervention and
because of dehydration as monitoring the specimen. rise in sodium monitoring the
nausea and evidence by: patient should level and the patient is able to
vomiting increased in be able to concentration and regain it’s
Objective: serum sodium, regain it’s dilution of urine in strength, have
Elevated Urine increase in strength, have response of fluid her serum
specific gravity: urine specific her serum change. sodium and urine
1.0357 gravity and sodium and specific gravity
Elevated serum inability to urine specific Observe and measure Urine may be dark back to normal,
sodium: 155 respond to thirst gravity back to urinary output hourly or because of be able to
meq/l reflex. normal, be able for 24 hr as indicated. concentration and respond back to
to respond back specific gravity her thirst and is
to her thirst and high number now well
be well associated with hydrated.
hydrated. dehydration with
usual range being Long term:
Long Term: 1.010 to 1.025 After a week of
After a week of Maintaining accurate continuous
continuous intake and output Accurate records monitoring the
monitoring the records is important in patient is able to
patient should assessing the go back to her
be able to go patients condition. old self and
back to her old Monitoring vital signs exhibit
self and exhibit Sudden changes continuous
continuous in vital signs can tolerance to fluid
tolerance to fluid indicate other and is now free
and will be free illness such as of any possible
of any signs of Dependent: hypovolemia. signs of
dehydration. Give appropriate Fluids dehydration.

We need to
replace the lost
fluid volume due
to nausea that
decreases her oral
intake of fluids
Administer IV fluids and through a
electrolytes as supervision.
prescribed
Fluids used for
replacement
depend on the
type of
dehydration
present (e.g.,
hypertonic or
hypotonic) and the
degree of deficit
determined by
age, weight, and
Collaborative: type of condition
Collaborate with causing the deficit
physician to identify or
characterize the nature Dehydration is
of fluid and electrolyte often categorized
Deficit. according to
serum sodium
concentration.
More than one
cause may exist at
a given time.