BANAGEN, PHILIP B.

18-6650-963
BSN3B – GRP A

Potential NCP
Assessment Explanation Of The Problem Objective Intervention Rationale Expected Outcome
Subjective: STO: Dx STO:
Deficient FluidVolume Within 30 minutes of 1. Monitor and record vital 1. Febrile states decrease (Goal Met)
Related to nausea , dysuria,and effective nursing signs. Especially the body fluids by Within 8 hours of
Objective: fever, evidenced by decreased interventions: temperature. perspiration and effective nursing
Nesua urine output .  Patient X verbalizes increased respiration. interventions the
Fever awareness of causative This is known as patients X will be able
Dysuria Reference: factors and behaviors insensible water loss. to verbalize awareness
Doenges, M., Moorhouse, M., & essential to correct 2. Signs of dehydration of causative factors
Murr, A., (2012). Nurse’s Pocket fluid deficit. are also detected and behaviors essential
Guide p. 413-417 2. Record intake and through the skin. to correct fluid deficit
output to determine 3. A normal urine output and will identify
Diagnosis: fluid balance. is considered normal individual risk factors
Risk for deficient fluid not less than and appropriate
volume related to fever 3. Note presence of nausea, 30ml/hour. interventions
and nausea. . vomiting and fever. Concentrated urine LTO:
denotes fluid deficit. (Goal Met)
LTO: 4. These factors influence Within 24 to 72 hours
Within 8 hours of effective Tx intake, fluid needs, and of effective nursing
nursing interventions: 1. Weigh daily with same route of replacement. interventions, the
scale, and preferably at patient will be able to
the same time of day. 1. Weight is the best maintain fluid volume
assessment data for at a functional level as
possible fluid volume evidenced by
imbalance. An individually adequate
 Patient X 2. Monitor active fluid loss increased in 2 lbs a urinary output with
Maintain fluid volume at a from vomiting; maintain week is consider normal specific
functional level as accurate input and normal. gravity, stable vital
evidenced by individually output record. 2. Fluid loss from signs, moist mucous
adequate urinary output vomiting cause membranes, good skin
with normal specific
gravity, stable vital signs,
moist mucous membranes,
good skin turgor, and
prompt capillary refill.
3. Maintain IV fluid decreased fluid volume turgor, and prompt
replacement as and can lead to capillary refill.
ordered to maintain. dehydration.
EDX 3. Dehydrated patients
1. Emphasize importance may be weak and
of oral hygiene. unable to meet
prescribed intake
independently.

1. Fluid deficit can cause

2. Encourage the patient to
drink prescribed amount
of fluid.
a dry, sticky mouth.
Attention to mouth
care promotes interest
in drinking and reduces
discomfort of dry
mucous membranes.

2. Oral fluid replacement

is indicated for mild
fluid deficit and is a
cost-effective method
for replacement
treatment. Oral
hydrating solutions
(e.g., Rehydralyte) can
be considered as
needed.