Name: Trisha Ericka Surigao BSN 3A

Subject: RLE 114

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS EVALUATION

■ Subjective: Risk for deficient fluid volume Short Term INDEPENDENT: Short Term
related to insufficient At the end of 6 hours of nursing At the end of 6 hours of
Client verbalized knowledge about fluid needs intervention, the client will: • Provide fresh water and oral fluids preferred by the client. Can be 1200 ml in the nursing intervention, goal
“ Dili kaayo ko tig-inom as evidenced by insufficient morning, 800 ml on afternoon, and 200 ml on nights. met as evidenced by:
og tubig. Muinom ra ko fluid intake • Slowly introduce frequent
og duha ka baso drinking of water. Can be 1200 Rationale: • Client verbalized
paghuman og kaon” Reference: ml of water for the first 6 hours To hydrate the patient importance of drinking
Nursing Diagnosis Handbook, of intervention. sufficient fluid
■ Objectives: eleventh edition
• Offer snacks such as fresh fruits and fresh fruit juices.
• Dry lips • Verbalized importance of • Client has already the
• Dry skin sufficient fluid intake knowledge and was able to
Rationale: explain the measures in
Fresh fruit juice and fresh fruit such as watermelon contain water and may help client to treating or preventing fluid
• Explain measures that can be gain fluid in his body.
taken to treat or prevent fluid loss
volume loss
• Monitor total fluid intake and output every 4 hours. Instruct client that the normal fluid • Client introduces fluid in
intake should be 8 to 10 glasses of water a day. And output should be atleast every 6 the body frequently
• Describe symptoms of hours
dehydration that indicate the
need to consult with healthcare Long Term
provider Rationale:
Urine output is an accurate indicator of fluid balance .
• Client maintained drinking
Long Term: 2 liters of water a day.
• Weigh client every 1 week and watch for sudden decrease Though not in large amounts
At the end of two weeks of but frequent.
intervention: Rationale:
Body weight changes of 1kg represent fluid loss lf 1L. • Client presented normal
• Client will maintain frequent BP, temperature and heart
drinking of water amounting to 2 • Check skin turgor of client in the forehead and axilla; check for dry mucous membranes rate
liters per day and sunken eyes
• Client shows normal skin
• Maintain elastic skin turgor, Rationale: turgor, hydrated lips and oral
moist tongue and mucous Older clients commonly have decreased skin turgor from normal age-related loss of mucosa.
membrane. As well as, hydrated elasticity; therefore, checking skin turgor on the arm is not reflective of fluid volume
skin and lips. • Client shows no signs of
• Instruct client to note the color of urine. Teach client the normal color of urine in order fluid overload
• Maintain usual weight for him to compare. Normal urine color should be light yellow.

• Shows no signs of fluid Rationale:

overload such as edema Changes in urine color are indicative of any abnormalities in urine output

• Monitor client for excess fluid volume during the treatment of deficient fluid volume:
auscultate lung sounds, assess for edema, and note vital signs

Rationale:
Older client has decreased ability to adapt rapid increases in intravascular volume and
may quickly develop fluid overload
 • Provide health teachings to client regarding the importance of adequate fluid intake;
measures in preventing fluid loss; and symptoms of dehydration that may need
immediate call to health care provider
Mr. Juan Dela Cruz – Nursing Care Plan