Assessment Diagnosi Goals and Nursing Rationale Evaluation

s Outcome Intervention

Subjective Data: Fluid Short-term Goal: INDEPENDENT A decrease in Goal partially met.
“Matubig parin volume After 8- hours of Monitor and circulating After 8-hours of
yung dumi ng deficit nursing document vital blood volume nursing
anak ko hanggang related to interventions: signs, especially can cause interventions
ngayon” as Diarrhea  Patient’s BP and HR. hypotension  Patients SO
verbalized by the significant and demonstrate
mother of the others tachycardia. d and
patient. demonstrat Alteration in verbalized
es lifestyle HR is a on how to
changes to compensatory monitor and
avoid mechanism to measure
Objective Data: progression maintain intake and
of cardiac output of
 Three or dehydration output. patient at
more . Usually, the home
watery pulse is weak  Patients SO
stools per  Patient’s and irregular verbalized
day intake and if electrolyte the
 Decrease output will imbalance als measures
d urine stabilize o occurs. that can
output prevent
 Crying  Patients’ fluid
without significant volume
tears  others loss.
  explain Assess skin turgor
measures and oral mucous Loss of skin
that can be membranes for elasticity can
taken to signs of be a sign of
treat or dehydration. dehydration.
prevent
fluid
volume Monitor intake and
loss. output. Weigh the This will
diaper after determine the
Long-term Goals: defecating patient’s net
After 12 hours of loss of fluid.
nursing
interventions:  Encourage to A patient
drink enough may have
Patient SO will amounts of fluid as restricted oral
report patient tolerated or based intake in an
experiencing less on individual attempt to
than three loose needs. control
stools per day urinary
symptoms,
reducing
homeostatic
 reserves and
increasing the
risk of
dehydration
or
hypovolemia.
Teach family
members how to
monitor output in
the home. Instruct
them to monitor An accurate
both intake and measure of
output. fluid intake
and output is
an important
indicator of a
patient’s fluid
status.

Provide necessary
education about
maintaining
appropriate
hydration to patient

DEPENDENT

 Administer
intravenou
s fluid and
give
antidiarrhe
al drugs as
ordered.