Assessment 

Planning  Intervention  Rationale  Evaluation

Subjective: Short Term Goal:   Encourage increase For hydration Short Term
“Naka 7 suka na siya simula pa The patient’s face will go fluid intake Evaluation: 
nung umaga. Medyo madalas din back to normal after 1 providing
ang pagtatae niya” as verbalized hour. appealing liquids After 8 hours
by her husband. For hydration of nursing
Long Term Goal:  Encourage to eat intervention,
Objective:  After 8 hours of nursing foods no
 Weak in appearance  intervention, no with high fluid hypovolemic
 Sunken Eye ball hypovolemic shock and content, shock was
 Poor skin turgor no signs of dehydration such as noted and
will be noted. watermelon, that the
 BP – 100/70 grapes To prevent mucosa of
 T – 35.8  diarrhea for Stool formation the patient
 CR –95 was moist,
 Encourage to eat
indicating no
 02 - 98  banana, rice, apple,
signs of
toast
To prevent further dehydration.
Nursing Diagnosis  dehydration
Deficient Fluid Volume related  Encourage to avoid
to nausea, vomiting, and diarrhea food that cause
as evidenced by decreased urine dehydration such as
output, skin turgor, dry mucous coffee, tea Accurate records
membranes. are critical in
 Ensure accurate assessing the
intake patient’s fluid
and output
monitoring The decreasing venous volume
from blood loss and the
 Monitor client’s sympathetic nervous system
vital signs, and attempt to increase or
especially the maintain the falling blood
blood pressure.  pressure through systemic
vasoconstriction.