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Cues/Needs Nursing Rationale Goals and Interventions Rationale Evaluation

Diagnosis objectives
Subjective data: Risk for fluid Fluid volume Short term goal: Independent: After 4 hours of nursing
volume deficit deficit occurs After 4 hours of 1.Continue monitoring 1.Indicates excessive fluid loss interventions the goal
Objective data: related to from a loss of nursing intake and output or resultant of dehydration. was partially met as
>Oral Fluid Intake of decreased fluid body fluid or the interventions, the (accurately), character, and Accurate records are critical in manifested by the
30cc for 8 hours intake. shift of fluids patient will amount of stools, vomiting assessing the patient’s fluid patient’s ability to
into the third maintain adequate and bleeding. balance. maintain adequate fluid
>Concentrated urine- space, or from a fluid volume at a volume as evidenced
dark yellow in color reduced fluid functional level as 2.Monitor for neurologic 2.Potassium is vital electrolyte by:
intake. One evidenced by: and neuromascular for skeletal and smooth muscle
>Dry skin, Dry common source individually manifestations of activity. > patient was relaxed
mucous membranes of fluid loss is adequate fluid hypokalemia (e.g., muscle
nausea and volume and weakness, lethargy, altered >Maintained good skin
>Weakness, Changes vomiting, electrolyte balance level of consciousness). turgor 2 seconds
in mental status bleeding and as evidenced by 3. Vital signs changes such as
(restlessness, excessive urine output greater 3. Continue assessing vital increased heart rate, decreased >Maintained normal
irritability) urination. In than 30 ml/hr, stable signs (BP, pulse, blood pressure, and increased capillary refill 2
Dengue vital signs, moist temperature). temperature indicate seconds
>pale conjunctiva Hemorrhagic mucous membranes, hypovolemia. Hypotensive and
Fever signs and good skin turgor increased pulse rate can be an >had moist mucous
>pale nailbeds symptoms that and balance intake indication that patient is membrane
could manifest and output. dehydrated.
Vital signs taken as are vomiting and >Urine output of 30-40
follows: frequent Long term goal: 4. Oral hygiene can increase cc per hour
BP: 90/60 mmHg bleeding from After 3 days of 4.Provide oral hygiene. By patient’s appetite for eating and
PR: 98 bpm gastrointestinal health teaching and means of teaching patient to interest in drinking essential >Stable vital signs:
T: 36° C tract in the form nursing brush teeth thrice a day or amount of fluid. BP: 90/60 mmHg
of hematemesis interventions: every after meal. (Use soft PR: 88 bpm
Weight: 55 lbs or melena that 1. Gain weight. bristle to prevent bleeding T:36.0 C
may lead to fluid 2. Shows no episodes)
loss. sign of 5.Oral fluid replacement is
dehydration 5.Encourage patient to drink indicated for mild fluid deficit.
prescribed fluid amounts. If Elderly patients have a
oral fluids are tolerated, decreased sense of thirst and
provide oral fluids patient may need ongoing reminders to
prefers. Provide fresh water drink. Increasing fluid intake
and a straw. Be creative in can maintain patient
selecting fluid sources (e.g., dehydrated.
flavored gelatin, frozen
juice bars, sports drink)

6. Weigh daily. 6. To determine weight loss


which can be due to severe
dehydration.

7.Describe or teach causes 7.Excessive intestinal loss may


of fluid losses or decreased lead to electrolyte imbalance.
fluid intake. Explain Patients need to understand the
importance of maintaining importance of drinking extra
proper nutrition and fluid during bouts of fever, and
hydration. other conditions causing fluid
deficits.
Dependent:
1.Administer Oral hydrating Oral rehydration replaces and
solutions/ORESOL as maintains fluids and
prescribed by the physician. electrolytes balance which is
loss in the body.

References: Handbook of Common Communicable and infectious Disease by Dionesia Monjejar-Navales, RN, MAEd
Lippincott Review Series Medical Surgical Nursing 4th Ed