Assessment Diagnosis Planning Nursing Rationale Evaluation

Intervention
SUBJECTIVE: Fluid volume deficit SHORT TERM GOAL: -Maintain NPO -To minimize losses SHORT TERM GOAL:
related to decreased through vomiting and
“Suka ng suka po ang intake and losses After 30 minutes of minimize abdominal After 30 minutes of
anak ko” as secondary to loss of nursing intervention distension. nursing intervention
verbalized by the appetite, vomiting. the patient will the patient received
mother. receives sufficient -Note presence of -These indicate sufficient fluids to
fluids to replace physical signs (dry dehydration. replace losses.
losses. mucous membrane,
OBJECTIVE: poor skin turgor,
sunken eyeball,
-episodes of vomiting LONG TERM GOAL: weakness, weight LONG TERM GOAL:
more than 3x a day loss)
-Fever After 2 hours of After 2 hours of
-Irritability nursing intervention -Monitor intake and -To accurately nursing intervention
-Weight loss the patient will output determine the the patient exhibited
-Weakness exhibits signs of replacement needs. signs of adequate
-poor skin turgor adequate hydration. hydration.
-Maintain integrity of -Administer
infusion site intravenous fluids
and electrolytes as
prescribed.

-Encourage oral fluid -To promote

intake if tolerable. hydration

-Provide tepid sponge -To reduce fever.

bath.
-Medication may be
-Administer indicated to prevent
medication such as fluid volume
antiemetics and imbalance if
antipyretic as individual becomes
ordered. sick.