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Patient’s Name: Palon, Eduardo Name: Jesse James Edjec

Age: Group 2 BN3-N
Sex: M
Marital Status:
CC: loose watery stool
Medical Diagnosis: Acute gastroenteritis with moderate dehydration
Date of Admission: May 5, 2010
Time of Admission:
Assessment Data Nursing Rationale Desired Outcome Nursing Interventions Justification Evaluation
Increase Output After 16hours of nurse-client
Independent intervention, the client was
Actual/Abnormal Fluid Volume (diarrhea) At the end of 16hrs nurse- able to:
Findings deficit related to client intervention, the client
loose watery Decrease in total will be able to: 1. Assess vital signs; note strength of -To evaluate degree of fluid
peripheral pulses. deficit.
Subjective: stool (Diarrhea) body water
• Thirst AEB thirst, 1. Maintain fluid volume at a 2. Keep fluids within clients reach -to correct/ replace losses to
• Weakness weakness, reductions in both the functional level as evidenced and encourage frequent intake as reverse pathophysiologic
Objective: decreased urine intracellular and by individually adequate appropriate. mechanisms.
• Decreased urine output, poor skin extracellular fluid urinary output with normal
output turgor, BP- volumes specific gravity, stable vital 3. Control humidity and ambient air -To reduce high fever and
100/80, Pulse-84 signs, moist mucous temperature as appropriate. Reduce elevated metabolic rate.
• Poor skin turgor membranes, good skin turgor beddings/clothes, provide tepid
intravascular volume
• BP-100-80 Definition: depletion and prompt capillary refill. sponge bath.
• Pulse-84 Decreased
Risk Related Factors 4. Change position frequently. -To promote comfort and
intravascular, thirst, weakness, 2. Verbalize understanding of
• Anxiety safety.
interstitial, decreased urine output, causative factors and purpose
• Infrequent fluid and/or poor skin turgor, of individual therapeutic 5. Provide safety measures when -To promote safety.
intake intracellular decrease BP, increase interventions and medications. client is confused.
Strengths fluid. This refers pulse rate and
• Strong family to dehydration, temperature 3. Demonstrate behaviors to Collaborative -to limit gastric/intestinal
support water loss alone monitor and correct deficit as 1. Administer medications as losses.
• Strong without sodium. Fluid Volume Deficit indicated.
Compliance to 2. Establish 24-hour fluid -To prevent peaks/valleys in
medications Definition: Reference: replacement needs and fluid level.
Reference: routes to be used.
Nurse’s pocket
Guide 9th edition 906999-overview 3. Administer IV fluids as -To replace losses to reverse
indicated. pathophysiologic