ST.

PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
SY 2015-2016

Subjective Objective Nursing Scientific analysis Planning Intervention Rationale Expected Outcome
Cues Cues Diagnosis
Pagkahuman -Alterations Deficient NPO instructions is That after 8 -Monitor and -Decrease in That after 8
appendectom in mental Fluid Volume the prevention of hours of document vital circulating hours of nursing
y wala nani state related to aspiration pneumonia, nursing signs especially blood volume interventions,
siya gipa- -Alterations postoperative e.g. in those who interventions the patient will
kaon ug in mental restrictions will undergo general , the patient BP and HR. can cause be normovolemic
gipainom ug state (NPO)as anesthesia, will be able hypotension and as evidenced by:
tubig as -Dry mucous evidenced by gastrointestinal to be tachycardia. -Systolic BP
verbalized membranes alterations in blockage. Alteration normovolemic -Assess skin turgor greater than or
by the S.O -Tachycardia mental status in mentation may be as evidenced and oral mucous -Signs of equal to 90 mm HG
(115 bpm) secondary to caused by abnormally by: membranes for signs dehydration are (or patients
-Weakness appendectomy high or low glucose. -Systolic BP of dehydration. also detected baseline)
Deficient fluid greater than through the skin. -Absence of
volume is a state or or equal to orthostasis, HR
Deficient condition where the 90 mm HG (or -Assess alteration 60 to 100
Fluid Volume- fluid output exceeds patients in mentation/ -Alteration in beats/min
Decreased the fluid intake. It baseline) sensorium mentation/sensori -No alteration of
intravascular, happens when water -Absence of um may be caused menatal status
interstitial, and electrolytes are orthostasis, by abnormally -Moist mucous
and/or lost as they exist in HR 60 to 100 high or low membrane
intracellular normal body fluids. beats/min glucose,
fluid. This -Monitor and electrolyte
refers to document abnormalities
dehydration, Reference: temperature.
water loss nurseslabs.com -Febrile states
alone without Retrieved: -Emphasize decrease body
change in June 2, 2017 importance of oral fluids by
sodium. hygiene. perspiration and
increased
-Provide respiration.
comfortable -Fluid deficit
environment by can cause a dry,
covering patient sticky mouth.
with light sheets.
-Drop situations
where patient can
experience
overheating to
ST. PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
SY 2015-2016

prevent further
fluid loss.