St.
Anthony’s College
NAME:C,S
AGE:58
Dr.: A
CC:BODY WEAKNESS
CUES
Subjective:
“Sige lang ko ug pangihi
ug pirmi uhaw bisag sige
ko inom ug tubig bugnaw”
as verbalized by the patient
Objective:
Elevated temperature of 38
o
C/ axilla
Increased urine output
Profuse sweating noted
Excessive thirst noted
Body malaise noted
Dry skin, mucous
membrane, and sunken
eyeballs noted
San Jose, Antique
Nursing Department
NURSING CARE PLAN
NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Fluid volume Glucose appears in Short term: Establish rapport To have a friendly Short term:
deficit r/t the urine (glycosuria) After 3° of NI, patient relationship with patient After 3o of NI, patient has
intracellular because the kidney shall have verbalized Take and record vital and to be able to verbalize verbalized understanding of
dehydration 2o DM excretes the excess understanding of signs each other’s concern. causative factors and purpose
type II glucose to make the causative factors and of individual therapeutic
To obtain baseline data
blood glucose level purpose of individual Assess skin turgor and interventions and medications.
normal. Glucose therapeutic mucous membrane for
excreted in the urine interventions and signs of dehydration Dry skin and mucous
acts as osmotic medications. membranes are signs of
diuretic and causes Encourage the patient to dehydration Long term:
excretion of increased Long term: increase oral fluid intake After 2 days of NI, the patient
amount of water, After 2 days of NI, the has maintained fluid volume at
resulting in fluid patient shall have Administer IVF as To replace the fluid loss a functional level as evidenced
volume deficit or maintained fluid ordered and prevent dehydration by individual good skin turgor,
polyuria. volume at a functional moist mucous membrane and
To replace electrolytes
level as evidenced by Administer anti-pyretic stable vital signs.
and fluid loss
individual good skin as ordered
turgor, moist mucous To decrease body
membrane and stable temperature and will have
vital signs. less occurrence of
dehydration