Apego N-40 Assessment Nursing Diagnosis Deficient Fluid Volume related to nausea, vomiting, and diarrhea as evidenced by decreased urine output, skin/tongue turgor, dry mucous membranes
Patient: Palaran C/c: Loose bowel movement Planning Intervention Rationale Evaluation
Objective: 2x Loose stools Dry skin Capillary refill > 2 secs Pale
After 8 hours of nursing intervention, no hypovolemic shock and no signs of dehydration will be noted.
Assess patient's condition Assess likes and dislikes, provide favorite fluids Weight patient daily
After 8 hours of nursing intervention, no hypovolemic shock was noted and that the mucosa of the patient was moist, indicating no signs of dehydration.
Changes in weight can provide information in fluid balance and the adequacy of fluid volume replacement For hydration
For hydration
Encourage to eat foods with high fluid content, such as watermelon, grapes
dehydration
Encourage to avoid food that cause dehydration such as coffee, tea Ensure accurate intake and output monitoring Maintain on IVF hydration
Accurate records are critical in assessing the patients fluid balance Initial goal is to correct circulatory volume deficit.Isotonic saline will rapidly expand extracellular fluid volume. The secondary goal, correction of water deficit, is usually accomplished by a hypotonic solution To ensure that there is adequate hydration To aid in preventing infection