ASSESSMENT

Subjective:
Mas madalas akong
tumae ngayon kaysa
nung kahapon, as
verbalized by the patient.
Obejective:
Dry Skin
Dry mouth
Increased Peristalsis
Fatigue and Weakness
V/S taken:
Bp: 110/90
T: 39.4C
P: 80
R: 20

NSG DIAGNOSIS
Acute Dehydration due
to due to the increased
body temperature and
sweating

GOAL
After 8 hours of
nursing
intervention:
Patient will report
normal urine
output
Patient will report
normal bowel
movements
Patient will
improve in the
objective cues

INTERVENTION
(i) Obtain patient history to ascertain
the probable cause of the fluid
disturbance,
Which can help to guide
interventions. This may
include acute trauma and
bleeding, reduced fluid intake
from changes in cognition,
large amount of drainage
postsurgery, or persistent
diarrhea.
(i) Assess or instruct patient to monitor
weight daily and consistently, with
same scale, and preferably at the same
time of day
To facilitate accurate
measurement and follow
trends.
(i) Evaluate fluid status in relation to
dietary intake. Determine if patient has
been on a fluid restriction.
Most fluid enters the body
through drinking, water in
foods, and water formed by
oxidation of foods.
(i) Monitor and document vital signs.
Sinus tachycardia may occur
with hypovolemia to maintain
an effective cardiac output.
Usually the pulse is weak, and
may be irregular if electrolyte
imbalance also occurs.
Hypotension is evident in
hypovolemia.
(i) Monitor blood pressure for
orthostatic changes (from patient lying
supine to high Fowler's).
Note the following orthostatic
hypotension significance:

Greater than 10 mm Hg drop:

circulating blood volume is
decreased by 20%.

IMPLEMENTATION
Ontained Patient
history.
Assessed and
monitored
patients
weight, intake
and output,
vital signs
Assessed skin
turgor
Encouraged
patient to
increased fluid
intake

EVALUATION
After nursing
interventions,
patient reported
normal intake and
output, increased
fluid intake and
normal skin turgor.
Patient also is
afebrile and
demonstrated
regain of energy.

Greater than 20-30 mm Hg

drop: circulating blood volume
is decreased by 40%.

(i) Assess skin turgor and mucous

membranes for signs of dehydration.
The skin in elderly patients
loses its elasticity; therefore
skin turgor should be
assessed over the sternum or
on the inner thighs.
Longitudinal furrows may be
noted along the tongue.
(i) Assess color and amount of urine.
Report urine output less than 30 ml per
hr for 2 consecutive hours.
Concentrated urine denotes
fluid deficit.
(i) Monitor temperature.
Febrile states decrease body
fluids through perspiration and
increased respiration.
(i) Monitor active fluid loss from wound
drainage, tubes, diarrhea, bleeding, and
vomiting; maintain accurate input and
output.
(c) Monitor serum electrolytes and urine
osmolality and report abnormal values.
Elevated hemoglobin and
elevated blood urea nitrogen
(BUN) suggest fluid deficit.
Urine-specific gravity is
likewise increased.
(i) Document baseline mental status
and record during each nursing shift.
Dehydration can alter mental
status.