TAMARGO, Janina Marie V.

BSN134
Cues/Need Nursing Analysis Goals and Interventions Rationale Evaluation
s Diagnosis objectives
Subjective Risk for fluid Fluid volume After 8 hours Independent: After 8 hours
data: volume deficit occurs of nursing 1. Continue 1. Indicates of nursing
The mother deficit from a loss of interventions monitoring intake excessive interventions
of the related to body fluid or , the patient and output fluid loss or the goal was
patient decrease the shift of will maintain (accurately), resultant of partially met
verbalized fluid intake. fluids into adequate character, and dehydration. as
“mahina the third fluid volume amount of stools, Accurate manifested
siya uminom space, or at a vomiting and records are by the
ng from a functional bleeding. critical in patient’s
tubig.konti reduced fluid level as assessing ability to
lng naiinom intake. One evidenced the patient’s maintain
niya”. common by: fluid adequate
source of individually 2. Monitor for balance. fluid volume
Objective fluid loss is adequate neurologic and as evidenced
data: nausea and fluid volume neuromuscular 2. Potassium by:
(+)dry lips vomiting, and manifestations of is vital
(+)dry skin bleeding and electrolyte hypokalemia electrolyte > patient
(+)weakness excessive balance as (e.g., muscle for skeletal was relaxed
(+)pale urination. In evidenced weakness, and smooth
conjunctiva Dengue by urine lethargy, altered muscle >Maintained
(+)pale nail Hemorrhagic output level of activity. good skin
beds Fever signs greater than consciousness). turgor 2
and 30 ml/hr, seconds
symptoms stable vital 3. Monito vital
that could signs, moist signs. >Maintained
manifest are mucous normal
vomiting and membranes, capillary
frequent good skin 3. Vital signs refill 2
bleeding turgor and changes seconds
from balance such as
gastrointesti intake and increased >had moist
nal tract in output. heart rate, mucous
the form of decreased membrane
hematemesis blood
or melena pressure, >Urine
that may and output of 30-
lead to fluid increased 40 cc per
loss. temperature hour
indicate
hypovolemia >Stable vital
. signs: