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    Cues Nursing Diagnosis Rationale Planning Nursing Intervention Rationale Evaluation Subjective: Short Term Goal: Short Term Goal

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    kingnath1523
    The patient was admitted to the hospital due to episodes of loose watery stools with particles and moderate abdominal tenderness, weakness, dry lips, and sunken eyes indicating signs of dehydration and malnutrition from fluid loss. The nursing diagnosis was fluid volume deficit related to active fluid loss from diarrhea. The short-term goal was for the patient to restore normal circulating body fluids by the end of the shift through monitoring, assessment, oral care, encouragement of fluid intake, regulation of IV fluids if needed, and comfort measures. The long-term goal was for the patient to maintain optimal fluid balance and hydration after 1 day of care through decreased diarrhea, less abdominal issues, and normalized appearance.

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    Cues Nursing Diagnosis Rationale Planning Nursing Intervention Rationale Evaluation Subjective: Short Term Goal: Short Term Goal

    Uploaded by

    kingnath1523
    1K views2 pages
    The patient was admitted to the hospital due to episodes of loose watery stools with particles and moderate abdominal tenderness, weakness, dry lips, and sunken eyes indicating signs of dehydration and malnutrition from fluid loss. The nursing diagnosis was fluid volume deficit related to active fluid loss from diarrhea. The short-term goal was for the patient to restore normal circulating body fluids by the end of the shift through monitoring, assessment, oral care, encouragement of fluid intake, regulation of IV fluids if needed, and comfort measures. The long-term goal was for the patient to maintain optimal fluid balance and hydration after 1 day of care through decreased diarrhea, less abdominal issues, and normalized appearance.

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    NCP

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    The patient was admitted to the hospital due to episodes of loose watery stools with particles and moderate abdominal tenderness, weakness, dry lips, and sunken eyes indicating signs of dehydration and malnutrition from fluid loss. The nursing diagnosis was fluid volume deficit related to active fluid loss from diarrhea. The short-term goal was for the patient to restore normal circulating body fluids by the end of the shift through monitoring, assessment, oral care, encouragement of fluid intake, regulation of IV fluids if needed, and comfort measures. The long-term goal was for the patient to maintain optimal fluid balance and hydration after 1 day of care through decreased diarrhea, less abdominal issues, and normalized appearance.

    Copyright:

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    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1K views2 pages

    Cues Nursing Diagnosis Rationale Planning Nursing Intervention Rationale Evaluation Subjective: Short Term Goal: Short Term Goal

    Uploaded by

    kingnath1523
    The patient was admitted to the hospital due to episodes of loose watery stools with particles and moderate abdominal tenderness, weakness, dry lips, and sunken eyes indicating signs of dehydration and malnutrition from fluid loss. The nursing diagnosis was fluid volume deficit related to active fluid loss from diarrhea. The short-term goal was for the patient to restore normal circulating body fluids by the end of the shift through monitoring, assessment, oral care, encouragement of fluid intake, regulation of IV fluids if needed, and comfort measures. The long-term goal was for the patient to maintain optimal fluid balance and hydration after 1 day of care through decreased diarrhea, less abdominal issues, and normalized appearance.

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    CUES NURSING RATIONALE PLANNING NURSING RATIONALE EVALUATION

    DIAGNOSIS INTERVENTION
    SUBJECTIVE: Fluid Volume Deficit Pathogens cause SHORT TERM >Establish rapport. >To gain the pt’s trust SHORT TERM GOAL:
    r/t Active fluid tissue damage and GOAL: After 30 minutes of
    Nung bago kami ma- volume loss AEB inflammation by After the shift, the rendered care, the
    admit dito sa episodes of loose releasing endotoxins patient will be able >Monitor v.s. >To obtain baseline patient had restored
    hospital, sumusuka watery stools that stimulate the to restore its data his body’s circulating
    siya ng 3 beses at mucosal lining of the normal circulating fluids.
    dumudumi ng intestine resulting body fluids >Assess & monitor the >To determine the
    madami. in the greater I&O extent of dehydration
    secretion of water LONG TERM LONG TERM GOAL:
    OBJECTIVE: and electrolytes GOAL: After 1 day of
    into the intestinal After 1 day of >Assess the level of >To determine the rendered nursing care,
    > episodes of loose lumen. The active rendering nursing dehydration extent of dehydration the patient had
    watery with secretions of care, the patient maintained optimum
    particles stool, chloride and will able to normal circulating
    moderate in amount bicarbonate ions are reestablish and >Give oral care >To clean the mouth & body fluids as
    and scanty. the small bowel maintain body fluids avoid further drying evidence by negative
    leads to the as will be of the lips BM per shift, lips are
    > tenderness of the inhibition of sodium manifested by no longer dry, no
    stomach re-absorption. To decrease BM per > Provide comfort >To prevent stress and tenderness of
    balance the excess shift, lips are no measures anxiety that may stomach, intestinal
    >weak in appearance sodium, large longer dry, no induce peristalsis colic is decrease and
    amounts of protein intestinal colic and eye is no longer sunken
    >dry lips rich foods fluids are no tenderness of >Encourage fluid > To replace loss of
    secreted in the the stomach, and intake water and for
    > eyes are slightly bowel’s ability to eye is not sunken. rehydration
    sunken and teary reabsorb the fluid
    and leading to
    >c o2 inhalation via diarrhea. >Proper regulation of >Maintain hydration
    facemask regulated IVF and electrolyte
    at 4-5L balance

    >c signs of
    malnutrition

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