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NURSING
CUES GOAL NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE FLUID VOLUME DEFICIT Within 8 hours of INDEPENDENT Within 8 hours of
related to osmotic rendering holistic nursing rendering holistic nursing
>” Sige man ko ug diuresis secondary to care, the patient will : 1. Obtain history of illness 1. Assist estimation of total volume care, the patient achieved
uhawon. Ganahan ko increased blood glucose depletion. Symptoms may have and demonstrated
mo inom ug tubig kay levels >Achieve/Demonstrate been present for varying amounts evidences of adequate
dali ra magmala akong adequate hydration as of time. hydration and stable vital
baba” as verbalized evidenced by stable V/S signs:( with moist lips and
and increased intake of 2. Monitor BP changes 2. Hypovolemia is manifested by minimal moisture on skin;
OBJECTIVE Inference: fluid. hypotension along with tachycardia vital signs as follows:
Increased serum and tachypnea; estimates of the T – 37.4 °C
> Received on bed in glucose levels severity the hypovolemia may be P – 85 bpm
supine position, with an made when BP drops more than R – 21 cpm
ongoing IVF of PLR 1L @ F & E from cells are 10mmHg BP – 110/70 mmHg
900 cc level, regulated pulled by greater
at 40 gtts/min, hooked osmotic power of 3. Assess peripheral pulses, capillary refill, 3. Indicators of level of DHN, and
at right cephalic vein, glucose skin turgor and mucous membranes. circulating volume adequacy
with Foley bag catheter
attachment Cellular dehydration 4. Monitor I & O, calculate 24-hour fluid 4. Provides ongoing estimate of
balance, weight daily and monitor urine volume replacement needs, kidney.
Urinary output of 400- Kidneys excrete specific gravity.
600 cc per shift excess glucose
5. Provide frequent TSB. 5. TSB promotes skin moisture and
>Diluted urine, color is Water is pulled prevents dryness. Also promotes
yellow because of high comfort of patient.
osmotic power of
>Thirsty most of the glucose(osmotic 6. Discourage intake of alcoholic and 6. Alcohol and caffeine exert a diuretic
time, takes frequent sips diuresis) caffeinated beverages. effect increasing fluid loss.
of water
Increased 7. Provide frequent oral care and eye 7. Fluid losses from body, decreases
>Dry lips with cracks urination(polyuria) care. the skin and mucosal moisture
noted thereby rendering the area
susceptible to injury.
>Dry skin with little to
no moisture noted
Poor skin turgor noted
8. Promote patient safety. 8. Patients manifest symptoms of
>Vital Signs as follows: decreasing LOC with fluid loss
T - 38°C making patient susceptible to
P – 110 bpm accidents.
R – 36 cpm
BP – 100/60 mmHg
COLLABORATIVE COLLABORATIVE
4. Monitor and regulate IVF as ordered. 4. This is to prevent over infusion and
under infusion of patient; IVF
therapy replaces fluids and
electrolyte losses.
>Weakness noted
Insufficient insulin leads
>Limited movements to decreased uptake of 5. Increase patient participation in 5. Increases confidence level, self-
noted glucose to cells thereby activities of daily living as tolerated. esteem as well as tolerance level.
causing weakness.
>Lack of interest in 6. Encourage patient to take in adequate 6. Appetite to eat is necessary in
activities noted food and promote appetite. order to provide extra energy and
Presence of infection prevent further fatigue.
triggers the inflammatory
process and the immune 7. Encourage fluid intake of not less than 7. Adequate fluid intake replenishes
>Vital Signs as follows: system to react against 1,500 ml/ day. fluid loss.
T - 38°C the causative agents.
P – 110 bpm Therefore, there is an
R – 36 cpm increase in the metabolic
BP – 100/60 mmHg demands of the body. 8. Promote safety of patient. 8. By assisting patient with
ambulation, the patient’s safety is
promoted preventing any
accidents.
9. Provide health teaching with patient 9. Health teachings increases
regarding condition and how to patient’s awareness and promotes
prevent fatigue. independence.
10. Involve SO with patient care and 10. The SO should be involved with
health teachings. patient care and health teachings
to promote health education and
enabling SO to care for patient in
home-based care.