San Beda College College of Nursing Avila, Danica Rose B.

ASSESSMENT
Subjective: parang pakiramdam ko palagi akong uhaw as verbalized by the patient. Objective: Increased urine output Decreased skin turgor Decreased pulse rate V/S taken as follows: T: 36 C BP: 120/80 PR: 64 RR: 18 Deficient fluid volume r/t After 8 hours of nursing decreased intake of Interventions, the patient isotonic fluid. will maintain fluid volume at a functional level as evidenced by individually adequate urinary output, stable vital signs, and good skin turgor.

DIAGNOSIS

PLANNING

INTERVENTION
Independent: Note possible conditions/ Processes that may lead to deficits: fluid loss, limited intake, fluid shifts, environmental factors. Assess vital signs, including temperature (often elevated), pulse (may be elevated), and respirations. Note strength of peripheral Pulses.

RATIONALE

EVALUTAION

To assess causative/ precipitating factors.

To evaluate degree of Fluid deficit.

After 8 hours of nursing Interventions the patient was able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output, stable vital signs, and good skin turgor.

To correct/replace fluid limit intake of alcohol/ losses to reserve caffeinated beverages that tend pathophysiological to exert a diuretic effect. mechanisms.

Collaborative: Administer or discontinue To promote comfort medications, as indicated when and safety. disease process or medications are contributing to dehydration, as prescribed by the physician. Review/instruct in To promote wellness Medication regimen and (Teaching/Discharge administration and interactions Considerations) /side effects.

ASSESSMENT
Subjective: kung tuluyan ko lang tinigilan yung paginom ko edi sana hindi na ako ulit na confine dito sa hospital Objective: Behavioral: poor eye contact, restlesness Sympathetic:, increased blood pressure Parasympathetic: urinary urgency, decreased pulse

DIAGNOSIS

PLANNING

INTERVENTION Independent:

RATIONALE

EVALUATION

Anxiety specify level: mild r/t exposure to toxins

After 8 hours of nursing interventions, the patient will verbalized awareness of feelings of anxiety and identify healthy ways to deal with and express anxiety.

Monitor vital signs(e.g., rapid or irregular pulse, rapid breathing/hyperventilation, changes in blood pressure, diaphoresis, tremors, or restlessness) Observe behaviors, which can point to the patients level of anxiety: MILD- alert; more aware of environment; restless; irritable; wakeful; Be available to patients for listening and talking. Assist patient to identify precipitating factors and new methods of coping with disabling anxiety. Collaborative: Determine current prescribed medications and recent drug history of prescribed or OTC medications (e.g., steroids, thyroid preparations, weight loss pills, or caffeine). Review medication regimen and possible interactions, especially with over-the-counter drugs/alcohol. Discuss appropriate drug substitutions, changes in dosage, or time of dose

To indentify physical
responses associated with both medical and emotional conditions.

After 8 hours of nursing interventions, the patient was able to verbalized awareness of feelings of anxiety and identifies healthy ways to deal with and express anxiety.

To assess level of anxiety.

To assist client to identify feelings and begin to deal with problems. To promote wellness (Teaching/Discharge Considerations).

To assess level of anxiety.

To minimize side effects.