Assessment Nursing Planning Intervention Rationale Evaluation
diagnosis
Fluid Status
Subjective Risk for Goal: Monitor Monitor Improvemen
Data: Fluid Intake and Intake and t:
Volume ● The Output (I&O) Output (I&O)
● Patien Deficit patien ● Expe
t related to t will ● Interv cted
report vomiting and maint entio Outco
s decreased ain n: ● Ratio me:
nause oral intake as adequ Docu nale: The
a, evidenced by ate ment Monit patien
vomiti dry mucous fluid and oring t will
ng, membranes, balan track I&O demo
and decreased ce all provid nstrat
inabilit urine output, and fluid es e
y to decreased avoid intake essen impro
keep skin turgor, further (oral tial ved
food and patient fluid and data hydrat
or complaints of deficit IV) on the ion,
fluids dizziness and by the and patien as
down weakness. end of output t's evide
for the the (urine, fluid nced
last shift emesi balan by
24 (or s, ce, moist
hours. within diarrh helpin muco
● Compl the ea). g to us
aints desig identif memb
of nated Administer y ranes,
dizzin timefr prescribed early impro
ess, ame IV fluids as signs ved
dry for needed. of skin
mouth recov dehyd turgor
, and ery). ● Interv ration (no
feelin entio or tentin
g Outcomes: n: fluid g),
weak. Admin overlo and
1. The ister ad. absen
Objective patien isotoni ce of
Data: t will c IV Administer dizzin
have fluids prescribed ess.
● Vital impro such IV fluids as ● Evalu
signs: ved as needed. ation:
Elevat hydrat norma Check
ed ion l ● Ratio for
heart status saline nale: impro
rate , as (0.9% IV ved
(tachy evide NaCl) fluids skin
turgor
cardia nced or help (no
), by lactat to tentin
hypot moist ed restor g),
ensio muco Ringe e lost moist
n us r’s fluids muco
(e.g., memb solutio and us
BP ranes, n electr memb
90/60) impro based olytes, ranes,
, and ved on the especi and
tachy skin health ally in decre
pnea. turgor, care cases ased
● Dry and provid where report
muco an er’s oral s of
us absen orders intake dizzin
memb ce of . is ess or
ranes dizzin Adjust insuffi weakn
and ess. the cient ess.
dry 2. The rate or
tongu patien accor vomiti Vital Signs
e. t will ding ng Stabilization:
● Decre exhibit to the preve
ased stable patien nts ● Expe
urine vital t's absor cted
output signs needs ption. Outco
(e.g., (norm (e.g., Isoton me:
< 30 al bolus ic Blood
mL/hr) blood for fluids press
. press acute are ure
● Skin ure deficit prefer will
turgor: and or red to stabili
Decre heart maint preve ze
ased, rate). enanc nt within
with 3. The e further the
tentin patien fluids) compli patien
g on t will . cation t’s
the demo s in norma
forear nstrat Monitor vital electr l
m. e an signs olyte range
● Sunke adequ regularly balan (e.g.,
n ate (especially ce. 120/8
eyes urine blood 0
and output pressure, Monitor vital mmH
dry, of at heart rate, signs g),
flaky least and regularly and
skin. 30 temperature) (especially pulse
● Weigh mL/hr, . blood rate
t loss with pressure, will
since urine ● Interv heart rate, return
admis beco entio and to
sion ming
(e.g., less n: temperature) norma
3-4 conce Check . l (e.g.,
pound ntrate vital 60-
s over d. signs ● 100
24 4. The every ● Ratio bpm).
hours) patien 4 nale: ● Evalu
. t will hours Tachy ation:
● Capill verbal or as cardia Asses
ary ize indicat and s vital
refill > under ed by hypot signs
3 standi patien ensio at
secon ng of t n are regula
ds. the status classi r
import . c interv
ance Focus indicat als.
of on ors of Stable
fluid tracki fluid blood
intake ng deficit, press
and blood and ure
the press close and
risks ure monit pulse
of (for oring rate
dehyd signs helps will
ration. of in indicat
hypot early ea
ensio detect positiv
n) and ion of e
pulse worse respo
rate ning nse to
(for dehyd treatm
tachyc ration ent.
ardia). or
comp Urine Output
Encourage ensat Improvemen
small, ory t:
frequent mech
sips of oral anism ● Expe
fluids if s. cted
tolerated. Outco
Encourage me:
● Interv small, The
entio frequent patien
n: sips of oral t will
Offer fluids if maint
clear tolerated. ain a
fluids urine
in ● output
small ● Ratio of at
amou nale: least
Small,
nts freque 30
(e.g., nt sips mL/hr,
5-10 of and
mL liquid urine
every are will
5-10 better appea
minut tolerat r
es), ed lighter
such and in
as help color
water, preve (less
clear nt conce
broths further ntrate
, or vomiti d).
oral ng ● Evalu
rehydr while ation:
ation rehydr Monit
solutio ating or
ns the urine
(ORS) patien output
. t. Oral to
rehydr ensur
Administer ation e it
antiemetics solutio return
as ns s to a
prescribed. can norma
replac l rate
● Interv e and is
entio electr less
n: olytes conce
Admin lost ntrate
ister during d
antie vomiti (indic
metic ng. ative
medic of
ations Administer adequ
(e.g., antiemetics ate
ondan as hydrat
setron prescribed. ion).
,
metoc ● Symptom
lopra ● Ratio Resolution:
mide) nale:
as Anti- ● Expe
prescr nause cted
ibed a Outco
by the medic me:
physic ations The
ian to help patien
preve
contro nt t will
l further report
nause vomiti a
a and ng, decre
vomiti which ase in
ng. reduc sympt
● Asses es oms
s skin fluid of
turgor loss dehyd
and and ration,
muco allows such
us the as dry
memb patien mouth
ranes t to ,
for keep dizzin
signs fluids ess,
of down, and
dehyd thus weakn
ration. impro ess.
ving ● Evalu
Intervention: hydrat ation:
Perform ion. Asses
regular s the
assessments Assess skin patien
of skin turgor, turgor and t’s
mucous mucous subjec
membranes, membranes tive
and overall for signs of sympt
appearance. dehydration. oms.
Check for dry A
or cracked ● decre
lips and a dry ● Ratio ase in
tongue. nale: dehyd
These ration-
Encourage are relate
rest and import d
minimize ant sympt
stimuli that clinica oms
may induce l signs sugge
further of sts
nausea. dehyd effecti
ration. ve
● Interv Early fluid
entio recog replen
n: nition ishme
Creat of nt.
ea these
calm, sympt Patient
quiet oms Education:
allows
enviro for ● Expe
nment timely cted
for the interv Outco
patien ention me:
t and to The
encou preve patien
rage nt t will
rest. more verbal
Avoid sever ize
strong e fluid under
odors imbal standi
or ance. ng of
stimuli the
that Encourage import
might rest and ance
provo minimize of
ke stimuli that fluid
nause may induce intake
a. further and
nausea. recog
nize
● early
● Ratio signs
nale: of
Rest dehyd
reduc ration.
es the ● Evalu
metab ation:
olic Asses
dema s the
nd on patien
the t's
body under
and standi
helps ng
impro throug
ve h
overal verbal
l feedb
comfo ack
rt. and
Minimi ensur
zing e they
nause know
a how
trigger to
s aids mana
in fluid ge
intake fluid
and intake
reduc at
es home.
further
vomiti
ng.
