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Nursing Management: Assessment Nursing Diagnosis Planning Intervention Evaluation

Watcher reported patient had LBM for a week 4 times daily with loose, watery, greenish stool. At the end of 3 days of nursing care and intervention the patient was able to: maintain fluid volume at functional level as evidenced by adequate urinary output.

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Sunshine Jaranilla
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57 views2 pages

Nursing Management: Assessment Nursing Diagnosis Planning Intervention Evaluation

Watcher reported patient had LBM for a week 4 times daily with loose, watery, greenish stool. At the end of 3 days of nursing care and intervention the patient was able to: maintain fluid volume at functional level as evidenced by adequate urinary output.

Uploaded by

Sunshine Jaranilla
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

NURSING MANAGEMENT

ASSESSMENT
SUBJECTIVE: Watcher reported patient had LBM for a week 4 times daily with loose, watery, greenish stool.

NURSING DIAGNOSIS
Deficient fluid volume related to active fluid volume loss secondary to prolonged diarrhea as evidenced by passage of loose watery stool 4x/day.

PLANNING
At the end 3days of nursing care and intervention the patient will be able to: maintain fluid volume at functional level as evidenced by adequate urinary output

INTERVENTION
INDEPENDENT: Instruct SO to Increase patients Fluid intake To replace any fluid loss and maintain circulation. Note change in usual behavior or functional abilities. These signs indicate sufficient dehydration to cause poor cerebral perfusion or electrolyte imbalance. Monitor I and O To more accurately determine fluid replacement needs. Instruct watcher not to offer carbonated drinks These exerts osmotic diuresis. DEPENDENT: Administer D5 IMB @ 20cc/hr as ordered: For balanced multiple maintenance solution, given by IV to prevent loss of electrolytes and dehydration.

EVALUATION
Goal met. At the end of 3 days of nursing care and intervention the patient was able to: Maintain fluid volume at functional level as evidenced by adequate urinary output as evidenced by: 800cc intake in 24 hrs and with an output of 250cc in 24 hrs on DATE:_ 1.26.12 Passage of semi formed yellowish stool 3x daily on Date: 1.27.12

OBJECTIVE: Increased pulse 139 Restlessness Passage of loose watery stool 4x/day, greenish in color, soft Body malaise, irritability Decreased skin turgor noted Dry lips and oral mucosa noted Platelet- 116 Hematocrit - 26.7

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