Situation:

Rosalka Kuba, a 30 years old mother of 2 was admitted last August 9, 2010 with a chief complaint of Epigastric pain. She was
diagnosed to have Acute Gastroenteritis ( AGE ). Today, August 12, 2010, you have assessed the patient with the following data:
Sunken eyeballs, poor skin turgor, BP: 170/100, PR: 82 bpm, RR: 40 bpm, and T: 36.7°C. The patient verbalizes pain the scale of
8/10.

CUES NURSING SCIENTIFIC PLANNING NUSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOMES°

S: “ Kanina pa Deficient Fluid Volume After 8° of • Monitor and • Tachycardia, After 8° of

ako dumudumi Volume related depletion, or Nursing record vital dypnea, or Nursing
ng malambot na to active fluid extracellular Interventions, signs q 2° or hypotension Interventions,
malambot.” volume loss. fluid (ECF) the patient fluid as often as may indicate the patient’s
volume and blood necessary fluid volume fluid and blood
contraction, volume will until stable. deficit or volume return to
O: occurs as a return to Then monitor electrolyte normal as
( + ) sunken result of loss of normal. and record imbalance. evidenced by
eyeballs. total body vital signs q stable vital
( + ) poor skin sodium. Causes 4°. signs.
turgor. include vomiting,
Pain scale of excessive • Measure • Low urine
8/10 sweating, intake and output and
V/S as follows: diarrhea, burns, output q 4°. high specific
BP: diuretic use, and Record and gravity
170/100mmHg kidney failure. report indicates
PR: 82 bpm Clinical features significant hyovolemia.
RR: 40 bpm, include changes.
and diminished skin Include urine,
T: 36.7°C turgor, dry and stools.
mucous
membranes, • Administer • To replace
tachycardia, and fluids, blood, fluids and
orthostatic or blood whole blood
hypotension. products, or loss and
plasma facilitate fluid
expanders. movement
into
intravascular
space.

• Assess skin • To check for

turgor and dehydration.
oral mucous
membranes q
4°.

• Give • To avoid
oral/mouth dehydrating
care q 4° mucous
membranes

• Don’t allow • To avoid

patient to sit orthostatic
or stand up hypotension
quickly as and possible
long as syncope.
circulation is
compromise.

• Administer • To prevent
and monitor further fluid
medications. loss.