K00IfK0 C0I LK

Nursing Diagnosis Nursing Goals Nursing Interventions Rationale Implementation Evaluation

Subjective:
'Madalas akong
mauhaw at medyo nanghihina
pa ako, as verbalized by the
patient.

Objective:
O ! 90/60
O % 36.0SC
O ! 81 bpm
O # 20 bpm
O !allor
O !oor skin turgor
O ry lips
O ry skin

Nursing iagnosis:
O eIicient Iluid
volume r/t loss oI
Iluid through
abnormal route
(Upper
Gasstrointestinal
leeding).



Within 8 hours oI nursing
intervention, the patient will
maintain Iluid volume at
Iunctional level as evidenced
by moist mucous membrane
and good skin turgor.

1. Maintain accurate record
oI intake and output.



2. !erIorm Irequent oral
hygiene.

3. Encourage Iluid intake and
promote intake oI high
water content Ioods.

4. Limit Iluids that tends to
exert a diuretic eIIect. (ex.
CoIIee)

5. Administer intravenous
Iluid as prescribed.

1. !rovide inIormation about
Iluid status and
replacement need.


2. ecrease dryness oI oral
mucous membrane.

3. #elieves thirst and
discomIort oI dry mucous
membrane.

4. %o prevent Iurther Iluid
loss.


5. %o deliver Iluids
accurately at desired rates.

#eIerences:
Nurse`s !ocket Guide
(iagnosis, !rioritized
Interventions, And
#ationales) pp. 320-326

AIter 8 hours oI nursing
interventions, the patient
maintained Iluid volume at
Iunctional level as evidenced
by moist mucous membrane
and good skin turgor.