FLUID/HYDRATION PROBLEMS

DATE

TIME

SHIFT 6-2

FOCUS Nausea related to disease process

D-ata

A-ction

R-esponse

5/4/12 0900 0915 0945 1000

6-2

Fluid Volume Deficit related to nausea and vomitting

1010

1300 1400 Fluid Volume Excess related to congestive heart failure

1410

2200

D: Pt. states she's nauseated. Vomited 100ml clear fluid A: Given __________ IV . R: Pt. reports no further nausea . No further vomiting. D: weightloss of 3 lbs in 1 day, intake of 550ml in 24 hours; urine output of 800ml/24h;emesis 240ml x3 A: Maintained IV fluids; encouraged small frequent fluid intake (400ml over 2-3 hours); placed the client in upright position; requested and administered antiemetic drug as prescribed by physician. R: Pt. reports no further nausea . No further vomiting. D: Maglisud ko ug ginhawa as verbalized by client; S3 heart sounds,restlessness/ anxiety,jugular vein distention noted; A:positioned bed to semi-fowlers position; administered O2 as ordered;limit fluid intake to 800ml / day;administered diuretics as ordered R: ct reports of ease in breathing, decrease anxiety noted