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ASSESSMENT DIAGNOSIS SCIENTIFIC

BACKGROUND

PLANNING NURSING

INTERVENTION

RATIONALE EVALUATION

Subjective:ilang araw ngngtatae at

nagsusuka anganak ko asverbalized bythe mother

Objective:>dry mucousmembrane>slightly irritable>seen vomitingthe milk>dry skin with

poor turgor>depressedfontanelles

>Vital Signs asfollows:RR: 37cpmPR: 124bpmT: 38.8

Fluid volumedeficit related tofluid loss

A state in whichanindividual is

experiencingvascular,cellular, orintracellulardehydration duetoactive orregulatorylosses of bodywater inexcess of needsor

replacementcapability.

After 12 hoursof renderingnursing

intervention, thepatient will beable to replacelost fluidgradually orevidence by:a. drinking milkwithout vomitingb. patients IVFis adequatelyregulated asordered

c. increaseintake of waterfor 2ml per day

Monitor vitalsigns

Monitor input and

output

Weigh daily andcompare with 24hours fluidbalance

Regulated IVFaccording tospecified flowrate basing on

the doctors order

Provide skin andmouth care

Advise mother orsignificant others

to increased fluidintake of hepatient

Instruct mother topractice propermilk preparationof food handling

Encouragemother to offerbaby withmashed banana

Serve as baselinedata

Fluid replacement

needs are based oncorrection of currentdeficits and ongoinglosses

Measurementprovides useful datafor comparison

Regulation of fluid iscritical inmaintainingadequate circulating

fluids to recover foramount of water lossthrough vomiting

Skin and mucousmembranes are drywith decreasedelasticity because ofvasoconstriction andreduced intracellularwater

To maintain fluidand electrolyte

balance

After 12 hours ofrendering nursingintervention, the

patient replacedfluid loss.

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