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    Assessment NSG Diagnosis Goal Intervention Implementation Evaluation

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    Michelle Erika
    The patient presented with increased bowel movements, dry skin and mouth, increased intestinal activity, fatigue and weakness. Vital signs showed elevated temperature and pulse. The nursing diagnosis was acute dehydration due to increased temperature and sweating. Goals were for normal urine output and bowel movements and improved objective symptoms after 8 hours. Interventions included obtaining history, monitoring weight, intake and output, vital signs, skin turgor and mucous membranes. Fluid intake was increased and symptoms improved with interventions.

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    Assessment NSG Diagnosis Goal Intervention Implementation Evaluation

    Uploaded by

    Michelle Erika
    85 views2 pages
    The patient presented with increased bowel movements, dry skin and mouth, increased intestinal activity, fatigue and weakness. Vital signs showed elevated temperature and pulse. The nursing diagnosis was acute dehydration due to increased temperature and sweating. Goals were for normal urine output and bowel movements and improved objective symptoms after 8 hours. Interventions included obtaining history, monitoring weight, intake and output, vital signs, skin turgor and mucous membranes. Fluid intake was increased and symptoms improved with interventions.

    Original Description:

    Leadership and management

    Original Title

    DELIV 6 LM

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    The patient presented with increased bowel movements, dry skin and mouth, increased intestinal activity, fatigue and weakness. Vital signs showed elevated temperature and pulse. The nursing diagnosis was acute dehydration due to increased temperature and sweating. Goals were for normal urine output and bowel movements and improved objective symptoms after 8 hours. Interventions included obtaining history, monitoring weight, intake and output, vital signs, skin turgor and mucous membranes. Fluid intake was increased and symptoms improved with interventions.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    85 views2 pages

    Assessment NSG Diagnosis Goal Intervention Implementation Evaluation

    Uploaded by

    Michelle Erika
    The patient presented with increased bowel movements, dry skin and mouth, increased intestinal activity, fatigue and weakness. Vital signs showed elevated temperature and pulse. The nursing diagnosis was acute dehydration due to increased temperature and sweating. Goals were for normal urine output and bowel movements and improved objective symptoms after 8 hours. Interventions included obtaining history, monitoring weight, intake and output, vital signs, skin turgor and mucous membranes. Fluid intake was increased and symptoms improved with interventions.

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    ASSESSMENT

    Subjective:
    Mas madalas akong
    tumae ngayon kaysa
    nung kahapon, as
    verbalized by the patient.
    Obejective:
    Dry Skin
    Dry mouth
    Increased Peristalsis
    Fatigue and Weakness
    V/S taken:
    Bp: 110/90
    T: 39.4C
    P: 80
    R: 20

    NSG DIAGNOSIS
    Acute Dehydration due
    to due to the increased
    body temperature and
    sweating

    GOAL
    After 8 hours of
    nursing
    intervention:
    Patient will report
    normal urine
    output
    Patient will report
    normal bowel
    movements
    Patient will
    improve in the
    objective cues

    INTERVENTION
    (i) Obtain patient history to ascertain
    the probable cause of the fluid
    disturbance,
    Which can help to guide
    interventions. This may
    include acute trauma and
    bleeding, reduced fluid intake
    from changes in cognition,
    large amount of drainage
    postsurgery, or persistent
    diarrhea.
    (i) Assess or instruct patient to monitor
    weight daily and consistently, with
    same scale, and preferably at the same
    time of day
    To facilitate accurate
    measurement and follow
    trends.
    (i) Evaluate fluid status in relation to
    dietary intake. Determine if patient has
    been on a fluid restriction.
    Most fluid enters the body
    through drinking, water in
    foods, and water formed by
    oxidation of foods.
    (i) Monitor and document vital signs.
    Sinus tachycardia may occur
    with hypovolemia to maintain
    an effective cardiac output.
    Usually the pulse is weak, and
    may be irregular if electrolyte
    imbalance also occurs.
    Hypotension is evident in
    hypovolemia.
    (i) Monitor blood pressure for
    orthostatic changes (from patient lying
    supine to high Fowler's).
    Note the following orthostatic
    hypotension significance:

    Greater than 10 mm Hg drop:


    circulating blood volume is
    decreased by 20%.

    IMPLEMENTATION
    Ontained Patient
    history.
    Assessed and
    monitored
    patients
    weight, intake
    and output,
    vital signs
    Assessed skin
    turgor
    Encouraged
    patient to
    increased fluid
    intake

    EVALUATION
    After nursing
    interventions,
    patient reported
    normal intake and
    output, increased
    fluid intake and
    normal skin turgor.
    Patient also is
    afebrile and
    demonstrated
    regain of energy.

    Greater than 20-30 mm Hg


    drop: circulating blood volume
    is decreased by 40%.

    (i) Assess skin turgor and mucous


    membranes for signs of dehydration.
    The skin in elderly patients
    loses its elasticity; therefore
    skin turgor should be
    assessed over the sternum or
    on the inner thighs.
    Longitudinal furrows may be
    noted along the tongue.
    (i) Assess color and amount of urine.
    Report urine output less than 30 ml per
    hr for 2 consecutive hours.
    Concentrated urine denotes
    fluid deficit.
    (i) Monitor temperature.
    Febrile states decrease body
    fluids through perspiration and
    increased respiration.
    (i) Monitor active fluid loss from wound
    drainage, tubes, diarrhea, bleeding, and
    vomiting; maintain accurate input and
    output.
    (c) Monitor serum electrolytes and urine
    osmolality and report abnormal values.
    Elevated hemoglobin and
    elevated blood urea nitrogen
    (BUN) suggest fluid deficit.
    Urine-specific gravity is
    likewise increased.
    (i) Document baseline mental status
    and record during each nursing shift.
    Dehydration can alter mental
    status.

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