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ASSESSMEN NURSING ANALYSIS GOALS AND NURSING RATIONALE EVALUATION

T DIAGNOSIS OBJECTIVES INTERVENTIONS


Goal:
Subjective: Deficient After the nursing After the
“Bigla akong fluid volume interventions, the nursing
nanghina related to client will be able interventions,
bago ako diarrhea to maintain fluid the client was
dalhin sa volume at a able to
ospital. Akala functional level maintain fluid
ko as evidenced by volume at a
matutuluyan individually functional
na ako.” The adequate urinary level as
client output with evidenced by
verbalized. normal individually
specific gravity, adequate
Objective: stable vital signs, urinary output
 Low blood moist mucous with normal
pressure: membranes, specific
- 90/60 good skin turgor, gravity, stable
mmHg and prompt vital signs,
 Altered capillary refill. moist mucous
Serum • Note possible • To determine membranes,
sodium: Objectives: conditions/ process the underlying good skin
- low: 1. Assess that may lead to cause of the turgor, and
136.00 causative/ deficits disorder prompt
mmol/L precipitating capillary refill.
factors • Determine effects • Very young and
of age extremely elderly
individuals are
quickly affected
by fluid volume
deficit, and are
least able to
express need

• Evaluate nutritional • To determine


status, noting current the current of
intake, weight status of the
changes, problems client
with oral intake, use of
supplement/tube
feedings

• Assess vital signs • To provide


2. Evaluate baseline data with
degree of fluid regards to the
deficit current status of
the client.
• Note change in usual
mentation/ behavior/ • These signs
functional abilities indicate sufficient
dehydration to