.

Fluid Volume deficient

Cues Nursing Scientific Objectives Nursing Rationale Evaluation

Diagnosis Explanations Interventions
S Fluid Volume Because of After series of 1. Maintain - Provides Is there still the
 Deficient related vomiting NI the pt. will accurate record information presence of;
to vomiting excessive losses maintain of I&O, noting about fluid a. vomiting
through normal adequate fluid output less than status/circulating b. dry skin
O routes occur thus volume as Intake, increased volume and c. dry
- (+) pallor causes Fluid evidenced by urine specific replacement mouth
- (+) body Volume moist mucous gravity. Assess needs. d. poor skin
weakness Deficient membranes and skin/mucous turgor
- (+) good skin turgor, membranes, e. body
vomiting peripheral weakness
- with poor pulses, and
skin capillary
turgor refill.
- (+) dry
skin 2. Perform - Decreases
- (+) dry frequent oral dryness of oral
mouth hygiene mucous
membranes;
reduces
risk of oral
bleeding.

3. Provide skin - Skin and

and mouth care mucous
membranes are
dry, with
decreased
 elasticity,
because of
vasoconstriction
and reduced
intracellular
water.
4. Increase fluid - promotes
intake hydration.

5. Ascertain - Relieves thirst

patient’s and discomfort
beverage of dry mucous
preferences, and membranes
set up a 24- and augments
hr schedule for parenteral
fluid intake. replacement.
Encourage foods
with high
fluid content.

6. Administer - Reduces nausea

antiemetics, e.g., and prevents
prochlorperazine vomiting.
(Compazine) as
ordered by the
physician.
Post-operative NCP
3. Knowledge Deficit

Cues Nursing Scientific Objectives Nursing Rationale Evaluation

Diagnosis Explanations Interventions
S Deficient There is this After an hour 1. Provide - Information can - Does the
“pwede bang knowledge presence of of nurse-patient explanations decrease anxiety, patient
maulit ang related to knowledge interaction the of/reasons for test thereby reducing understands
sakit ko” as condition, deficit due to patient will procedures and sympathetic and could
verbalized by prognosis, some Verbalize preparation stimulation. recall all
the patient treatment, unfamiliar understanding needed. the
self-care, and information of disease teachings
discharge that causes process, 2. Review - Provides knowledge given?
O needs some confusion prognosis, and disease base from which - Is there
- Frequently to the client potential process/prognosis. patient can make a significant
asking that needs to be complications. Discuss informed choices. changes
question discussed. hospitalization Effective that occur
about his and prospective communication and on the
condition, treatment as support patients
treatment indicated. at this time can knowledge
and diet Encourage diminish anxiety and regarding;
- With questions, promote healing. a. disease
worried expression of condition
gaze concern. b. diet
c. treatment
- Gallstones often d. medication
3. Review drug recur, necessitating e. self-care
regimen, possible long-term therapy. needs
side effects.

- Prevents/limits
4. Instruct patient recurrence of
to avoid gallbladder attacks.
food/fluids high
in fats (e.g.,
whole milk, ice
cream, butter,
fried foods, nuts,
gravies,
pork), gas
producers (e.g.,
cabbage, beans,
onions,
carbonated
beverages), or
gastric irritants
(e.g., spicy
foods, caffeine,
citrus).
- Promotes gas
5. Suggest patient formation, which can
limit gum increase gastric
chewing, sucking distension/discomfort.
on straw/hard
candy, or
smoking.
 a. Drug Study

Name of Drug Date Route/ Action Indication Adverse Nursing Consideration

Ordered Dosage and Reaction
Frequency
GN: H2Bloc 02-13-06 PO - Anti-ulcer -for short term - headache, 1. Check for doctor’s order
(Pepcidine) 20 mg tab at - competitively treatment of dizziness, 2. not to be given in patients
BN: bedtime inhibits action duodenal ulcer malaise, dry hypersensitive to drugs
Famotidine of histamine on mouth 3. Inform the patient about the
the H2 at possible side effect of the drug
receptor sites of 4. Instruct patient to take drug
parietal cells, with food
decreasing 5. Advised patient to take drug
gastric acid once daily usually at bed time
secretion 6. Advise patient to report
abdominal pain or blood in
stools or is vomiting.

GN: 02-13-06 IV - anti-infective - perioperative - Nausea and 1. Check for doctor’s order
Cefuroxime 750 mg - a 2nd prophylaxis Vomiting 2. Perform ANST prior to
BN: Zinacef every 8o generation admission
prior to OR cephalosporin 3. Should not be given if
(30 to 60 that inhibits positive skin test
minutes cell-wall 4. Slow IV push
before) synthesis, 5. Inform the patient about the
promoting possible side effect of the drug
osmotic 6. Advise patient to report any
instability discomfort on the IV insertion
site