NURSING

DIAGNOSIS

CUES
SUBJECTIVE
>Sobrang
dalas
ng pag-ihi ko as
verbalized by the
patient.
OBJECTIVE
>Diluted urine,
color is yellow
>Thirsty most of
the time, takes
frequent sips of
water
>Dry
lips
cracks noted

with

>Vital
Signs
as
follows:
T - 38C
P 110 bpm
R 25 cpm
BP 140/80
mmHg

FLUID VOLUME
DEFICIT related to
osmotic diuresis
secondary to
increased blood
glucose levels

GOAL
Within 8 hours of
rendering
holistic
nursing care, the
patient will :
>Achieve/Demonstr
ate
adequate
hydration
as
evidenced by stable
V/S and increased
intake of fluid.

NURSING INTERVENTIONS

RATIONALE

EVALUATION

INDEPENDENT
1. Obtain history of illness
2. Monitor BP changes
3. Assess peripheral pulses,
capillary refill, skin turgor and
mucous membranes.
4. Monitor I & O, calculate 24-hour
fluid balance, weight daily and
monitor urine specific gravity.
5. Provide frequent TSB.

1. Assist estimation of total

volume depletion.
Symptoms may have been
present for varying amounts
of time.
2. Hypovolemia is manifested
by hypotension along with
tachycardia and tachypnea;
estimates of the severity the
hypovolemia may be made
when BP drops more than
10mmHg

6. Discourage intake of alcoholic

and caffeinated beverages.

3. Indicators of level of DHN,

and
circulating
volume
adequacy

7. Provide frequent oral care and

eye care.

4. Provides ongoing estimate of

volume replacement needs,
kidney.

8. Promote patient safety.

9. Keep fluids within clients reach
and encourage frequent intake
not less than 1500 ml/day.

5. TSB promotes skin moisture

and prevents dryness. Also
promotes comfort of patient.
6. Alcohol and caffeine exert a
diuretic effect increasing
fluid loss.
7. Fluid

losses

from

body,

Within 8 hours of
rendering
holistic
nursing
care,
the
patient achieved and
demonstrated
evidences
of
adequate hydration
and stable vital signs:
( with moist lips and
minimal moisture on
skin; vital signs as
follows:
T 37.4 C
P 85 bpm
R 21 cpm
BP 120/80
mmHg

COLLABORATIVE
1. Do IV follow-ups, as ordered.

decreases the skin and

mucosal moisture thereby
rendering
the
area
susceptible to injury.

2. Administer medications as
indicated.
3. Monitor and regulate IVF as
ordered
.
4. Monitor lab studies, e.g. Hct;
BUN/Cr; Serum osmolality;
Sodium; Potassium;

8. Patients manifest symptoms

of decreasing LOC with fluid
loss
making
patient
susceptible to accidents.
9. Encouraging patient to
rehydrate maintains fluid
balance and replaces fluid
loss from present condition.
COLLABORATIVE
1. IV therapy promotes
rehydration and restores
fluid balance.
2. Insulin injection promotes
utilization of glucose to cells.
3. This is to prevent over
infusion and under infusion
of patient; IVF therapy
replaces
fluids
and
electrolyte losses.

Assesses level of hydration and is

often
elevated
because
of
hemoconcentration that occurs

after osmotic diuresis.

Elevated
values
may
reflect
cellular
breakdown
from
dehydration or signal the onset of
renal failure.
Elevated due to hyperglycemia and
dehydration.