ASSESSMENT

Subjective
>Client reports dryness of
her oral mucosa
Objective
>Vital signs
T:35.4
PR:60
RR:22
BP:100/60
>pale conjunctiva

PLANNING
Short-term goal

INTERVENTION
RATIONALE
Independent
>Assess for the signs of
>To determine the cause
At the end of this shift, the dehydration including skin of pharyngeal pain. This
client exhibit signs of
turgor, oral mucosa, etc.
will provide a data that
improvement in hydration
could be used to evaluate
status.
the proper intervention
that the client needs.

EVALUATION
After doing the necessary
nursing interventions and
teachings, the client:

>Review ways to improve

the clients hydration
status

>normal appetite
>has intermittent fever

>Ensure that the client is

receiving right amount of
maintenance fluids.

>decreased skin turgor

>normal capillary refill
time
>elevated WBC count

>Provide comfort
measures

>Achieved appropriate
urine output

>Encourage the client to

increase the fluid intake.

>To reduce the dryness of

the oral mucosa

>Participated in health
teaching

>Monitor I & O and IV

fluids

>To determine if IV fluid

and electrolyte
replacement are needed

>Followed the prescribed

pharmacological regimen.

>Keep a quiet
environment and calm
activities.

>To reduce stress and

anxiety

>Provide health teachings

on avoidance of
dehydration

>To promote awareness on

related factors

>Demonstrated use of
relaxation skills to reduce
anxiety

PRIORITY #2: Deficient knowledge (Learning need) regarding electrolyte imbalance as evidenced by verbalization of
questions and concerns.
ASSESSMENT
PLANNING
INTERVENTION
RATIONALE
EVALUATION
Subjective:
Short term goal:
>Assess level of
>Some clients may need
>Client responded to the
>Verbalization of
>Assist client to use given knowledge of the client.
the help of SO or
learning plan and actions
questions:
information in all
caregivers to learn.
performed.
Ano bang causes ng
applicable areas including
dehydration at
environmental causes
>Determine the clients
>Client might not be
gastroenteritis?
readiness and barriers to
physically or emotionally >Client provided a
>Provide information and learning.
capable at this time.
positive feedback and
self-learning modules
adherence to the teaching.
Objective:
regarding her disease
>Identify support persons. >Reinforcement learning
>Vital signs
(e.g. mother, other family process allows the client to
T:35.4
members)
proceed at her own pace.
>Client was able to deal
PR:60
>Give information
with her anxiety.
RR:22
accurately and clearly.
BP:100/60
>Teach the client to cease >To give awareness on the
alcohol consumption
possible complications of
>Inaccurate understanding
because of the possible
having vices
of her disease
complications.
(pathophysiology)
>Begin with the info the
>Can arouse interest/limit
client already know and
sense of being
move to what she does not overwhelmed.
know, progressing from
simple to complex.