ASSESSMEN
T
DIAGNOSIS PLANNING INTERVENTI
ON
RATIONALE EVALUATIO
N
Objective:
- general
body
weakness
- poor skin
turgor
Risk for
deficient fluid
volume
related to
factors
influencing
fluid needs
(hypermetab
olic state)
After 8
hours of
nursing
intervention
, the patient
will be able
to:
- Identify
individual
risk factors
and
appropriate
intervention
s.
- Maintain
fluid
volume at a
functional
level as
evidenced
by
individually
adequate
urinary
output with
normal
specific
gravity,
stable vital
signs, moist
mucous
membranes
, good skin
turgor, and
prompt
capillary
refill.
-
Demonstrat
e behaviors
Independen
t:
1. Note
client’s level
of
consciousne
ss and
mentation
2. Assess
older
client’s
“hydration
habits”
3. Evaluate
nutritional
status,
noting
current
intake, type
of diet (e.g.,
client is
NPO or is
on a
restricted
diet). Note
problems
(e.g.,
impaired
mentation,
nausea,
fever, facial
injuries,
immobility,
insufficient
time for
intake)
4. Review
patient's
medications
,including
prescription
Independen
t:
1. To
evaluate
ability to
express
needs
2. To
determine
best
approach if
client has
potential
for
dehydration
. Note: A
recent
study
identified
four
categories
of nursing
home
residents:
(1) Can
drink (the
client is
functionally
capable of
consuming
fluids, but
doesn’t for
any number
of rea-
sons), (2)
can’t drink
(frailty or
dysphagia
makes this
cli- ent
incapable of
After 8 hours
of nursing
intervention,
the patient
was able to:
- Identified
individual risk
factors and
appropriate
interventions.
- Maintained
fluid volume
at a
functional
level as
evidenced by
individually
adequate
urinary
output with
normal
specific
gravity, stable
vital signs,
moist mucous
membranes,
good skin
turgor, and
prompt
capillary refill.
-
Demonstrate
d behaviors
or lifestyle
changes to
prevent
development
of fluid
volume
deficit.
