AssessmentExplanation of problemObjectivesInterventionsRationaleEvaluation

S>Hindi ako umiinom ng tubid

O> -200 mL consumed of water since morning

-Weak in appearance

-Dry skin and lips

-Poor skin turgor

-Capillary refill of 3 seconds

-BP: 80/60

Diagnosis: Deficient fluid volume related to Inadequate fluid intake

Prior to admission, patient experienced having a fever for 3 days. He was admitted on this 3rd day. In the shift, the patient stated that he doesnt drink water. The normal range per day is 2000 ml. In half a day he only consumed 200ml. STO:Within 8 hours of nursing interventions, the patient will be able to consume 500ml to 1000ml of drinking water

LTO:Within 2-3 days of nursing interventions, the patient will be able to Consume 2000ml of water per day (24 hour period)Assess fluid intake

Note some signs of dehydration

Keep drinking water available within reach

Assist in changing position

Advise to drink water up to 2000mL a day

Encourage to always have available drinking water supply

Encourage to add fruits and vegetables in dietMost fluid enters the body through drinking, water in foods, and water formed by oxidation of food

Signs of dehydration is a indication for deficient fluid volume

To promote drinking water more accessible

Changing position reduces pressure on dry skin

Water replacement is important to promote hydration

To promote the replacement of loss fluids

Selective fruits and vegetables have electrolyte needed in process of fluid replacementSTO:

Within 8 hours, goal was met. Patient was able to consume 850 ml of drinking water

LTO:

DrugMode of ActionIndicationContraindicationsSide effectsNursing management

Generic Name:Paracetamol, Acetaminophen

Brand Name: Biogesic, Panadol, Tylenol

Classification: Non-narcotic analgesic, Antipyretic

Dosage: