What could be the problem?

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Abdominal pain
Altered nutrition (Malnutrition)
Cramps
Nausea
Family dynamics
Vomit
Hemorrhoids
Risk for dehydration
Risk for electrolyte imbalance
UTI
Frequent drinking
Smoking
Loose, dark stool.
High BP

NANDA
Impaired urinary elimination r/t urinary tract infection AEB difficulty and
discomfort urinating.
Risk for electrolyte imbalance r/t vomiting AEB vomiting for 2 days.
Nausea r/t pain AEB patient complains of abdominal pain 9/10
Deficient Fluid Volume related to active fluid loss as evidenced by vomiting
for 2 days.

What would you assess?

Assess skin turgor, mucous membranes and complaints of thirst.
Assess for signs and symptoms of UTI
Assess fluid intake and output.
Assess Vital signs (main focus pain)
Assess BUN/ creatine ratio (Normal ratio is 10:1 to 15:1. Ratios greater than
20:1 are associated with dehydration.)
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Assess for pain (numbered pain scale)
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Assess food intake (24 hour diet recall)
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Monitor input and output characteristics of the urine and stool
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Assess neurological status.(altered sodium levels)
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Assess the patient's voiding patterns
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What would you do?

Review laboratory results for abnormal findings.
Monitor laboratory tests: electrolytes, creatinine, WBC.

Consult nutritionist and nephrologist.

Administer antibiotics as ordered by physician.
Evaluate time intervals between voidings and and bowel movement and
record it.
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Establish a therapeutic relationship.
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Ask physician for hemocult test.

Week # 11
Student: Yarylenn Mayor
Plan of Care
Mr. P.R
Nursing Diagnosis (Nanda r/t): Deficient Fluid Volume related to active fluid loss
As evidence by (Supporting Data-Patient/ Family, Vitals, Labs/Result, Assessment):
Objective: Pt vomiting for 2 days
Short Term Goal: Patient will regain adequate fluid volume and electrolyte balance
as evidenced by client free from vomiting 2 hours after admission.
Long Term Goal: Patient will regain adequate fluid volume and electrolyte balance
by day of discharge AEB urine output more than 30 ml per hour, and blood
pressure 120/80.
Nursing Interventions:
(Assess, Assist/Encourage, Administer,
Teach, Consult)
Monitor manifestation of hypokalemia
(fatigue, malaise, confusion, muscle
weakness)
24 hour intake and output balance
Record the amount, color and
characteristics of vomitus and feces.

Monitor vital signs; compared with normal

results of client / previous. Measure blood
pressure with sitting, sleeping, standing if
possible.
Administer parenteral fluids as ordered

Scientific Principle/Rationale
Cardiac rhythm disorders can result from
hypokalemia
Accurate records are critical to maintain
patients fluid balance.
Assist in distinguishing gastric distress. Bright
red blood indicates the presence or acute
arterial bleeding, probably due to gastric ulcer;
dark red blood probably old blood (stuck in the
intestines) or bleeding from varicose veins.
Postural hypotension showed decreased
circulating volume.

Parenteral fluid replacement is indicated to

prevent dehydration and restore fluids lost.
Monitor laboratory tests; electrolytes, BUN, To monitor renal dysfunction and determine if
creatinine, hemocults.
there are signs or not of improvement in
condition.
Administer antiemetics (against vomiting To prevent further fluid loss
and nausea) and antidiarrheals