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Make a concept map using the appropriate

Make a concept map using the appropriate nursing plan given below. You may use software or canva. DATA: SUbjective: “Hindi na po sya gaanong kumakain at nabawasan din po ang kanyang timbang.” as verbalized by significant others. Objective: Altered mental status (+) confusion poor oral intake (+) cachectic dry mucous membranes sodium level of 167mmol/L creatinine level of 1.8mg/dl(137.25umol/L) NURSING DIAGNOSIS: Fluid Volume Deficit related to poor oral intake. GOAL: Patient is normovolemic as evidenced by normal vital signs, urine output greater than 30 mL/hr and normal skin turgor. Outcome/Plan: After 8hours of nursing interventions, the patient will be able to: – explains measures taken to treat and prevent fluid volume loss. – verbalize awareness to correct fluid deficit. – shows signs of improvement in hydration status. NURSING INTERVENTION: Independent: Monitor vital signs every 4hours, status of the mucous membranes and document. Assess color and amount of urine. Report urine if output less than 30 ml/hour for two (2) consecutive hours. Encourage patient to drink atleast 1-2L per day and as tolerated. Assess alteration in sensorium and document. Weigh patient daily with the same scale, dress and time of day. Aid and advise significant others to assist patient with meal and fluid intake as necessary. Dependent: Provide and supervise administration of IV fluids as ordered. Administer medications like multivitamins as ordered. Do routine tests of electrolytes as ordered. Collaborative: Collaborate with nutritionist for a structured program of nutritional therapy. RATIONALE: Independent Alteration in the heart rate is a compensatory mechanism to maintain cardiac output. Usually, the pulse is weak and irregular if electrolyte imbalance occurs and hypotension is evident in hypovolemia. Signs of dehydration are also detected through the skin especially in elder people. A Normal urine output is not less than 30ml/hour. A Concentrated urine denotes fluid deficit. Oral fluid replacement is indicated for mild fluid deficit and replacement treatment especially since older patients have a decreased sense of thirst and may need constant reminder. Alteration in mentation may be caused by electrolyte imbalanced and acidosis. To best assess data for possible fluid volume imbalance. Dehydrated patients are prone to be weak and might need assistance in daily activities. Dependent Intravenous Fluids are necessary to maintain hydration status. The type and amount of fluid to be replaced will depend on the extent of the condition. To promote proper nutrition. Collaborative: To support client with nutritional status. EVALUATION: Goals met as evidenced by : Maintaining a fluid balance. Normal vital signs. A urine output of 1-2 cc / kg body weight / hour. A normal skin turgor. A normal creatinine level 0.6-1.2mg/dl A normal sodium level 135-145 mmol/L

 
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