Ruth

Vasquez
Nursing Care Plan


Priority Nursing Diagnosis Deficient fluid volume related to compromised endocrine regulatory mechanism as evidence by hypernatremia of 155
mEq/L.

Goals Patient will experience normal fluid volume by normal serum sodium level between 133-145 mEq/L in 72 hours.

Outcome Criteria
Interventions
Scientific Rationale
Evaluation




Patient will have an intake of 1.5
Monitor patients fluid intake Q 4 H.
Fluid intake helps the body
NOT MET
liters a day in 24 hours.

maintain hydration to properly
Patient had a total fluid intake of 670cc (PO


balance the electrolytes in the
270cc and IV parenteral 400cc).


blood. The more water in the



body system the more diluted the


blood concentration becomes



resolving high concentrations of



sodium serum.





Patient will have a urinary output of Monitor patients urine output Q 2 H.
Too much excretion of urine can
MET
264cc per 12-hour shift in 48 hours.
interfere with balancing of
Patient had a total urine output of 277cc in a
(Following the 2cc/kg/hr rule of

electrolytes, the same with the
12-hour shift.
thumb)

retention of fluids in the body.



Monitoring urine output can help


demonstrate fluid status of the



body.





Patient will have a decreased thirst
Monitor for increased thirst (polydipsia) of
Polydipsia is a good indicator of a MET
sensation in 24 hours.
patient Q shift.
fluid imbalance because there is a Patient had a decreased desire to drink fluid

desire to drink to replenish a
PO (270cc in a 12-our shift).

hydrated state.


Outcome Criteria

Patients weight will maintain at
10.8 kg in 72 hours.

Patients urine specific gravity will
be between 1.001-1.030 in 48 hours.




Patients serum and urine osmolality
will be with in 500-800 mosm/kg in
48 hours





Patients serum sodium levels will be
between 133-145 mEq/L in 48
hours.



Patients serum potassium levels will
be between 3.3-5.1 mEq/L in 48
hours.

Interventions

Obtain patients weight on the same scale Q
day.

Obtain patients urine specific gravity Q
shift.




Obtain patients serum and urine osmolality
Q shift.






Obtain patients serum sodium levels Q
shift.




Obtain patients serum potassium levels Q
shift.

Scientific Rationale

Weight loss could occur with
excessive fluid loss.

A urine specific gravity of a child
that is more than 1.030 indicates
a dehydration status or solute
content that is too high in the
urine.

Increased urine osmolality is an
indicator of dehydration,
hypernatremia, or adrenal
insufficiency. Decreased urine
osmolality is an indictor of
diabetes insipidus, excess fluid
intake, or renal insufficiency.

Hypernatremia indicates a high
concentration of sodium that is
caused by a decrease in total
body water relative to electrolyte
content.

Hypokalemia may result from
increase of urinary output of
potassium.

Evaluation

MET
Patients weight remained at 10.8 kg.

NOT MET
A urine specific gravity analysis was not
obtained.



NOT MET
Urine analysis was not obtained.






NOT MET
Patients sodium serum was 155 mEq/L.




MET
Patients serum potassium level was 4.5
mEq/L.


Outcome Criteria

Patients heart rate will be between
70-110 beats/minute in 24 hours.







Patients breathing rate will be
between 20-30 breaths per minute
in 24 hours.

Patients palpable blood pressure
will be between 55/0 -90/0 in 24
hours.

Patients temperature will be
between 34.7-37.3C in 24 hours.



Patient will have easy access to fluid
source in one hour.

Interventions

Monitor patients heart rate Q 4 hours.








Monitor patients breathing rate Q 4 hours.



Monitor patients palpable blood pressure Q
4 hours.


Monitor patients temperature Q 4 hours.




Provide an easily accessible fluid source by
bedside Q 2 hours.

Scientific Rationale

Frequent assessment of heart
rate, breathing rate, blood
pressure, and temperature can
detect changes early for rapid
intervention. Polyuria causes
decreased circulatory blood
volume and increases the risk for
hypovolemic shock.














This will allow the patient to have
its thirst intact by maintaining
adequate hydration to
compensate the amount urinated.

Evaluation

NOT MET
Patients heart rate was 120.







MET
Patients breathing rate was 30 breaths per
minute.

NOT MET
Patients palpable blood pressure was 100/0.


MET
Patients temperature was 36.8C.



MET
Fluids were kept at bedside.

Outcome Criteria

Patient will have parenteral fluid
replacement per order.


Patient will take prescribed diuretic
per order.

Interventions

Administer D5 0.2% NaCl infusion at the rate
of 40 ml/hr via IV continuous.


Administer DIURIL 250mg/5ml suspension
40 mg PO BID.

Scientific Rationale

Hypotonic IV fluids provide free
water and help lower serum
sodium levels gradually.

This diuretic can help cause a
decrease in urine volume through
a series of mechanisms that
increase water reabsorption in
the distal tubules.

Evaluation

MET
Patient received fluid replacement via IV.


MET
Patient received DIURIL as prescribed.