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Assessment

Nursing Diagnosis
Deficient Fluid Volume related to nausea, vomiting, and diarrhea as evidenced by decreased urine output, skin/tongue turgor, dry mucous membranes

Analysis

Planning

Intervention

Rationale

Evaluation

Subjective: Naka 10 suka na cya sa bahay, naka 3 dumi din cya, medyo basa at mabaho. as verbalized by the mother Objective: On admission 2x Loose stools 1x Vomiting (+) Anorexia (+) decrease fluid intake (+) dry lips

The nursing diagnosis is fluid volume deficit related to loose stools and vomiting is a priority problem because the patient is at risk for hypovolemic shock due to current condition, thus the need for hydration is a priority.

After 12 hours of nursing intervention, no hypovolemic shock and no signs of dehydration will be noted.

Assess patient's condition Assess likes and dislikes, provide favorite fluids Weight patient daily

To monitor for other signs and symptoms To promote hydration Changes in weight can provide information in fluid balance and the adequacy of fluid volume replacement For hydration

After 12 hours of nursing intervention, no hypovolemic shock was noted and that the mucosa of the patient was moist, indicating no signs of dehydration.

Encourage increase fluid intake providing appealing liquids Encourage to eat foods with high fluid content, such as watermelon, grapes Encourage to eat banana, rice, apple, toast Encourage to avoid food that cause dehydration such as coffee, tea Ensure accurate intake and output monitoring

For hydration

To prevent diarrhea, for stool formation To prevent further dehydration Accurate records are critical in assessing the patients fluid

balance Maintain on IVF hydration Initial goal is to correct circulatory volume deficit.Isotonic saline will rapidly expand extracellular fluid volume. The secondary goal, correction of water deficit, is usually accomplished by a hypotonic solution To ensure that there is adequate hydration To aid in preventing infection To aid in the general health of the patient

Ensure proper IVF regulation Antibiotics given as ordered Vitamins given as ordered