Cues Objective: Loss of weight from 30kg to 28.5 kg.

. Dry lips, excessive dryness of mucous membranes Hair is dry Abnormal color of urine: Yellow High Specific gravity of urine: 1.030 High hematocrit level: 52% Increase pulse rate and body temperature: September 24, 2012 8:00am T: 36oC P: 76bpm

Nursing diagnosis Deficient fluid volume related to DFS as evidenced by dry mucous membranes, decrease pulse volume and pressure.

Analysis Dehydration can have a seriously damaging effect on body cells and the execution of body functions. Because the thirst mechanism is poorly develop in humans dehydration can develop unnoticed in normal person under adverse conditions. Often a person may feel a sense of thirst only after dangerous excess or deficit of various serum electrolyte levels has occurred. A chronically and serious ill patient who is not receiving adequate fluids either orally or parentally is at high risk for dehydration unless monitored properly. (Weber, 2007, p. 126) Dehydration occurs when your body loses too much fluid. This can happen when you stop drinking water or lose large amounts of fluid through diarrhea, vomiting, sweating, or exercise. Not drinking enough fluids can cause muscle cramps. You may feel faint. Usually your body can reabsorb fluid from your blood and other body

Goals and Objectives Goal: After 8 hours of nursing intervention, the client will be able to maintain fluid volume at functional level with good mucous membrane, good skin turgor and normal elimination pattern. Objectives:

Nursing Intervention

Rationale

Evaluation

Nursing Interventions: 1. Monitor and record vital signs 2. Monitor urine output and specific gravity 1. To provide baseline data 2. Measures the kidneys ability to concentrate urine. In intrarenal failure, specific gravity is usually equal to/less than 1.010, indicating loss of ability to concentrate the urine. 3. To provide baseline The client stabilized fluid volume and maintained fluid and electrolyte balances. The patient was able to exhibit moist mucous membrane and good skin turgor. The client was able to maintain normal elimination pattern for her age.

* After nursing interventions, the client will stabilize fluid volume and maintain fluid 3. Measure and and record electrolyte amount of

R: 20 breaths/min BP: 110/80 September 24, 2012 8:00am T: 36.8oC P: 69 bpm R: 15 breaths/min BP: 90/60

tissues. But by the time you become severely dehydrated, you no longer have enough fluid in your body to get blood to your organs, and you may go into shock, which is a lifethreatening condition.

balances.

intake and output including urine stools, vomitus. 4. Assess patients behaviour and activity level every shift.

data The client maintained normal weight. 4. A child with dehydration may develop anorexia, decreased activity level and general malaise. 5. Daily body weight is best monitor of fluid status. A weight gain of more than 0.5 kg/day suggests fluid retention 6. To evaluate degree of fluid excess and to obtain

* After nursing interventions, Dehydration can occur in the client will anyone of any age, but it is maintain most dangerous for babies, good small children, and older adults. elimination (http://www.webmd.com/fitness- pattern for age. exercise/tc/dehydration-topicoverview) *After nursing interventions, the client will maintain normal weight.

5. Compare current weight gain with admission or previous stated weight gain.

6. Review laboratory results like BUN, Creatinine, and Serum

electrolyte. (Collaborative)

baseline data.

7. Monitor IV infusion every hour.

7. Fluid balance is less stable in young children, infusing too rapidly or too slow can lead to fluid imbalance. 8. To protect the site and allow the child to move his hand and arm freely. 9. To prevent ulcerations.

8. Secure the IV site by wrapping it in soft bandage.

9. Observe skin mucous membranes

10. Evaluate mental status for confusion and personality changes.

10. May reflect fluid shifts, accumulation of toxins, acidosis, electrolyte

imbalances, or developing hypoxia. 11. Promote overall health measure. 11. To promote wellness and comfort. To reduce pain.