NURSING CARE PLAN

Assessment:

Subjective Cue:
> Nagsige gihapon siyag suka hantod karun, as verbalized by mother.

Objective Cue:
> VS are as follows: T = 39.1 C, P = 73 bpm, R = 25 cpm, BP = 90/50 mmHg
> persistent vomiting
> dry mucous membrane
> sunken eyes
> poor skin turgor
> urine output = <30 ml/hr
> serum sodium 155 mEq/L
> serum potassium 3.2 mEq/L

Diagnosis:

Fluid Volume Deficit related to loss of fluid and electrolytes as manifested by vomiting

Planning:

Short term goal:
After 8 hours of nursing intervention, the patient will be able to:
> Exhibit moist mucous membrane and good skin turgor.
> Retain feedings without experiencing vomiting
> Have a urine output of more than 240 ml

Long term goal:
After 5 days of nursing intervention, the patient will be able to:
> Exhibit fluid and electrolyte balance (normal serum sodium and potassium levels)
> Maintain normal weight

Interventions:

Assess or instruct patient to monitor weight daily and consistently, with same scale, and preferably at
the same time of day
Rationale: To facilitate accurate measurement and follow trends.
Assess skin turgor, mucous membrane every shift.
Rationale: Fluid loss occurs first in extracellular spaces, resulting in poor skin turgor and dry mucous
membrane.
Monitor vital signs at least every four hours.
Rationale: Increased temperature and respiratory rate contribute to fluid loss. A weak, thread pulse and
drop in blood pressure indicate dehydration.
Assess childs behavior and activity level every shift.
Rationale: A child with dehydration may develop anorexia, decreased activity level and general malaise.
Obtain specimen for analysis of altered sodium levels (e.g., serum and urine sodium, urine osmolality,
and urine specific gravity) as indicated.
Rationale: Urine analysis provides information about retention or loss of sodium and the ability of the
kidneys to concentrate or dilute urine in response to fluid changes.
Assess color and amount of urine. Report urine output less than 30 ml per hr for 2 consecutive hours.
Rationale: Concentrated urine denotes fluid deficit.
Provide frequent oral hygiene.
Rationale: Oral mucous membranes become dry and sticky due to loss of fluid in the interstitial spaces.
Encourage patient to drink prescribed fluid amounts.
Rationale: To replace fluid loss without causing further GI irritation.

Administer IV therapy as prescribed.
Rationale: Parenteral fluid replacement is indicated to prevent shock.
Monitor IV fluid infusion every hour.
Rationale: Fluid balance is less stable in young children, infusing too rapidly or too slowly can lead to
fluid imbalance.
Administer antiemetic as ordered.
Rationale: To prevent further fluid loss.

Evaluation:

Short term goal:
Goals partially met.
After 8 hours of nursing intervention, the patient was able to exhibit moist mucous membrane but still
has a poor skin turgor. He was able to retain feedings without experiencing vomiting. He only had a urine
output of 200 ml.

Long term goal:
Goals partially met.
After 5 days of nursing intervention, the patient was be able to exhibit fluid and electrolyte balance as
manifested on his latest laboratory result. His current serum sodium level is 138 mEq/L and his serum
potassium level is 4.7 mEq/L. However, he wasnt able to maintain his normal weight.