NURSING CARE PLAN

CUES NURSING DIAGNOSIS and ANALYSIS

Deficient fluid volume related to malnutrition as evidence by weight loss, increased pulse rate, dry skin and hypotension.

GOALS/OBJECTIVES Goals: After 1 week of intervention, the client will be able to restore the normal fluid volume and be able to gain more knowledge about dehydration.

NURSING INTERVENTION

RATIONALE

EVALUATION

Interaction y (+)weight loss y (+) body weakness y Tachypneic y dry skin y output is greater than intake y Pagkatapos dumumi ako, nahihilo kong at

EFFECTIVENESS 1. The nurse was able to teach the client the definition of isotonic dehydration. > When treating dehydration, the type of water loss must be determined to ensure appropriate treatment
Ref: http://www.novelguide.com/a/dis cover/genh_0002_0002_0/genh_0 002_0002_0_00233.html

nanghihina

pinagpapawisan. Mabilis din tibok ng puso ko at parang nanlalabo ang paningin. The patient experienced this for three days. y The client drinks 2-3 glasses of water a day, approximately 720 ml/ day.

Objectives: 1. After 3 minutes of ANALYSIS: discussion, the client will be able to give the Physiologic changes definition of isotonic related to aging dehydration. make an elderly adult especially prone to dehydration. Because her sense of taste diminishes with age, 2. After 7 minutes of food may become discussion, the client will be able to state 5 out of 7 unappetizing. causes of dehydration. Consequently, she eats less and use more salt, raising her body's need for water. At the same time, however, her thirst response can diminish, so she may not recognize the need to drink more.

1. Was the client able to be able to give the definition of isotonic dehydration? Yes___No___Why?__

2. The nurse was able to teach the client the 7 causes of dehydration.

> When treating 2. Was the client able to dehydration, the underlying teach the client the 7 causes of dehydration? cause must be addressed.
Ref: http://www.novelguide.com/a/dis cover/genh_0002_0002_0/genh_0 002_0002_0_00233.html

Yes___No___Why?__

y She urinates at least six times a day, 1300 approximately

per day. The color is usually yellowish.

3. After10 minutes of discussion, the client will be able to verbalize 7 out of 9 common signs and symptoms of dehydration.

3. The nurse was able to teach the client the 9 common signs and symptoms of dehydration.

>It is very helpful to evaluate symptoms and signs in diagnosing the causes of health problems and in monitoring the status of diagnosed diseases.
Ref: http://www.medicinenet.com/sym ptoms_and_signs/article.htm

3. Was the client able to teach the client the 9 common signs and symptoms of dehydration? Yes___No___Why?__

NURSING CARE PLAN

y Parati akong nahihilo

For these reasons, an at nanghihina bigla elderly adult may severely kahit wala naman become dehydrated very akong ginagawa quickly, before she feels thirsty or anyone notices Observation symptoms.
y y (+)weight loss (+) body weakness

4. After 5 minutes of discussion, the client will be able to give 5 out of 6 complications of dehydration.

4. The nurse was able to teach the client the 6 complications of dehydration.

> The risk of life-threatening complications is greater for young children and the elderly. However, dehydration that is rapidly recognized and treated has a good outcome
Ref: http://www.novelguide.com/a/dis cover/genh_0002_0002_0/genh_0 002_0002_0_00233.html

4. Was the client able to teach the client the 6 complications of dehydration? Yes___No___Why?__

Her peptic ulcer disease also contributed to her malnutrition due to 5. After 5 minutes of the changes in her discussion, the client will be able to give 3 out of 4 diet. ways on how to prevent dehydration.

5. The nurse was able to teach the client the 4 ways on how to prevent dehydration.

> Every individual & and healthcare provider should focus on primary prevention. It is usually the least expensive intervention and provides the greatest benefits.
Ref: Foundations of Nursing by Lois nd White 2 Edition p.261

5. Was the client able to teach the client the 4 ways on how to prevent dehydration? Yes___No___Why?__

Ref: http://www.symptomsofdehydrati on.com/

EFFICIENCY Were resources available to the nurse Dehydration prevention is and client maximized? the best treatment for every age group Yes___No___Why?__ APPROPRIATENESS Were interventions appropriate to client situation? ( meaning age, health condition, etc.) Yes___No___Why?__

NURSING CARE PLAN

ACCEPTABILITY Were all interventions acceptable to the client? Yes___No___Why?__ ADEQUACY Were the number of interventions enough to solve the health problem? ___No___Why?__