NURSING CARE PLAN Problem Identified: risk for dehydration Nursing Diagnosis: Risk for fluid volume deficit

related to inadequate fluid intake secondary to infection Taxonomy: Nutritional metabolic pattern Cause Analysis: The negative fluid balance causing dehydration results from decreased intake, increased output (renal, gastrointestinal, or insensible losses), or fluid

shift (ascites, effusions, and capillary leak states such as burns and sepsis). The decrease in total body water causes reductions in both the intracellular and extracellular fluid volumes (www.emedicine.com)
CUES Subjective cues: OBJECTIVES Short term objectives: INTERVENTIONS Independent Interventions: Assist in estimation of total volume depletion. Symptoms may have been present for varying amounts of time. Baseline data for the severity of hypovolemic condition and determines future interventions to be undertaken. RATIONALE EVALUATION

Dili gyud ayo siya tig-inom ug Within 8 hours of nursing care 1. Obtain history from patient/SO tubig dayon walay gana mokaon the client will be able to related to duration/intensity of as verbalized by SO demonstrate adequate hydration symptoms eg. excessive urination as evidenced by stable vital signs and adequate intake of water. 2. Monitor vital signs Objective cues: decreased fluid intake Eats less of food served Dry skin and mucous membrane Poor skin turgor +1 for bacteria in urinalysis Long term objectives: After 2 -3 Days of rendering interventions to the patients hydration condition, patient may display urinary output within normal ranges, normal urine concentration, wt, gain to normal ranges ( 19 24 BMI) , good skin turgor, hydrated skin and mucous membrane.

3. Assess peripheral pulses, Indication of hydration level, capillary refill, skin turgor and circulating volume mucous membranes 4. Monitor Input and Output, note Provides ongoing estimate of urine specific gravity volume replacement needs, kidney function and effectiveness of therapy 5. Weight the patient daily Provides the best assessment of current fluid status and adequacy of fluid replacement.

6. Maintain fluid intake of at least Maintains hydration 2500ml/day with cardiac tolerance circulating volume. when oral intake is resumed.

and

7. Promote comfortable Avoid overheating, which could environment. Cover the patient promote further fluid loss. with light sheet. Collaborative Interventions: 1. Administer D5IMB 500 cc @ Facilitated fluid and electrolyte 50 cc/hr replacement. 2. Monitor laboratory studies Assess level of hydration status. e.g. Hct; BUN/creatinine (Cr); Serum Osmolality; Sodium; Potassium

REFERENCES: Nursing Care Plans by Doenges Nurses Pocket Guide by Doenges