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The client, a 22-year-old female, presented with deficient fluid volume, deficient knowledge regarding electrolyte imbalance, and imbalanced nutrition related to diarrhea, vomiting, and inadequate intake resulting in weight loss and dehydration; the nursing care plan addressed increasing fluid intake, providing education on her condition and risk factors, and instructing her on proper nutrition to regain weight through dietary changes and increased fluid consumption while monitoring for signs of improvement.
The client, a 22-year-old female, presented with deficient fluid volume, deficient knowledge regarding electrolyte imbalance, and imbalanced nutrition related to diarrhea, vomiting, and inadequate intake resulting in weight loss and dehydration; the nursing care plan addressed increasing fluid intake, providing education on her condition and risk factors, and instructing her on proper nutrition to regain weight through dietary changes and increased fluid consumption while monitoring for signs of improvement.
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The client, a 22-year-old female, presented with deficient fluid volume, deficient knowledge regarding electrolyte imbalance, and imbalanced nutrition related to diarrhea, vomiting, and inadequate intake resulting in weight loss and dehydration; the nursing care plan addressed increasing fluid intake, providing education on her condition and risk factors, and instructing her on proper nutrition to regain weight through dietary changes and increased fluid consumption while monitoring for signs of improvement.
Авторское право:
Attribution Non-Commercial (BY-NC)
Доступные форматы
Скачайте в формате DOC, PDF, TXT или читайте онлайн в Scribd
Subjective Short-term goal Independent After doing the necessary >Client reports dryness of >Assess for the signs of >To determine the cause nursing interventions and her oral mucosa At the end of this shift, the dehydration including skin of pharyngeal pain. This teachings, the client: client exhibit signs of turgor, oral mucosa, etc. will provide a data that Objective improvement in hydration could be used to evaluate >Achieved appropriate >Vital signs status. the proper intervention urine output T:35.4 that the client needs. PR:60 RR:22 >Review ways to improve >Encourage the client to >To reduce the dryness of >Participated in health BP:100/60 the client’s hydration increase the fluid intake. the oral mucosa teaching >pale conjunctiva status
>normal appetite >Monitor I & O and IV >To determine if IV fluid
>Ensure that the client is fluids and electrolyte >Followed the prescribed >has intermittent fever receiving right amount of replacement are needed pharmacological regimen. maintenance fluids. >decreased skin turgor >Keep a quiet >To reduce stress and environment and calm anxiety >Demonstrated use of >normal capillary refill >Provide comfort activities. relaxation skills to reduce time measures anxiety >Provide health teachings >To promote awareness on >elevated WBC count on avoidance of related factors dehydration • PRIORITY #2: Deficient knowledge (Learning need) regarding electrolyte imbalance as evidenced by verbalization of questions and concerns. ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION Subjective: Short term goal: >Assess level of >Some clients may need >Client responded to the >Verbalization of >Assist client to use given knowledge of the client. the help of SO or learning plan and actions questions: information in all caregivers to learn. performed. “Ano bang causes ng applicable areas including dehydration at environmental causes >Determine the client’s >Client might not be gastroenteritis?” readiness and barriers to physically or emotionally >Client provided a >Provide information and learning. capable at this time. positive feedback and self-learning modules adherence to the teaching. Objective: regarding her disease >Identify support persons. >Reinforcement learning >Vital signs (e.g. mother, other family process allows the client to T:35.4 members) proceed at her own pace. >Client was able to deal PR:60 >Give information with her anxiety. RR:22 accurately and clearly. BP:100/60 >Teach the client to cease >To give awareness on the alcohol consumption possible complications of >Inaccurate understanding because of the possible having vices of her disease’ complications. (pathophysiology)
>Begin with the info the >Can arouse interest/limit
client already know and sense of being move to what she does not overwhelmed. know, progressing from simple to complex. PRIORITY #3: Imbalanced Nutrition: Less than body requirements related to inadequate intake and fluid loss secondary to vomiting and diarrhea ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Short term goal: Independent: After 8 hours of nursing
care/teaching, patient has: “Ang laki ng pinayat ko.” >Assess risk/presence of >Familial traits or cultural conditions associated with >Obtain commitment for beliefs may place high >Decrease food intake rapid weight loss achieving desirable importance on food intake weight. as well as large body size. >Verbalize adherence to >Reported presence of (e.g. wrestler, football the plan of teaching for nausea in the morning >Encourage client to adhere to lineman, Samoan) attaining the desirable her prescribed diet (55:20:25) body weight with an >Sedentary lifestyle is optimal maintenance of Objective: frequently associated with health. >Vital signs >Provide information obesity and is a primary T:35.4 regarding her specific focus for modification. PR:60 nutritional needs. >Inform the client the RR:22 proper amount and kind >To help the client to >Client verbalizes her BP:100/60 of food that she needs to have a control on her goals by changing her eat, including: high eating habits. eating patterns, food >decrease 5% of the carbohydrates; low fat quantity/quality, and weight and protein; liquids with joining in an exercise high electrolyte content, programs/ >Poor skin turgor and solid to semi-solid foods. >Pale conjunctiva