NURSING CARE PLAN

Cues Diagnosis Justification

Subjective: Patient was experiencing 10 episodes of vomiting and had
“Pag uubo siya, nasusuka siya” Deficient fluid volume related to some loss of fever of 39.5’C prior to his admission. Children have a
as verbalized by his mother fluids and electrolytes as manifested by relatively high percentage of total body water, are sensitive to
vomiting loss, and are less able to control their fluid intake.
Objective: Dehydration is always hazard when children are febrile, when
 Vomiting this is accompanied by vomiting or diarrhea.
 Febrile- 39.5’C
 Dry skin and mucous membrane
 Poor skin turgor
 Serum electrolytes:
Sodium-132 mmol/L (low)

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Deficient fluid Dehydration is a Short term goal: Dependent: Short term goal:
“Pag uubo siya, volume related to common body fluid After 8 hours of 1. Assess skin Fluid loss occurs first Goals partially met.
nasusuka siya” some loss of fluids disturbance in Nursing Intervention turgor, in extracellular After 8 hours of
as verbalized by his and electrolytes as infants and children the patient will be mucous spaces, resulting in Nursing Intervention
mother manifested by and occurs, able to: membrane poor skin turgor and the patient:
vomiting whenever the total  Exhibit moist every shift dry mucous The patient was able
Objective: output of fluid mucous membrane to exhibit moist
 Vomiting exceeds the total membrane and mucous membrane
 Febrile- 39.5’C intake, regardless of good skin 2. Monitor Increased but still has a poor
 Dry skin and the cause. turgor. vital signs at temperature and skin turgor. He was
mucous Dehydration may  Retain feedings least every respiratory rate able to retain
membrane result from a without four hours. contribute to fluid feedings without
 Poor skin turgor number of diseases experiencing loss. A weak, thread experiencing
 Serum that cause insensible vomiting pulse and drop in vomiting
electrolytes: losses through the blood pressure
Sodium-132 mmol/L skin and respiratory Long term goal: indicate Long term goal:
(low) tract, through After 5 days of dehydration. Goals not met.
increased renal Nursing intervention Since the patient
excretion, and  Exhibit normal 3. Assess A child with was discharged in
through GI tract. elimination child’s dehydration may the hospital, he was
Although pattern for his behavior develop anorexia, not able to exhibit
dehydration can age. and activity decreased activity normal elimination
result from lack of  Maintain level every level and general pattern for his age.
oral intake , more normal weight shift. malaise. But he was not able
often it is a result of to maintain normal
abnormal losses weight.
such as those that 4. When To replace fluid loss
occurs in vomiting vomiting without causing
and diarrhea, when decreased, further GI irritation.
oral intake partially offer small
compensates for the amounts (5-
abnormal losses. 10ml) clear
fluids

5. Monitor IV Fluid balance is less

fluid stable in young
infusion children, infusing
every hour. too rapidly or too
(0.45% NaCl slowly can lead to
with 5% fluid imbalance.
Glucose +
20mmol
KCl / litre)

6. Secure the To protect the site

IV site by and allow the child
wrapping in to move his hand
it a soft and arm freely.
bandage.

Collaborative:
1. Provide In presence of
supplement reduced intake/
al IV fluids excessive loss, use
(0.45% NaCl of parenteral route
with 5% may correct,
Glucose + prevent deficiency.
 20mmol
KCl / litre)

References:

Ralph, Sheila Sparks and Taylor, Cynthia.  Nursing Diagnosis Reference Manual-6th Edition.  Pennsylvania: Lippincott Williams & Wilkins., 2005

Hockenberry, Marilyn.  Wong’s Essentials of Pediatric Nursing-7th Edition.  Singapore: Elsevier (Singapore)Pte. Ltd., 2005