Patients Name: Claudine Gianan Diagnosis: Parasitism with Moderate Dehydration Nursing Care Plan Cues Subjective: Tatlong

aldaw na siyang gapar suka as verbalized by mother Objective: Poor skin turgor Restlessness Dry mucous membranes Cold clammy skin Inference Dehydration describes a state of negative fluid balance that may be caused by numerous disease entities. Diarrheal illnesses are the most common etiologies. Worldwide, dehydration secondary to diarrheal illness is the leading cause of infant and child mortality. The normal response to dehydration, i.e. decreased effective arterial blood volume or Nursing Diagnosis Deficient Fluid Volume related to nausea, vomiting, and diarrhea as evidenced by decreased urine output, increased urine concentration, weakness, fever, decreased skin/tongue turgor, dry mucous membranes, and increased pulse rate. Planning GOAL: After 8 hours of nursing interventions the client will be able to maintain fluid volume at functional level. OBJECTIVES: Independent (1) Evaluate egree of fluid deficit. Interventions Rationale Evaluation After nursing intervention, goals are met.

a. Assess vital signs

b. Note physical signs of dehydration (2) Correct/replace losses to a. Administer medications reverse pathophysiologi c mechanism

Provides baseline for assessing and evaluating interventions. Predictors of fluid balance that should be in clients usual range in a healthy state. To limit gastric/intestinal losses; to treat bacteria

effective circulating volume is described. Due to water retention and drinking following stimulation of ADH secretion and thirst, osmoregulation is overruled by volume conservatory mechanisms, which lead to hyponatremia. Only patients with impaired mental function or those who are unable to drink will develop a progressive water deficit--with or without salt depletion-recognizable by hypernatremia

b. Encouraged fluid intake To detect early and monitoring of daily signs fluid intake and output of dehydration (3) Provide measures designed to allow the GI tract to rest a. Administer nothing by mouth possibly for days until acute symptoms subsided. b. Maintain bed rest a. Offer the client ice chips followed by clear liquids Allowing the gastric mucosa to heal

(4) ) Promote return to a regular diet

To gain energy for the immune system Fluid electrolyte replacement provides oral replacement therapy Refer to the list of predisposing or contributing factors to determine treatment needs. Depending on the avenue of fluid loss, differing electrolyte and metabolic imbalances may

Collaborative 1. Assist with identification of underlining cause 2. Monitor laboratory studies

be present and require correction. Subjective: Nasakitana siyang magdumi as verbalized by mother. Objective: Abdominal Pain Passage of hard, dry stools Infrequent passage of stool Constipation, Altered Bowel or irregularity, is Output related a condition of the to vomiting digestive system in which a person experiences hard feces that are difficult to expel. This usually happens because the colon absorbs too much water from the food. If the food moves through the gastro-intestinal tract too slowly, the colon may absorb too much water, resulting in feces that are dry and hard. Defecation may be extremely painful, and in severe cases (fecal impaction) After 8 hours of nursing intervention, patient passes soft, formed stool at a frequency perceived as "normal" by the patient. Patient or caregiver verbalizes measures that will prevent recurrence of constipation. Independent Determine stool, odor, Assist in consistency, frequency an identifying amount. causative or contributing factors and appropriate intervention. Auscultate bowel sounds. Bowel sounds are generally increased in constipation. Monitor Input and Output May identify with specific attention to dehydration, food and fluid intake. excessive loss of fluids or aid in identifying dietary deficiencies. Recommend avoiding gas Decrease gastric forming foods. distress and abdominal distension. Assess perineal skin Prevents skin condition frequently, excoriation and noting changes or breakdown beginning breakdown. Encourage or assist with perineal care after bowel movement. After 8 hours of nursing intervention, the patient was able to demonstrate changes in behavior as necessitated by causative and contributing factors.

lead to symptoms of bowel obstruction.

Discuss use of stool softeners, mild stimulants, enemas as indicated. Monitor effectiveness.

Facilitates defecation when constipation is present.

Collaborative Consult with dietitian to provide well balanced diet high in fiber and bulk.

Fibers resist enzymatic digestion and absorb liquids in its passage along the interstitial tract and thereby produce bulk which acts as stimulant for defecation.

Catanduanes State Colleges College of Health Sciences Department of Nursing Virac, Catanduanes

Nursing Care Plan

Submitted by: Maria Teresa Q. dela Rosa BSN-2A/ Group 4 Submitted to: Marilou Lopez RN, MAN Clinical Instructor