ASSESSMENT Subjective: ilang araw ng ngtatae at nagsusuka ang anak ko as verbalized by the mother Objective: >dry mucous membrane

>slightly irritable >seen vomiting the milk >dry skin with poor turgor >depressed fontanelles >Vital Signs as follows: RR: 37cpm PR: 124bpm T: 38.8

DIAGNOSIS Fluid volume deficit related to fluid loss

SCIENTIFIC BACKGROUND A state in which an individual is experiencing vascular, cellular, or intracellular dehydration due to active or regulatory losses of body water in excess of needs or replacement capability.

PLANNING After 12 hours of rendering nursing intervention, the patient will be able to replace lost fluid gradually or evidence by: a. drinking milk without vomiting b. patients IVF is adequately regulated as ordered c. increase intake of water for 2ml per day

NURSING INTERVENTION Monitor vital signs Monitor input and output

RATIONALE Serve as baseline data Fluid replacement needs are based on correction of current deficits and ongoing losses Measurement provides useful data for comparison Regulation of fluid is critical in maintaining adequate circulating fluids to recover for amount of water loss through vomiting Skin and mucous membranes are dry with decreased elasticity because of vasoconstriction and reduced intracellular water To maintain fluid and electrolyte balance

EVALUATION After 12 hours of rendering nursing intervention, the patient replaced fluid loss.

Weigh daily and compare with 24 hours fluid balance Regulated IVF according to specified flow rate basing on the doctors order

Provide skin and mouth care

Advise mother or significant others to increased fluid intake of he patient Instruct mother to practice proper milk preparation of food handling Encourage mother to offer baby with mashed banana

or apple