NURSING CARE PLAN

Assessment:

Subjective Cue:
> “Nagsige gihapon siyag suka hantod karun,” as verbalized by mother.

Objective Cue:
> VS are as follows: T = 39.1 °C, P = 73 bpm, R = 25 cpm, BP = 90/50 mmHg
> persistent vomiting
> dry mucous membrane
> sunken eyes
> poor skin turgor
> urine output = <30 ml/hr
> serum sodium 155 mEq/L
> serum potassium 3.2 mEq/L

Diagnosis:

Fluid Volume Deficit related to loss of fluid and electrolytes as manifested by vomiting

Planning:

Short term goal:

After 8 hours of nursing intervention, the patient will be able to:
> Exhibit moist mucous membrane and good skin turgor.
> Retain feedings without experiencing vomiting
> Have a urine output of more than 240 ml

Long term goal:

After 5 days of nursing intervention, the patient will be able to:
> Exhibit fluid and electrolyte balance (normal serum sodium and potassium levels)
> Maintain normal weight

Interventions:

• Assess or instruct patient to monitor weight daily and consistently, with same scale, and preferably at
the same time of day
Rationale: To facilitate accurate measurement and follow trends.
• Assess skin turgor, mucous membrane every shift.
Rationale: Fluid loss occurs first in extracellular spaces, resulting in poor skin turgor and dry mucous
membrane.
• Monitor vital signs at least every four hours.
Rationale: Increased temperature and respiratory rate contribute to fluid loss. A weak, thread pulse and
drop in blood pressure indicate dehydration.
• Assess child’s behavior and activity level every shift.
Rationale: A child with dehydration may develop anorexia, decreased activity level and general malaise.
• Obtain specimen for analysis of altered sodium levels (e.g., serum and urine sodium, urine osmolality,
and urine specific gravity) as indicated.
Rationale: Urine analysis provides information about retention or loss of sodium and the ability of the
kidneys to concentrate or dilute urine in response to fluid changes.
• Assess color and amount of urine. Report urine output less than 30 ml per hr for 2 consecutive hours.
Rationale: Concentrated urine denotes fluid deficit.
• Provide frequent oral hygiene.
Rationale: Oral mucous membranes become dry and sticky due to loss of fluid in the interstitial spaces.
• Encourage patient to drink prescribed fluid amounts.
Rationale: To replace fluid loss without causing further GI irritation.
• Administer IV therapy as prescribed.
Rationale: Parenteral fluid replacement is indicated to prevent shock.
• Monitor IV fluid infusion every hour.
Rationale: Fluid balance is less stable in young children, infusing too rapidly or too slowly can lead to
fluid imbalance.
• Administer antiemetic as ordered.
Rationale: To prevent further fluid loss.

Evaluation:

Short term goal:

Goals partially met.
After 8 hours of nursing intervention, the patient was able to exhibit moist mucous membrane but still
has a poor skin turgor. He was able to retain feedings without experiencing vomiting. He only had a urine
output of 200 ml.

Long term goal:

Goals partially met.
After 5 days of nursing intervention, the patient was be able to exhibit fluid and electrolyte balance as
manifested on his latest laboratory result. His current serum sodium level is 138 mEq/L and his serum
potassium level is 4.7 mEq/L. However, he wasn’t able to maintain his normal weight.