Kristyn Joy D.

Atangen October 25, 2020

BSN IV/ Section A/ Group D Josephine Minger
FDAR－PEDIA

F－Fluid volume deficit related to loose watery stool as evidenced by decreased urine
output, tenting skin turgor, increased blood pressure, and increased pulse rate

D－A 4.5-month-old female an alert but irritable and ill-appearing infant. The infant was
reported to have had 10 watery stools over the previous 24 hours, during which she became
quite unsettled, crying a lot, whilst drinking half her usual amount of liquids. There was no
history of vomiting. Skin was pale grey, tenting skin turgor, dry lips and dry buccal mucosa,
normal looking eyes but reduced tears, soft fontanele, and capillary refill time of 3 seconds.
The urine output was also decreased. Heart and lung examination were normal except for
tachycardia, the abdomen was swollen and slightly painful on palpation, no
hepatosplenomegaly. Abdominal and thorax radiographs were normal. There were no signs of
meningeal irritation. Upon checking for her Laboratory tests it reveals altered results. Vital
signs as follows: temp of 39.9°C; HR between 170 and 190 bpm; RR between 40 and 80bmp;
BP of 102/55 mmHg; Oxygen saturation by pulse oximetry of 100% and a weight of 3.99 kg
upon admission.

A－Monitor vital signs, including temperature, pulse and respiration. Note strength of
peripheral pulse. Measure blood pressure and capillary refill. Assess presence of physical
signs like dry mucous membranes and poor skin turgor. Assess change in usual mentation,
behavior or functional abilities like lethargy and dizziness. Observe urinary output, color,
and ,measurement. Review laboratory data. Assist with treatment of underlying conditions
contributing to drhydration and electrolyte imbalances. Administer fluid and electrolytes, as
indicated. Provide frequent oral hygiene to dehydrate mucous membrane. Change position
frequently. Provide safety measures. Replace electrolytes as ordered. Discuss factors related
to occurrence of deficit to the Parents. Instruct and encourage mother to maintain
breastfeeding to help meet specific fluid needed. Instruct SO on how to monitor color of urine
and how to measure and record I & O (by counting diapers of the infant). Instruct in
medication regimen, administration and interaction and side effect. Instruct signs and
symptoms indicating need for immediate or further evaluation.

R－Infant progressed toward desire outcome and Mother is receptive to health teachings