Sandra, a 2 month old infant, was experiencing frequent vomiting and poor feeding. Her mother reported she looked skinny and sick. The nursing assessment identified a risk for deficient fluid volume. The nursing care plan was to monitor Sandra's potassium levels and provide supplemental potassium if needed. Fluids were to be given orally or intravenously as tolerated to replace lost volume. The family was taught to monitor fluid intake and output at home, and an emergency plan was established in case of worsening symptoms.
Sandra, a 2 month old infant, was experiencing frequent vomiting and poor feeding. Her mother reported she looked skinny and sick. The nursing assessment identified a risk for deficient fluid volume. The nursing care plan was to monitor Sandra's potassium levels and provide supplemental potassium if needed. Fluids were to be given orally or intravenously as tolerated to replace lost volume. The family was taught to monitor fluid intake and output at home, and an emergency plan was established in case of worsening symptoms.
Sandra, a 2 month old infant, was experiencing frequent vomiting and poor feeding. Her mother reported she looked skinny and sick. The nursing assessment identified a risk for deficient fluid volume. The nursing care plan was to monitor Sandra's potassium levels and provide supplemental potassium if needed. Fluids were to be given orally or intravenously as tolerated to replace lost volume. The family was taught to monitor fluid intake and output at home, and an emergency plan was established in case of worsening symptoms.
Sandra, a 2 month old infant, was experiencing frequent vomiting and poor feeding. Her mother reported she looked skinny and sick. The nursing assessment identified a risk for deficient fluid volume. The nursing care plan was to monitor Sandra's potassium levels and provide supplemental potassium if needed. Fluids were to be given orally or intravenously as tolerated to replace lost volume. The family was taught to monitor fluid intake and output at home, and an emergency plan was established in case of worsening symptoms.
Subjective: The mother Risk for deficient fluid Within 3 hours of nursing 1. Obtain specimens for 1. Urine and serum analysis After 3 hours of nursing intervention of the patient verbalized volume related to intervention the patient will be able analysis of altered provides information about the patient has been able to that Sandra breastfed vomiting to tolerated clear liquids without potassium levels as extracellular levels of tolerated clear liquids without well for the first couple vomiting indicated. potassium. There is no vomiting of weeks, but since then practical way to measure “throws up all the time intracellular K. like she’s forcing all her 2. Administer prescribed 2. Low potassium levels are feedings out. She looks supplemental potassium dangerous and the patient skinny and sick, and she (PO, NG, or IV) per policy. may require supplements. cries and is fussy all the 3. Monitor for neurologic and 3. Potassium is a vital time.” neuromuscular electrolyte for skeletal and manifestations of smooth muscle activity. Objective: hypokalemia. - 4. Monitor for cardiac 4. Many cardiac rhythm manifestations of disorders can result from hypokalemia. hypokalemia. It is critical to monitor cardiac function with hypokalemia.
5. Maintain accurate intake 5. Accurate records are critical
and output record. in assessing the patient’s fluid balance. 6. Monitor vital signs as 6. Vital sign changes such as appropriate. increased heart rate, decreased blood pressure, and increased temperature indicate hypovolemia. 7. Give fluids as appropriate. 7. As her nausea decreases encourage her oral intake of fluids as tolerated, again to replace lost volume. 8. Administer IV therapy as 8. She will probably require prescribed. intravenous replacement of fluid. This is especially true because her oral intake is limited because of nausea and vomiting 9. Teach family members how 9. An accurate measure of to monitor output in the fluid intake and output is an home. Instruct them to important indicator of monitor both intake and patient’s fluid status. output. 10. Identify an emergency plan, 10. Some complications of including when to ask for deficient fluid volume help. cannot be reversed in the home and are life- threatening. Patients progressing toward hypovolemic shock will need emergency care.