NURSING CARE PLAN Cues Subjective: Pag uubo siya, nasusuka siya as verbalized by his mother Objective:  Vomiting

 Febrile- 39.5C  Dry skin and mucous membrane  Poor skin turgor  Serum electrolytes:
Sodium-132 mmol/L (low)

Diagnosis Deficient fluid volume related to some loss of fluids and electrolytes as manifested by vomiting

Justification Patient was experiencing 10 episodes of vomiting and had fever of 39.5C prior to his admission. Children have a relatively high percentage of total body water, are sensitive to loss, and are less able to control their fluid intake. Dehydration is always hazard when children are febrile, when this is accompanied by vomiting or diarrhea.

ASSESSMENT Subjective: Pag uubo siya, nasusuka siya as verbalized by his mother Objective:  Vomiting  Febrile- 39.5C  Dry skin and mucous membrane  Poor skin turgor  Serum electrolytes:
Sodium-132 mmol/L (low)

DIAGNOSIS Deficient fluid volume related to some loss of fluids and electrolytes as manifested by vomiting

INFERENCE Dehydration is a common body fluid disturbance in infants and children and occurs, whenever the total output of fluid exceeds the total intake, regardless of the cause. Dehydration may result from a number of diseases that cause insensible losses through the skin and respiratory tract, through increased renal excretion, and through GI tract. Although

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 Long term goal: After 5 days of Nursing intervention  Exhibit normal elimination pattern for his

INTERVENTION Dependent: 1. Assess skin turgor, mucous membrane every shift

RATIONALE

EVALUATION Short term goal: Goals partially met. After 8 hours of Nursing Intervention the patient: 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 Long term goal: Goals not met. Since the patient was discharged in the hospital, he was not able to exhibit

Fluid loss occurs first in extracellular spaces, resulting in poor skin turgor and dry mucous membrane Increased temperature and respiratory rate contribute to fluid loss. A weak, thread pulse and drop in blood pressure indicate dehydration. A child with dehydration may develop anorexia,

2. Monitor vital signs at least every four hours.

3. Assess childs behavior

dehydration can result from lack of oral intake , more often it is a result of abnormal losses such as those that occurs in vomiting and diarrhea, when oral intake partially compensates for the abnormal losses.

age.  Maintain normal weight

and activity level every shift.

decreased activity level and general malaise.

normal elimination pattern for his age. But he was not able to maintain normal weight.

4. When vomiting decreased, offer small amounts (510ml) clear fluids 5. Monitor IV fluid infusion every hour. (0.45% NaCl with 5% Glucose + 20mmol KCl / litre)

To replace fluid loss without causing further GI irritation.

Fluid balance is less stable in young children, infusing too rapidly or too slowly can lead to fluid imbalance.

6. Secure the IV site by wrapping in it a soft bandage.

To protect the site and allow the child to move his hand and arm freely.

Collaborative: 1. Provide supplement al IV fluids (0.45% NaCl with 5% Glucose +

In presence of reduced intake/ excessive loss, use of parenteral route may correct, prevent deficiency.

20mmol KCl / litre)

References: Ralph, Sheila Sparks and Taylor, Cynthia. Nursing Diagnosis Reference Manual-6th Edition. Pennsylvania: Lippincott Williams & Wilkins., 2005 Hockenberry, Marilyn. Wongs Essentials of Pediatric Nursing-7th Edition. Singapore: Elsevier (Singapore)Pte. Ltd., 2005