Cues/Needs Subjective data: Objective data: >Oral Fluid Intake of 30cc for 8 hours >Concentrated urinedark yellow

in color >Dry skin, Dry mucous membranes >Weakness, Changes in mental status (restlessness, irritability) >pale conjunctiva >pale nailbeds Vital signs taken as follows: BP: 90/60 mmHg PR: 98 bpm T: 36° C Weight: 55 lbs

Nursing Diagnosis Risk for fluid volume deficit related to decreased fluid intake.

Rationale Fluid volume deficit occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. One common source of fluid loss is nausea and vomiting, bleeding and excessive urination. In Dengue Hemorrhagic Fever signs and symptoms that could manifest are vomiting and frequent bleeding from gastrointestinal tract in the form of hematemesis or melena that may lead to fluid loss.

Goals and objectives Short term goal: After 4 hours of nursing interventions, the patient will maintain adequate fluid volume at a functional level as evidenced by: individually adequate fluid volume and electrolyte balance as evidenced by urine output greater than 30 ml/hr, stable vital signs, moist mucous membranes, good skin turgor and balance intake and output. Long term goal: After 3 days of health teaching and nursing interventions: 1. Gain weight. 2. Shows no sign of dehydration

Interventions Independent: 1.Continue monitoring intake and output (accurately), character, and amount of stools, vomiting and bleeding. 2.Monitor for neurologic and neuromascular manifestations of hypokalemia (e.g., muscle weakness, lethargy, altered level of consciousness). 3. Continue assessing vital signs (BP, pulse, temperature).

Rationale 1.Indicates excessive fluid loss or resultant of dehydration. Accurate records are critical in assessing the patient’s fluid balance. 2.Potassium is vital electrolyte for skeletal and smooth muscle activity.

Evaluation After 4 hours of nursing interventions the goal was partially met as manifested by the patient’s ability to maintain adequate fluid volume as evidenced by: > patient was relaxed >Maintained good skin turgor 2 seconds

3. Vital signs changes such as increased heart rate, decreased blood pressure, and increased temperature indicate hypovolemia. Hypotensive and increased pulse rate can be an indication that patient is dehydrated. 4. Oral hygiene can increase patient’s appetite for eating and interest in drinking essential amount of fluid.

>Maintained normal capillary refill 2 seconds >had moist mucous membrane >Urine output of 30-40 cc per hour >Stable vital signs: BP: 90/60 mmHg PR: 88 bpm T:36.0 C

4.Provide oral hygiene. By means of teaching patient to brush teeth thrice a day or every after meal. (Use soft bristle to prevent bleeding episodes)

5.Oral fluid replacement is 5.Encourage patient to drink indicated for mild fluid deficit.

6. Provide fresh water and a straw.prescribed fluid amounts. provide oral fluids patient prefers. If oral fluids are tolerated. 7. Explain importance of maintaining proper nutrition and hydration. References: Handbook of Common Communicable and infectious Disease by Dionesia Monjejar-Navales. flavored gelatin.g. 7. frozen juice bars. sports drink) 6. Dependent: 1.Administer Oral hydrating solutions/ORESOL as prescribed by the physician. Increasing fluid intake can maintain patient dehydrated. RN. Oral rehydration replaces and maintains fluids and electrolytes balance which is loss in the body. Weigh daily. To determine weight loss which can be due to severe dehydration.Describe or teach causes of fluid losses or decreased fluid intake. Be creative in selecting fluid sources (e. Patients need to understand the importance of drinking extra fluid during bouts of fever. Elderly patients have a decreased sense of thirst and may need ongoing reminders to drink. MAEd Lippincott Review Series Medical Surgical Nursing 4th Ed .Excessive intestinal loss may lead to electrolyte imbalance. and other conditions causing fluid deficits..

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