This action might not be possible to undo. Are you sure you want to continue?
to fever, vomiting and excessive perspiration. Rationale Situational Analysis Water content of the human body progressively decreases from birth to old age. In the neonate, fluid accounts for as much as 75% of body weight. Most of the decrease occurs in the first 10 years of life. Hypovolemia or extra cellular fluid volume deficit is the isotonic loss of body fluids, that is, relatively equal losses of sodium and water. Pediatric clients are more at risk of hypovolemia and dehydration because their bodies need to have a higher proportion of water to total body weight. Excessive fluid loss reduced fluid intake, thirdspace fluid shift, and a combination of these factors causes fluid volume loss. Fluid loss causes include abdominal surgery, diabetes mellitus, diarrhea, vomiting, excessive diuretic therapy, excessive use of laxatives, excessive perspiration and crying, fever, fistulas, hemorrhage, nasogastric drainage and renal failure with polyuria. Goal and Objectives Goal: After an 8-hour shift, client will be able to demonstrate adequate fluid balance as evidenced by good skin turgor, moist skin and mucous membranes; caregiver will be able to verbalize understanding of child’s fluid needs and will be able to demonstrate behaviors to prevent development of fluid volume deficit. Objectives: Facilitative 1.The causative or precipitating factors that cause the client’s condition & the degree of fluid deficit will be evaluated. 1.Note potential sources of fluid loss/intake. 2.Continue monitor the vital signs, mucous membranes, weight, skin turgor, breath sounds, urinary and gastric output. Interventions Rationale Evaluation Goal met. After an 8hour shift, client was able to demonstrate adequate fluid balance as evidenced by good skin turgor, moist skin and mucous membranes; caregiver will be able to verbalize understanding of child’s fluid needs and will be able to demonstrate behaviors to prevent development of fluid volume deficit. 1.Causative/contributing factors for fluid imbalances. 2.Indicators of hydration status. Note: Hypotension indicative of developing shock may not be readily observed in pediatric Objective met.
Observation: -Client appeared irritable. -Client is with fair reflexes. -Client has poor skin turgor assessed at the abdomen. -Client has unsunken eyes and fontanels. -Client has moist skin folds including the antecubital fossa. -Client has dry mucous membranes including the buccal and oral mucosa.
-Client passed out stool once in the morning. Stool was semi-soft, yellow in color and not watery. BP= 120/80 mmHg CR= 90bpm PR= 20cpm
acute peritonitis. hemoglobin/hematocrit (Hb/Hct). acute gastro enteritis. urine osmolality/specific gravity. 2. BUN. Developmental 1. 4. environmental conditions preventing fluid intake and psychiatric illness.g. metabolism. Another possible causes of reduced fluid volume are dysphagia.Request for laboratory results.Provides information for baseline and comparison. coma.Indicators of adequacy of hydration/therapeutic interventions. 5. Decreased renal blood flow triggers the rennin-angiotensin system to increase sodium-water reabsorption. Weight is a useful indicator of fluid balance. Moist towel may reduce the dryness of the oral musosa.Administer and monitor IV fluids as ordered. Weight loss indicates that child is not receiving adequate fluid replacement and adjustments need to be made. Cells are deprived of normal nutrients that serve as substrates for energy production. Fluid volume deficit decreases capillary hydrostatic pressure and fluid transport. 6. Continue monitor the patient’s weight and compare the result on the next days. Supplemental 1. Fluid shift related to burns during the initial phase. and other cellular functions. and systemic vascular resistance. 6.After 30 minutes of nursing care. 1..Close monitoring and regulation is required to prevent fluid overload while correcting fluid balance. Health Implication Hypovolemia is an isotonic disorder. 2. crushing injury. Instuct the caregiver to apply moist towel on client’s lips when noted dry. Facilitative 1.5 to 2 L of blood may accumulate in tissues around the fracture). .Temp: 37. Weigh on the same scale at the same time of day & wearing same amount of clothing patients until very late in the clinical course. acute intestinal obstruction. Provides fluid & nutritional support to replace active fluid loss. e. The cardiovascular system compensates by increasing heart rate. pancreatitis and pleural effusion may also contribute to fluid volume deficit. vomiting.Determine child’s normal pattern of elimination. hip or pelvic fracture (1.8c. cardiac contractility. Consistency with weight measurement helps ensure more accurate results. the client will be able to elicit no signs of dehydration.Provides baseline and comparison 5.Review patient’s intake of fluids. 2. venous constriction. Hydrate with water after every feeding. thus increasing 4.
After 15 minutes of nursing intervention. client will be able to comfortable and manifest no signs of irritability and will be able to rest comfortably. client will be able to feed with ease and without undue discomfort. at least twice a day 2. Provide fresh water and oral fluids preferred by the client (distribute over 24 hours) provide prescribed diet. . Developmental 1.Provide a quiet environment. 2007. 3. Objective met.Ensures continued preventive measures in home setting. After 15 minutes of nursing intervention. and so on). amount. frequency. pp. Note characteristics of stool (color.cardiac output and mean arterial pressure. 1. hypovolemic shock occurs in the following sequence: -decreased intravascular fluid volume -diminished venous return. It also triggers the thirst response. offer snacks. When compensation fails. (Pediatric Nursing Care Plans. -multiple organ dysfunction syndrome Possible complications of hypovolemia include shock and acute renal failure. signs of dehydration and different ways in preventing dehydration.Auscultate bowel sounds. pp. clean cloth. Instruct significant other to assist the client with feedings as appropriate. Facilitative 1. complications of dehydration.Educate caregiver factors contributing to dehydration. 1. Provide frequent oral hygiene. Oral hygiene decreases unpleasant tastes in the mouth and allows the client to respond to the sensation of thirst.Quiet environment promotes good rest and comfort. 2.Provides information about digestion/bowel function and may affect choice/timing of feeding.g. 1. (Lippincott Manual of Nursing Practice Series Pathophysiology. 2. releasing more antidiuretic hormone and producing more aldosterone. Swaeringer. clean linens.674-676) Objective met. The oral route is preferred for maintaining fluid balance Distributing the intake over the entire 24-hour period and providing snacks and preferred beverages increases the likelihood that the client will maintain the prescribed oral intake. etc. which reduces preload and stroke volume -reduced cardiac output -decreased mean arterial pressure -impaired tissue perfusion -decreased oxygen and nutrient delivery to cells. 2006.458-461) 3. Provide comfort measures (e. Promotes comfort level & distraction. 1. 2.) 3. 2.
Nursing diagnosis Risk for Bleeding related to altered clotting factor. Goals & Objectives After 8 hrs. . Observe color and consistency of stools or vomitus.After 3 hours of nursing intervention the patient will be able to identify factors that could increase risk of bleeding. Objective: · Weakness and irritability. · Restlessness. Independent: · Assess for signs and symptoms of G. Cues Subjective: “Isang araw parang dumugo ilong ko pero konting konti palang naman”as verbalized by the Patient.patient will be able to enumerate at least 3 out 5 infant care measures of preventing dehydration. with severe headache. the client will be at reduced risk for bleeding Intervention Rationale Evaluation Goal met. 5th Edition. the client was able to demonstrate behaviors that reduce the risk for bleeding. There may also be gastritis and some times bleeding. After 1 hr. Of nursing interventions.I tract (esophagus and rectum) is the most usual source of bleeding of its mucosal fragility.. muscle and joint pains (myalgias and arthralgias— severe pain gives it the name breakbone fever or bonecrusher disease) and rashes and usually appears first on the lower limbs and the chest. Check for secretions. Rationale This infectious disease is manifested by a sudden onset of fever. · Sub-acute Objective met. The G. After 20 minutes of nursing action. Taylor et. (Fundamentals of Nursing. Objectives: 1.I bleeding. 2005) Objective met. Of nursing interventions.8c.4. · V/S taken as follows: BP= 120/80 mmHg CR= 90bpm PR= 20cpm Temp: 37. al.
· Recommend Objective met . disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors. · In the presence of clotting factor disturbances. bleeding from one more sites. avoiding straining for stool.· Observe for presence of petechiae. ecchymosis.After 3 hours of Nursing intervention. be gentle with GI tube insertions. · An increase in pulse with decreased Blood pressure can indicate loss of circulating blood volume. · Changes may indicate cerebral perfusion secondary to hypovolemia. minimal trauma can cause mucosal bleeding. reducing risk for bleeding and hematoma. · Encourage use of soft toothbrush. · Note changes in mentation and level of consciousness. Apply pressure to venipuncture sites for longer than usual. and forceful nose blowing. · Avoid rectal temperature. · Rectal and esophageal vessels are most vulnerable to rupture. · Minimizes damage to tissues. · Use small needles for injections. the patient will be able to demonstrate ways to reduce risk for bleeding. 2. hypoxemia. Blood pressure. · Monitor pulse.
Pain fibers enter the spinal cord at the dorsal root ganglia and synapse in the dorsal horn. Collaborative: · Monitor Hb and Hct and clotting factors. Provides baseline and comparison Assess blood pressure and pulse and IV site. . results from activation of peripheral pain receptors and their specific A delta and C sensory nerve fibers (nociceptors). From there. With slight inflammation. and verbalization of reduction of pain.” as verbalized by the patient. The client was also able to identify 1 cause of pain. A pain scale of 5/10 Objective: Grimacing upon touching of arm Tender to touch and warm. and choose and apply one way to alleviate pain. sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than six months. Reduces discomforts. · Prolongs coagulation. Acute pain. which usually occurs in response to tissue injury. These include: • Discussion and BP= 120/80 mmHg CR= 90bpm PR= 20cpm Temp: 37. Nursing diagnosis Acute Pain related to IV medication/side drip of KCL Analysis Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage . or impending complications Cues Subjective: Complaining for (+) pain in her IV insertion site and arms. potentiating risk of hemorrhage. The client was able to experienced gradual reduction or relief of pain as evidenced by decreased pain scale from 5/10 to 2/10. the patient will be able to identify at least ways of pain reduction.avoidance of aspirin containing products. fibers cross to the other side and travel up the lateral columns to the thalamus and then to the Goals and objective GOAL: After 2 hours of student nurses’ intervention the patient’s pain scale will be reduced by two while on KCL side drip OBJECTIVES: After 30 minutes of assessment with the patient. Supplemental and Developmental: Assist with measures that reduce discomfort. Nursing interventions Rationale Evaluation Goal met. “Ang sakit sakit niya siguro dahil sa gamut o kaya baka wala na sa linya ung IV.. Facilitative: Assess nature and degree of discomfort.8c. having normal BP and PR. These data provide information about the subjective experience of discomfort for this client. · Indicators of anemia. active bleeding.
Peripheral nerves and nerves at other levels of the CNS may also be sensitized. • Warm to cold compress Ice provides local anesthesia. can sensitize peripheral nociceptors. epinephrine). neurokinin A) and other mediators (eg. prostaglandin E2. Divert pain to other stimulation/sensation. blood pressure and pulse are elevated with anxiety. talking with company. and reduces edema formation Pain may be associated with anxiety. the patient will be able to apply Facilitative: Institute comfort measures -Warm to cold Compress . including those involved in the inflammatory cascade. Forget about the feeling of pain by focusing on other activities • Reduction of stimulation in the environment • Provision of arm rubs Teach Diversional activities like sleeping.cerebral cortex. producing long-term synaptic changes in cortical receptive fields (remodeling) that maintain exaggerated pain perception. substance P. • After 2 ½ hours of discussion and demonstration to the patient.Slight Arm rubs Promotes comfort . promotes vasoconstriction. Repetitive stimulation (eg. These substances include vasoactive peptides (eg. serotonin. bradykinin. Substances released when tissue is injured. reading books. calcitonin gene-related protein. from a prolonged painful condition) can sensitize neurons in the dorsal horn of the spinal cord so that a lesser peripheral stimulus causes pain (wind-up phenomenon). demonstration to the client breathing relaxation techniques and encouraging use of breathing/relax ation techniques. Provides relaxation.
at least one way to alleviate pain Collaborative Administer analgesic as needed. promoting relaxation. with reasons. allows client compliance with orders. time factors and restrictions. Knowledge of typical effect aids in developing realistic expectations. facilitating rest and sense of well-being. . Knowledge of time restrictions. Explain action of analgesic. Assess effectiveness of pain medication. Analgesics act on higher brain centers to reduce perception of pain. After 3 hours of intervention the client will be able to verbalize improved comfortability.
This action might not be possible to undo. Are you sure you want to continue?