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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
Weigh on the same scale at the same time of day & wearing same amount of clothing patients until very late in the clinical course.Administer and monitor IV fluids as ordered.Indicators of adequacy of hydration/therapeutic interventions.. Hydrate with water after every feeding. Facilitative 1. Moist towel may reduce the dryness of the oral musosa. Developmental 1. cardiac contractility. hemoglobin/hematocrit (Hb/Hct). crushing injury. Weight loss indicates that child is not receiving adequate fluid replacement and adjustments need to be made. Provides fluid & nutritional support to replace active fluid loss. Cells are deprived of normal nutrients that serve as substrates for energy production.Provides information for baseline and comparison. Another possible causes of reduced fluid volume are dysphagia. acute intestinal obstruction. hip or pelvic fracture (1.g. Consistency with weight measurement helps ensure more accurate results. 2. e. Health Implication Hypovolemia is an isotonic disorder. BUN.Provides baseline and comparison 5.Determine child’s normal pattern of elimination.Close monitoring and regulation is required to prevent fluid overload while correcting fluid balance. coma. environmental conditions preventing fluid intake and psychiatric illness.5 to 2 L of blood may accumulate in tissues around the fracture). acute gastro enteritis. Weight is a useful indicator of fluid balance. 2. .8c. The cardiovascular system compensates by increasing heart rate. 6.Request for laboratory results. metabolism. the client will be able to elicit no signs of dehydration.Review patient’s intake of fluids. 1. Fluid volume deficit decreases capillary hydrostatic pressure and fluid transport. urine osmolality/specific gravity. acute peritonitis. 4. pancreatitis and pleural effusion may also contribute to fluid volume deficit. thus increasing 4. Continue monitor the patient’s weight and compare the result on the next days. 6. Supplemental 1. Instuct the caregiver to apply moist towel on client’s lips when noted dry.Temp: 37. 5. Fluid shift related to burns during the initial phase. and other cellular functions. vomiting. and systemic vascular resistance. Decreased renal blood flow triggers the rennin-angiotensin system to increase sodium-water reabsorption. venous constriction. 2.After 30 minutes of nursing care.
-multiple organ dysfunction syndrome Possible complications of hypovolemia include shock and acute renal failure. Provide fresh water and oral fluids preferred by the client (distribute over 24 hours) provide prescribed diet. Note characteristics of stool (color. signs of dehydration and different ways in preventing dehydration.cardiac output and mean arterial pressure. pp. 2007. Facilitative 1. 2. (Pediatric Nursing Care Plans. which reduces preload and stroke volume -reduced cardiac output -decreased mean arterial pressure -impaired tissue perfusion -decreased oxygen and nutrient delivery to cells. pp.) 3. Oral hygiene decreases unpleasant tastes in the mouth and allows the client to respond to the sensation of thirst. 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. After 15 minutes of nursing intervention. etc. 1. 1.Quiet environment promotes good rest and comfort. 1. 2. and so on). Swaeringer. . After 15 minutes of nursing intervention. It also triggers the thirst response.458-461) 3. Objective met. clean cloth. (Lippincott Manual of Nursing Practice Series Pathophysiology. clean linens.Auscultate bowel sounds.g. Provide frequent oral hygiene. When compensation fails. Developmental 1. 2.Ensures continued preventive measures in home setting. Instruct significant other to assist the client with feedings as appropriate. frequency. client will be able to feed with ease and without undue discomfort.Provides information about digestion/bowel function and may affect choice/timing of feeding. Promotes comfort level & distraction. releasing more antidiuretic hormone and producing more aldosterone. complications of dehydration. offer snacks.Educate caregiver factors contributing to dehydration. 3. client will be able to comfortable and manifest no signs of irritability and will be able to rest comfortably.674-676) Objective met. at least twice a day 2. Provide comfort measures (e. amount. 2006. 2.Provide a quiet environment. hypovolemic shock occurs in the following sequence: -decreased intravascular fluid volume -diminished venous return. 1.
Observe color and consistency of stools or vomitus. the client was able to demonstrate behaviors that reduce the risk for bleeding. 2005) Objective met. After 1 hr.4. Check for secretions. The G. Nursing diagnosis Risk for Bleeding related to altered clotting factor. After 20 minutes of nursing action. Of nursing interventions.. 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.patient will be able to enumerate at least 3 out 5 infant care measures of preventing dehydration.After 3 hours of nursing intervention the patient will be able to identify factors that could increase risk of bleeding. · Sub-acute Objective met. Independent: · Assess for signs and symptoms of G. Objectives: 1. with severe headache. the client will be at reduced risk for bleeding Intervention Rationale Evaluation Goal met. There may also be gastritis and some times bleeding. Goals & Objectives After 8 hrs. Rationale This infectious disease is manifested by a sudden onset of fever. al. Objective: · Weakness and irritability. .I bleeding. 5th Edition. · Restlessness. Taylor et. · V/S taken as follows: BP= 120/80 mmHg CR= 90bpm PR= 20cpm Temp: 37.8c. (Fundamentals of Nursing.I tract (esophagus and rectum) is the most usual source of bleeding of its mucosal fragility. Of nursing interventions. Cues Subjective: “Isang araw parang dumugo ilong ko pero konting konti palang naman”as verbalized by the Patient.
· Avoid rectal temperature. be gentle with GI tube insertions. 2. Apply pressure to venipuncture sites for longer than usual. the patient will be able to demonstrate ways to reduce risk for bleeding.After 3 hours of Nursing intervention. bleeding from one more sites. · An increase in pulse with decreased Blood pressure can indicate loss of circulating blood volume. disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors.· Observe for presence of petechiae. avoiding straining for stool. minimal trauma can cause mucosal bleeding. · Encourage use of soft toothbrush. · Recommend Objective met . · In the presence of clotting factor disturbances. · Changes may indicate cerebral perfusion secondary to hypovolemia. reducing risk for bleeding and hematoma. hypoxemia. · Minimizes damage to tissues. · Note changes in mentation and level of consciousness. ecchymosis. · Monitor pulse. · Use small needles for injections. Blood pressure. and forceful nose blowing. · Rectal and esophageal vessels are most vulnerable to rupture.
and choose and apply one way to alleviate pain. having normal BP and PR. . Pain fibers enter the spinal cord at the dorsal root ganglia and synapse in the dorsal horn. which usually occurs in response to tissue injury. Collaborative: · Monitor Hb and Hct and clotting factors. Facilitative: Assess nature and degree of discomfort. and verbalization of reduction of pain. or impending complications Cues Subjective: Complaining for (+) pain in her IV insertion site and arms.. “Ang sakit sakit niya siguro dahil sa gamut o kaya baka wala na sa linya ung IV. Nursing interventions Rationale Evaluation Goal met. active bleeding. These include: • Discussion and BP= 120/80 mmHg CR= 90bpm PR= 20cpm Temp: 37. The client was able to experienced gradual reduction or relief of pain as evidenced by decreased pain scale from 5/10 to 2/10. 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 . the patient will be able to identify at least ways of pain reduction. Acute pain. A pain scale of 5/10 Objective: Grimacing upon touching of arm Tender to touch and warm.” as verbalized by the patient. From there. The client was also able to identify 1 cause of pain. Reduces discomforts. With slight inflammation. results from activation of peripheral pain receptors and their specific A delta and C sensory nerve fibers (nociceptors). 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. · Prolongs coagulation. Provides baseline and comparison Assess blood pressure and pulse and IV site. These data provide information about the subjective experience of discomfort for this client. 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. potentiating risk of hemorrhage. · Indicators of anemia.avoidance of aspirin containing products.8c. Supplemental and Developmental: Assist with measures that reduce discomfort.
Repetitive stimulation (eg. blood pressure and pulse are elevated with anxiety. Peripheral nerves and nerves at other levels of the CNS may also be sensitized. can sensitize peripheral nociceptors. Substances released when tissue is injured. bradykinin. 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). • Warm to cold compress Ice provides local anesthesia. demonstration to the client breathing relaxation techniques and encouraging use of breathing/relax ation techniques. Divert pain to other stimulation/sensation. 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. promotes vasoconstriction. prostaglandin E2. Provides relaxation. neurokinin A) and other mediators (eg. epinephrine). 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 . serotonin. including those involved in the inflammatory cascade. These substances include vasoactive peptides (eg. calcitonin gene-related protein. producing long-term synaptic changes in cortical receptive fields (remodeling) that maintain exaggerated pain perception. reading books. talking with company.Slight Arm rubs Promotes comfort . • After 2 ½ hours of discussion and demonstration to the patient.cerebral cortex. substance P.
allows client compliance with orders. . with reasons. Analgesics act on higher brain centers to reduce perception of pain. promoting relaxation. facilitating rest and sense of well-being. After 3 hours of intervention the client will be able to verbalize improved comfortability.at least one way to alleviate pain Collaborative Administer analgesic as needed. Knowledge of typical effect aids in developing realistic expectations. Assess effectiveness of pain medication. Explain action of analgesic. time factors and restrictions. Knowledge of time restrictions.
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