ASSESSMENT EXPLANATION PLANNING INTERVENTION RATIONALE EVALUATION

Subjective An imbalance in fluids and Short term goal; After Dx

“Ryan’s not keeping his electrolytes can result in 8 hours of Nursing Short term goal;
feedings down” excessive amounts of fluids intervention: The 1. Assess skin turgor, - Fluid loss occurs first in extracellular
in the body or dehydration. mucous membrane spaces, resulting in poor skin turgor
as verbalized by the patient be able to Goal met
This can happen as a result every shift. and dry mucous membrane.
patient’s mother. of an alteration in body After 8 hours of
systems, chronic disease, -Exhibit moist mucous nursing intervention
certain medications, or an membrane and good The patient was able
Objective Data 2. Monitor vital signs ate
underlying illness. skin turgor. to exhibit moist
-Decreased skin turgor every four hours. - Increased temperature and
mucous membrane
-Decreased tongue turgor Reference: respiratory rate contribute to fluid
-Refrain feeding without and skin turgor turns
-Lethargic loss, weak pulse and low blood
experiencing vomiting back normally.
-Warm to touch pressure may indicate dehydration.
(Nurse Labs, 2019)
-Sunken Fontanels
Long term goal After 5
-Dry mucous membrane days of Nursing
intervention: The patient Long term goal;
3. Assess the
VS taken as ff: will be able to: - A child with dehydration may
child behavior and activity. develop anorexia, decreased
-T- 100 F Goal met
activity level and general malaise.
-PR-180 BPM -Exhibit fluid and After 5 days of
-RR- 45/ min electrolyte balance. nursing intervention
Tx
-Weight- 7 lbs. the patient was able
-Maintain normal to exhibit fluid
4. Weigh the patient daily. - Provides the best assessment for
NURSING DIAGNOSIS weight. current fluid status and adequacy of electrolyte balance
fluid replacement. as manifested on his
Fluid volume deficit related latest laboratory
to loss of result.
fluids and - Fluid balance is less stable in young
electrolytes as manifested by 5. Monitor IV fusion every children, infusing too rapidly or too
vomiting. hour. slowly can lead to fluid imbalance.
6. Secure the IV site by
wrapping it with a soft
bandage.
7. Provide mouth care
Edx:
8. Educate the pt’s family
member about possible
cause and effect of fluid
losses or decreased fluid
intake.
9. Promote family coping
- To protect the site and allow the
child to move his hand and arm
freely.
- The infant needs good mouth care
as the mucous membranes of the
mouth may be dry because of
dehydration and omission of oral
fluids before surgery; a pacifier can
satisfy the baby’s need for sucking
because of the interruption in
normal feeding and sucking habits.
- Enough knowledge aids the
patient’s family to take part in his or
her plan of care.
- Include the caregivers in the
preparation for surgery and explain
the importance of added IV fluids,
the reason for ultrasonographic or
barium swallow examination, and
the function of the NG tube and
saline lavage; describe the surgical
procedure to be performed; and
explain what to expect and how
long the operation will last.