Lopez, Maria Sofia B.

10/14/2020

3-BSN-B Prof. Zoleta

NURSING CARE PLAN: DEHYDRATION

NURSING PLANNING
ASSESSMENT DIAGNOSIS GOAL / NURSING RATIONALE EVALUATION
EXPECTED INTERVENTIO
OUTCOME NS
Subjective: Deficient fluid After a series -Monitored vital -to give the After a series
-history of volume of nursing signs. correct of nursing
vomiting & related to intervention, diagnosis and intervention,
diarrhea from the hypotonic the patient note changes the patient was
flu dehydration will be able to able to
as evidenced maintain fluid -Noted change -these signs maintain fluid
Objective: by history of volume at a in usual indicate volume at a
-rapid pulse vomiting & functional mentation, sufficient functional
-orthostatic diarrhea from level. behavior, or dehydration level.
Hypotension the flu, urine functional to cause poor
-urine output of output of 20 abilities cerebral
20 mL/hr mL/hr, skin perfusion or
-skin turgor poor turgor poor electrolyte
with tenting with tenting, imbalance.
- increased orthostatic
respiratory hypotension, - Monitored fluid - Most fluid
rate rapid pulse, status in comes into
and relation to the body
increased dietary intake. through
respiratory drinking,
rate. water in food,
and water
formed by
oxidation of
foods.
Verifying if
the patient is
on a fluid
restraint is
necessary.

- Noted - These
presence of factors
nausea, influence
vomiting and intake, fluid
fever. needs, and
route of
 replacement.

- Encouraged - Oral fluid

the patient to replacement
drink prescribed is indicated
amount of fluid. for mild fluid
deficit and is
a cost-
effective
method for
replacement
treatment.

- Aid the patient - Dehydrated

if he or she is patients may
unable to eat be weak and
without unable to
assistance,and meet
encourage the prescribed
family or SO to intake
assist with independentl
feedings, as y.
necessary.

- Administered - Fluids are

parenteral fluids necessary to
as prescribed. maintain
Consider the hydration
need for an IV status.
fluid challenge Determinatio
with immediate n of the type
infusion of fluids and amount
for patients with of fluid to be
abnormal vital replaced and
signs. infusion rates
will vary
depending on
clinical
status.

NURSING PLANNING
ASSESSMENT DIAGNOSIS GOAL / NURSING RATIONALE EVALUATION
EXPECTED INTERVENTIO
OUTCOME NS
Subjective: Impaired skin After a series -Monitored vital -to obtain After a series
-history of integrity of nursing signs. baseline data of nursing
vomiting & related to intervention, intervention,
diarrhea from the changes in the patient - Inspect skin for - Indicate the patient was
flu fluid status as will be able to changes in areas of poor be able to
evidenced by maintain color, turgor, circulation/br maintain
Objective: skin turgor optimal and vascularity. eakdown that optimal
-rapid pulse poor with nutrition and may lead to nutrition and
-orthostatic tenting. physical well- decubitus physical well-
Hypotension being. formation/infe being.
-urine output of ction
20 mL/hr
-skin turgor poor - Monitored fluid - Detects
with tenting intake and presence of
- increased hydration of skin dehydration
respiratory and mucous or
rate membranes. overhydration
that affects
circulation
and tissue
integrity at
the cellular
level

- Encouraged - Sufficient
adequate hydration and
nutrition and nutrition help
hydration: maintain skin
-2000 to 3000 turgor,
kcal/day (more if moisture, and
increased suppleness,
metabolic which
demands) provide
-Fluid intake of resilience to
2000 mL/day damage
unless medically caused by
restricted. pressure.
Patients with
limited
cardiovascul
ar reserve
may not be
able to
tolerate much
fluid.
-Provided -to provide a
optimum positive
 nutrition, nitrogen
including balance to
vitamins and aid in skin
increased and tissue
protein intake healing and
to maintain
general good
health

NURSING PLANNING
ASSESSMENT DIAGNOSIS GOAL / NURSING RATIONALE EVALUATION
EXPECTED INTERVENTIO
OUTCOME NS
Subjective: Diarrhea as After a series -Obtained -to obtain After a series
-history of evidenced by of nursing history and baseline data of nursing
vomiting & history of intervention, observe stools intervention,
diarrhea from the diarrhea from the patient for volume, the patient was
flu the flu will be able to frequency, and be able to
reestablish precipitating reestablish and
Objective: and maintain factors related maintain
-rapid pulse normal to occurrence normal pattern
-orthostatic pattern of of diarrhea. of bowel
Hypotension bowel functioning.
-urine output of functioning. -Restricted -to allow for
20 mL/hr solid food bowel rest
-skin turgor poor intake, as and reduced
with tenting indicated intestinal
- increased workload
respiratory
rate -Provided - to avoid
changes in foods or
dietary intake substances
that
precipitate
diarrhea

-Assess for -indicating

presence of dehydration
postural
hypotension,
tachycardia,
skin hydration,
and condition
of mucous
membranes

-Administered -to decrease

antidiarrheal gastrointestin
medications as al motility and
ordered by the minimize fluid
physician. losses

-Encouraged to -helps to
increase oral avoid from
fluid intake. constipation

NURSING PLANNING
ASSESSMENT DIAGNOSIS GOAL / NURSING RATIONALE EVALUATION
EXPECTED INTERVENTIO
 OUTCOME NS
Subjective: Imbalanced After a series -Noted real, - These After a series
-history of Nutrition: less of nursing exact weight; anthropomorp of nursing
vomiting & than body intervention, do not hic intervention,
diarrhea from the requirements the patient estimate. assessments the patient was
flu related to will be able to are vital that able to
ingest food demonstrate they need to verbalize
Objective: as evidenced progressive be accurate. understanding
-rapid pulse by history of weight gain These will be of body and
-orthostatic vomiting & toward goal. used as basis energy needs.
Hypotension diarrhea from for caloric and
-urine output of the flu. nutrient
20 mL/hr requirements.
-skin turgor poor
with tenting - Noted the - Various
- increased patient’s psychological,
respiratory perspective psychosocial,
rate and feeling religious, and
toward eating cultural
and food. factors
determine the
type, amount,
and
appropriatene
ss of food
utilized.

- If patient lacks - Nursing

strength, assistance
schedule rest with activities
periods before of daily living
meals and (ADLs) will
open packages conserve the
and cut up food patient’s
for patient. energy for
activities the
patient values.
Patients who
take longer
than one hour
to complete a
meal may
require
assistance.

-Considered six
small nutrient- -Eating small,
dense meals frequent
instead of three meals lessens
larger meals the feeling of
 daily to lessen fullness and
the feeling of decreases the
fullness. stimulus to
vomit.

NURSING PLANNING
ASSESSMENT DIAGNOSIS GOAL / NURSING RATIONALE EVALUATION
EXPECTED INTERVENTIO
OUTCOME NS
Risk for After a series -Monitored -Tachycardia, After a series
electrolyte of nursing heart rate and bradycardia of nursing
imbalance intervention, rhythm by and other intervention,
the patient palpation and dysrhythmias the patient was
will be able to auscultation. are able to
display associated
laboratory with
results within potassium,
normal range calcium and
for individual. magnesium
imbalances.

-Monitored -The levels of

serum electrolytes in
electrolyte the body can
levels. become too
low or too
high. Early
detection of
abnormality in
serum
electrolyte
levels allows
prompt
initiation of
measures to
prevent
further
imbalances.

-Administered -Oral or IV
electrolyte administration
replacements of electrolytes
as prescribed. may be
prescribed to
keep
electrolyte
balance for
patients at risk
for
imbalances.

-Educated the -Patients need

patient about to learn to
dietary sources read labels to
of electrolytes. identify all
sources of
sodium in
foods.
Changing
from table salt
to a
potassium-
based salt
substitute is
another way
to shift your
sodium-
potassium
balance, and
some
preliminary
study implies
that making
this switch
may have
benefits for
the heart.