University:
West Coast University
Course:
NURS 110 | Introduction to Professional Nursing
Academic year:

2020
Views:

141

Pages:

2
Author:

Jasmine Esparza

Assessment Subjective cues: (State verbalization of patient with regards to decrease fluid intake) Objective cues: BP: 100/70m mHg RR: 19 cpm HR: 83 bpm Decrease d fluid intake of 20cc. Diagnosis (NANDA-based) Risk for Dehydration related to deficient fluid intake. Planning Short term: 1. At the end of 30 minutes of health education, the patient will be able to perceive importance of re-hydration. 2. At the end of 8 hours, the patient will be able to increase fluid intake by 500 cc. Long term: 1. At the end of 2 days, the client will be able to improve skin turgor from dry to fair. 2. At the end of 4 days, the client will have a balanced intake and output. NURSING CARE PLAN Intervention Independent: 1. Monitor signs and symptoms of hypokolemia. 2. Strict monitoring of intake and output. 3. Encourage patient to increase fluid intake. 4. Educate client on drinking small amounts of fluid every hour. 5. Refer if patient is experiencing hypotension and tachycardia. 6. Encourage patient to eat potassium rich foods such as banana. Collaborative/Dependent: 1. Educate patient and mother about the benefits and importance of adequate fluid intake and drug supplements. 2. Collaborate in treatment of underlying condition. 3. Administer oral rehydration salts such as Pedialyte. Rationale (cite sources) Evaluation (actual) (NANDA, 12th edition) Independent: 1. Hypokolemia can be lifethreatening. Careful assessment for early presence is needed. 2. Because 40mEq of potassium is lost per every liter of urine. 3. To prevent dehydration and improve skin turgor. 4. To slowly adapt to new hydration plan and fluid intake. 5. Tachycardia, bradycardia, and other dysrhthmias are associated with potassium, calcium and magnesium imbalances. Collaborative/Dependent: 1. Education allows patient and mother to understand the benefits of adequate fluid intake and drug supplements. 2. To prevent or limit effects of electrolyte imbalances. Short term: 1. After 30 minutes, patient expresses want to increase fluid intake. 2. After 8 hours, patient increased her fluid intake from 20 cc to 500 cc. 3. After 1 hour, both client and mother verbalized understanding of the importance of adequate fluid intake. Long term: 1. After 2 days, the client shows negative dryness of skin and lips. Skin is fair and lips are not cracked. 2. After 4 days, the Laborato ry result: Decrease d potassiu m level of 3.44 mEq. Dry skin Dry lips Poor pulse in lower extremiti es 3. At the end of 1 week, the client will be able to maintain body fluid level and increase potassium level. 3. To recover electrolyte imbalances. client’s intake and output are balanced with minimal difference. 3. After 1 week, client has increased fluid intake from 450 cc to 700 cc and potassium levels have increased to normal.