FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING

2010-2011

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION

S: Ineffective Airway Dehydration GOAL: The goal was partially met, the
- Client’s mother Clearnce related to means your body After 4 hours of patient was able to demonstrate
verbalized retained clearance does not have as nursing shift, the adequate fluid balance as
“Nahihirapan as manifested by much water and patient may be evidenced by stable vital signs,
siyang huminga unproductive fluids as it should. able to feel free palpable pulses/good quality,
dahl sa kanyang cough. Dehydration can from diarrhea. normal skin turgor, moist
sipon at ubo” be caused by mucous membranes; individual
- She also added, losing too much OBJECTIVES: appropriate urinary output; lack
“ayaw niya fluid, not drinking The patient may of excessive weight fluctuation
idura/ ilabas enough water or be able to: (loss/gain), and absence of
yung plema, fluids, or both. edema.
nilulunok niya, Vomiting and 1. Maintain a. Note potential Causative/contributing
bata e.” diarrhea are hydration sources of fluid factors for fluid
common causes. loss/intake, presence imbalances.
O: of conditions such as
- Presence of Infants and diabetes, burns, use of
unproductive children are more total parenteral
cough nutrition (TPN), etc.
susceptible to
- Irritable
- Difficulty in dehydration than b. Note child’s age, Affects ability to tolerate
vocalizing adults because of size, weight, and fluctuations in fluid level
- Restlessness their smaller body cognitive abilities. and ability to respond to
- Vital signs: weights and higher fluid needs.
 RR: 38bpm turnover of water
 PR: 150cpm
and electrolytes.
c. Monitor vital signs, Indicators of hydration
The elderly and mucous membranes, status. Note: Hypotension
those with weight, skin turgor, indicative of developing
illnesses are also breath sounds, urinary shock may not be readily
at higher risk. and gastric output, observed in pediatric
amount of blood patients until very late in
draws, hemodynamic the clinical course.
Dehydration is measurements.
classified as mild,
d. Review child’s intake Children often do not
moderate, or
of fluids. take in enough oral fluids
severe based on
to meet hydration needs.
how much of the
body's fluid is lost e. Determine child’s Provides information for
or not replenished. normal pattern of baseline and comparison.
When severe, elimination, and If child is in diapers,
whether child is toilet output may be
dehydration is a
trained. determined by weighing
life-threatening
diapers.
emergency.
f. Determine whether Evaluation of these issues
child has problems is important for
with urination, such as determining cause and
urine retention, bed- treatment of underlying
wetting, burning, problem.
holding.

g. Note uses of May increase fluid and

drainage devices such electrolyte losses.
as nasogastric tube,
wound drain; use of
laxatives, enemas, and
suppositories.

2. Promote a. Administer IV fluids Because smaller volumes

wellness via control are administered, close
device/pump. monitoring and
regulation is required to
prevent fluid overload
while correcting fluid
balance.

b. Replace electrolytes Oral replacement

as indicated by oral solutions formulated for
route whenever children are often safer
possible. and better tolerated
when given orally if
time/condition allows.

c. Monitor laboratory Indicators of adequacy of

results, e.g.,
hemoglobin/hematocri hydration/therapeutic
t (Hb/Hct), BUN, urine interventions.
osmolality/specific
gravity.

d.Arrange with
laboratory to combine Excessive/repetitive
common tests and blood draws may
draw smallest amount markedly reduce Hb/Hct
of blood that is levels in pediatric
necessary to perform patients.
required tests.