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Patient: R.U. Case: Dengue DCN Assessment: Cues and Clues Signs and Symptoms Su )e$ti(e Cues: ayaw niyang uminom ng tubig as verbalized by the mother & )e$ti(e Cues: -dry cracked lips -vomits 2x -irritable -decreased skin turgor Platelet:6 !P: " #6 $emp: %& P': (%) '': %* Nursing Diagnosis (Pro lem ! "tiology# 'isk +or de+icient +luid volume related to inade,uate +luid intake as mani+ested by dry mucous membranes secondary to dengue +ever S$ienti%i$ Rationale Client &ut$ome Planning Nursing Implementations' Inter(entions Rationale Group: 11 III"(aluation
-luid volume de+icit or hypovolemia occurs +rom a loss o+ body +luid. the shi+t o+ +luids into the third space or +rom a reduced +luid intake/ $he therapeutic goal is to treat the underlying disorder and return the extracellular +luid compartment to normal/ $reatment consists o+ restoring +luid volume and
S*ort +erm: 0+ter (hour o+ nursing interventions. the client will be able to: -1nderstand and verbalize the importance o+ hydration -2emonstrate techni,ues and behaviors that could help in preventing dehydration such as increase oral +luid intake/
S*ort term: -$o +acilitate cooperation as well as to gain pt6s trust - $o identi+y early signs o+ dehydration 0+ter (hour o+ nursing interventions. the client was able to: -1nderstand and verbalize the importance o+ hydration -2emonstrate techni,ues and behaviors that could help in preventing dehydration
-0ssess skin turgor and mucous membranes +or signs o+ dehydration -4onitor and document vital signs -0ssess skin color and amount o+ urine/ 'eport urine output less than % ml#hr +or 2 consecutive hours/ -5denti+y the patient6s +luid pre+erences:
correcting any electrolyte imbalances/ 'esource: Nursing Care Plans (Nursing Diagnosis and inter(ention ,t* "d# -y: Gula$.'/yers pp. 01-01
-3ncourage the patient to increase +luid intake/ a/ Place +luids at bedside within easy reach/ b/ Provide +resh water and straw/ c/ !e creative in selecting +luid sources e/g/ +lavored gelatin. +rozen :uice bars. sports drink/ 2"A3+2 +"AC2INGS: -describe and teach patient the causes o+ +luid losses or decreased +luid intake -instruct client#;< how to measure and record 5#< -encourage regular oral intake
-;electing those +luids that the patient en:oys drinking can +acilitate replacement therapy/ -5ncrease +luid intake prevents dehydration and maximizes circulation thus promotes a better and stable temperature/
-maintain 20$ # 327- diet as needed -proper hygiene and clean environment D"P"ND"N+: -'egulate 5= rate as re,uested by actual doctor6s order/ -$o ensure that ade,uate amount o+ parenteral +luid would be taken by the patient/