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Nursing Diagnosis Risk for dehydration related to interference affecting access, intake or absorption of fluid (e.g.

presence of blisters and lesions in the oral cavity) Definition: - Occurs whan a body is at risk of losing body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Source: 11th edition Nurses Pocket Guide by Doenges

Rationale Viral invasion on the blood stream

Desired Outcome After 12 hours Of nursing intervention, the client will be able to: Identify individual risk factors and appropriate interventions.

Nursing Intervention

Justification

Evaluation After 12 mins. of nursing intervention, the client was able to:

Invasion of the mucous membrane

Independent: Note possible conditions/proce sses that may lead to fluid deficits:

Irritation of the sublingual and submandibular area

Fever, wounds, sores, indwelling catheters, sweating, diarrhoea and other factors can lead to excessive fluid loss. Noting such factors can serve as basis for next intervention. To ensure accurate picture of fluid status.

Infection and inflammation of the oral Cavity

Formation of Painful blister like lesion in the buccal mucosa, tongue, gums, and hard palate

Monitor I/O balance being aware of altered intake or output, as well as insensible losses. Assess skin turgor/oral mucous membranes for signs of dehydration.

Signs of dehydration reveals skin integrity, cracked lips, dryness of skin and other factors. Such information needs to be noted for further evaluation of clients condition.

Goal Met: Identify individual risk factors and appropriate interventions Goal Met: Perform therapeutic countermeasure s to diminish the risk for dehydration. Goal Met: Implement behaviors or lifestyle changesto prevent development of fluid volume deficits

Risk for Dehydration

Perform therapeutic countermeasures to diminish the risk for dehydration.

Fluids offered through a straw can reduce pain for the client when rehydrating orally. Independent: Offer fluids between meals and regularly throughout the day via straw.

Fluids may be given in this manner if client is unable to take oral fluid or is

NPO for procedures. Collaborative: Provide supplemental fluids (tube feed, IV) as indicated/prescri bed.

To stop/limit fluid losses.

Implement behaviors or lifestyle changes to prevent development of fluid volume deficit.

Administer medications as appropriate (e.g., antiemetics, antidiarrheals, antipyretics)

necessary to determine replacement needs.

Independent: Encourage mother to maintain diary of food/fluid intake, number and amount of voidings, and estimate of other fluid losses (e.g., wounds, liquid stools) Discuss individual risk factors/potential problems (e.g. excessive activities, friction hazards,

to reduce risk of heat injury and dehydration

Maintain optimal nutrition/physical well-being.

improper diets proper clothing/bedding for infants and elderly during hot weather, use of room cooler/fan for comfortable ambient environment)

Participate in prevention measures and treatment program.