Define these Nursing Care Plan Items on DEHYDRATION:

1. Assessment
2. Nursing Diagnosis
3. Expected Outcomes
4. Implementation and Rationale
5. Evaluation
6. Subjective Data
7. Objective Data
8. Medical diagnosis
9. Nursing Dx. With R/T (related to) and AEB (as evidence by) components

Answer:

Assessment:

1. Monitor and document vital signs especially BP and HR.--- Decrease in circulating blood volume can cause hypotension and tachycardia. Alteration in HR is a compensatory mechanism to maintain cardiac output. Usually, the pulse is weak and may be irregular if electrolyte imbalance also occurs. Hypotension is evident in hypovolemia.

2. Assess skin turgor and oral mucous membranes for signs of dehydration.--- Signs of dehydration are also detected through the skin. Skin of elderly patients losses elasticity, hence skin turgor should be assessed over the sternum or on the inner thighs. Longitudinal furrows may be noted along the tongue.

3. Assess alteration in mentation/sensorium (confusion, agitation, slowed responses)--- Alteration in mentation/sensorium may be caused by abnormally high or low glucose, electrolyte abnormalities, acidosis, decreased cerebral perfusion, or developing hypoxia. Impaired consciousness can predispose patient to aspiration regardless of the cause.

4. Assess color and amount of urine. Report urine output less than 30 ml/hr for 2 consecutive hours.--- A normal urine output is considered normal not less than 30ml/hour. Concentrated urine denotes fluid deficit.

5. Auscultate and document heart sounds; note rate, rhythm or other abnormal findings.--- Cardiac alterations like dysrhythmias may reflect hypovolemia and/or electrolyte imbalance, commonly hypocalcemia.

6. Weigh daily with same scale, and preferably at the same time of day.--- Weight is the best assessment data for possible fluid volume imbalance. An increased in 2 lbs a week is consider normal.

7. Monitor for the existence of factors causing deficient fluid volume (e.g., gastrointestinal losses, difficulty maintaining oral intake, fever, uncontrolled type II diabetes mellitus, diuretic therapy).--- Early detection of risk factors and early intervention can decrease the occurrence and severity of complications from deficient fluid volume. The gastrointestinal system is a common site of abnormal fluid loss.

Nursing Diagnosis:

Fluid Volume Deficit

Expected Outcomes:

• Patient is normovolemic as evidenced by systolic BP greater than or equal to 90 mm HG (or patient's baseline), absence of orthostasis, HR 60 to 100 beats/min, urine output greater than 30 mL/hr and normal skin turgor.
• Patient demonstrates lifestyle changes to avoid progression of dehydration.
• Patient verbalizes awareness of causative factors and behaviors essential to correct fluid deficit.
• Patient explains measures that can be taken to treat or prevent fluid volume loss.
• Patient describes symptoms that indicate the need to consult with health care provider.

Implementation and Rationale:

1. Urge the patient to drink prescribed amount of fluid.---Oral fluid replacement is indicated for mild fluid deficit and is a cost-effective method for replacement treatment. Older patients have a decreased sense of thirst and may need ongoing reminders to drink. Being creative in slecting fluid sources (e.g., flavored gelatin, frozen juice bars, sports drink) can facilitate fluid replacement. Oral hydrating solutions (e.g., Rehydralyte) can be considered as needed.

2. Educate patient about possible cause and effect of fluid losses or decreased fluid intake.--- Enough knowledge aids the patient to take part in his or her plan of care.

3. Enumerate interventions to prevent or minimize future episodes of dehydration.---Patient needs to understand the value of drinking extra fluid during bouts of diarrhea, fever, and other conditions causing fluid deficits.

4. Teach family members how to monitor output in the home. Instruct them to monitor both intake and output.--- An accurate measure of fluid intake and output is an important indicator of patient's fluid status.

5. If patient can tolerate oral fluids, give what oral fluids patient prefers. Provide fluid and straw at bedside within easy reach. Provide fresh water and a straw.--- Most elderly patients may have reduced sense of thirst and may require continuing reminders to drink.

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

Evaluation:

• Patient is now normovolemic as evidenced by systolic BP greater than or equal to 90 mm HG (or patient's baseline), absence of orthostasis, HR 60 to 100 beats/min, urine output greater than 30 mL/hr and normal skin turgor.
• Patient was able to demonstrate lifestyle changes to avoid progression of dehydration.
• Patient was able to verbalize awareness of causative factors and behaviors essential to correct fluid deficit.
• Patient was able to explain measures that can be taken to treat or prevent fluid volume loss.
• Patient was able to describe symptoms that indicate the need to consult with health care provider.

Subjective Data:

"I have this feeling that I want to drink all the time and lately I am feeling weak. I also had diarrhea for the past 2 days."

Objective Data

• Alterations in mental state
• Patient complaints of weakness and thirst that may or may not be accompanied by tachycardia or weak pulse
• Weight loss (depending on the severity of fluid volume deficit)
• Concentrated urine, decreased urine output
• Dry mucous membranes, sunken eyeballs
• Weak pulse, tachycardia
• Decreased skin turgor
• Decreased blood pressure, hemoconcentration
• Postural hypotension
• temperature of 37.8

Medical diagnosis:

Dehydration

Doctors can often diagnose dehydration on the basis of physical signs and symptoms.

Nursing Dx. With R/T (related to) and AEB (as evidence by) components

Fluid Volume Deficit related to active fluid volume loss as evidenced by diarrhea

Fluid Volume Deficit related to Failure of regulatory mechanism as evidenced by fever, Weak pulse and tachycardia

Answers are given rationale and below are the references. 

https://nurseslabs.com/deficient-fluid-volume/#nursing_assessment_for_fluid_volume_deficit

https://www.mayoclinic.org/diseases-conditions/dehydration/diagnosis-treatment/drc-20354092