V-sim Care Plan for Eva Madison (Core)_2020 | NUR 308 _ V-sim Care Plan for Eva Madison (Core)

V-sim Care Plan for Eva Madison (Core) Nursing Diagnosis: 1. Deficient fluid volume r/t vomiting & diarrhea as evidenced by tenting on hands, dry mucous membranes, increase in body temperature, increased heart rate, and weakness. 2. Ineffective peripheral tissue perfusion r/t severe dehydration as evidenced by capillary refill 3 seconds, increased heart rate, cold extremities, skin tenting, hyperactive bowel sounds, and anuria 3. Deficient knowledge r/t unfamiliarity w/ disorder and treatment as evidenced by anxiety, lack of information, and verbalized misconceptions. Source for Care Plan: Martin, P., Martin, P., & Martin, P. (2019, April 10). 4 Gastroenteritis Nursing Care Plans. Retrieved from Assessment data Planning and Implementation Phase Rationale (Cite References) Evaluation Goals met/partially met Or unmet Goals (1 Long, 2 Short Term) Interventions (Min. of 3 per goal) Subjective: Patient was admitted from the ED w/ 3 day history of vomiting & diarrhea, inability to keep fluids down, and no urination since 20:00 yesterday. She has lost 0.7kg since her last check up (a few months ago). She is pale and listless; mucous membranes are dry; rates abdominal pain 2/10 (FACES PAIN SCALE) Objective: Patient was AAO X 3; heart sounds-S1, S2; lung sounds-clear; brachial pulse bilateral +2; ECG reading: sinus tachycardia; tenting sign of skin; cold extremities; prolonged capillary refill time (8 seconds) SHORT TERM: 1. The child will return to normal hydration status & will not develop hypovolemic shock 2. Patient maintains maximum tissue perfusion to vital organs as evidenced by warm & dry skin, present & strong peripheral pulses, vitals w/in normal range, balanced I&O, normal ABGs, alert LOC, absence edema, absence of chest pain LONG TERM: 1. Client & caregivers will understand causes of gastroenteritis, mode of transmission, and management of symptoms 1. - Assess the client’s skin turgor & mucous membranes for signs of dehydration - Assess the volume & frequency of vomiting -Assess the consistency & number of bowel movements -Assess the color & amount of urine -Assess pt temperature - Monitor weight daily & consistently w/ the same scale preferably @ the same time of day -Administer intravenous fluids as ordered. Monitor for crackles in dependent portions of the lungs -Encourage regular oral hygiene. 2. - Assess for signs of decreased tissue perfusion -Assess PR & BP; monitor BP for orthostatic changes (drop of 20 mmHg systolic BP or 10 mmHg diastolic BP w/ position change -Check for pallor, cyanosis, mottling, cool or clammy skin. Assess quality of every pulse 1.Assess client’s knowledge of gastroenteritis, its mode of transmission, and its treatment. - Educate the client & family about the causes and treatments of gastroenteritis -Educate the client about the importance of hand washing after toileting and perianal hygiene and before preparing food for others. 1. -Frequent assessment of hydration status facilitates rapid intervention & evaluation of the effectiveness of fluid replacement - Vomiting is associated with fluid loss -Gastroenteritis is associated with an increased frequency of very loose or watery bowel movements. The inflammation in the large intestine limits the colon’s ability to absorb water, leading to fluid volume deficit. -A decrease in urine volume and concentrated urine, as evidenced by a darker urine color, denotes fluid deficit. Fever that occurs with gastroenteritis increases fluid loss through perspiration and increased respiration. -The client with gastroenteritis may experience weight loss from fluid loss with diarrhea and vomiting. Instruction facilitates accurate measurement and assessment provides useful data for comparisons and helps in following trends. - Replace fluid lost from the body. Excessive replacement of sodium containing fluids could cause extracellular fluid volume excess. -Fluid deficit can cause a dry, sticky mouth. Attention to mouth care promotes interest in drinking and reduces the discomfort of dry mucous membranes. -Particular clusters of s/s occur w/ differing causes. Evaluation of Ineffective Tissue Perfusion defining characteristics provide a baseline for future comparison -Stable BP is needed to keep sufficient tissue perfusion. -Nonexistence of peripheral pulses must be reported or managed immediately. Systemic vasoconstriction resulting from reduced cardiac output may be manifested by diminished skin perfusion & loss of pulses. Therefore, assessment is required for comparison 1. Clients who experience diarrhea and vomiting may not correlate the symptoms with an acquired intestinal infection. The client may not realize the risk for transmitting the infection to others. -Knowledge about the possible cause of this episode of gastroenteritis will help the client initiate to prevent future episodes. The client needs to recognize that the use of antibiotics is controversial in managing diarrhea. The client needs to understand the importance of fluid replacement. -Good hand washing will prevent the spread of infectious agents. N/A - - - - - -- Continued