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SOAPIE

1. The patient, Kent Russel Agustin, is a 2-year-old male diagnosed with DHF who was experiencing decreased oral fluid intake, concentrated urine, dry skin and mucous membranes, weakness, and changes in mental status. 2. The nurse assessed the patient to be at risk for fluid volume deficit and created a plan to maintain adequate fluid volume through monitoring, oral hygiene, encouraging fluid intake, daily weighing, education, and oral hydration solutions. 3. After 4 hours of nursing interventions, the goal was partially met as the patient maintained adequate skin turgor, capillary refill time, urine output, and stable vitals, though mucous membranes were still dry.

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1K views3 pages

SOAPIE

1. The patient, Kent Russel Agustin, is a 2-year-old male diagnosed with DHF who was experiencing decreased oral fluid intake, concentrated urine, dry skin and mucous membranes, weakness, and changes in mental status. 2. The nurse assessed the patient to be at risk for fluid volume deficit and created a plan to maintain adequate fluid volume through monitoring, oral hygiene, encouraging fluid intake, daily weighing, education, and oral hydration solutions. 3. After 4 hours of nursing interventions, the goal was partially met as the patient maintained adequate skin turgor, capillary refill time, urine output, and stable vitals, though mucous membranes were still dry.

Uploaded by

mcd7r8
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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Agustin, Mario Jr. A.

10 December
2010

BSN IV – A Group 2 Mr. Godofredo S. Perea,


R.N

SOAPIE

Patient Name: Agustin, Kent Russel DHF/2 y.o

Subjective data:

Objective data:
>Oral Fluid Intake of 30cc/1 diaper for 8 hours
>Concentrated urine-dark yellow in color
>Dry skin, Dry mucous membranes
>Weakness, Changes in mental status (restlessness, irritability)
>pale conjunctiva
>pale nail beds

Vital signs taken as follows:

BP: 90/60 mmHg


PR: 98 bpm
T: 36° C

Assessment:

Risk for fluid volume deficit related to decrease fluid intake.

Planning:

After 4 hours of nursing interventions, the patient will maintain adequate


fluid volume at a functional level as evidenced by, individually adequate fluid
volume and electrolyte balance as evidenced by urine output greater than
30 ml/hr, stable vital signs, moist mucous membranes, good skin turgor and
balance intake and output.

Intervention:
Independent:

1. Continue monitoring intake and output (accurately), character, and


amount of stools, vomiting and bleeding.

2. Monitor for neurologic and neuromuscular manifestations of hypokalemia


(e.g., muscle weakness, lethargy, altered level of consciousness).

3. Continue assessing vital signs (BP, pulse, temperature).

4. Provide oral hygiene. By means of teaching parents/patient to brush teeth


thrice a day or every after meal. (Use soft bristle to prevent bleeding
episodes)

5. Encourage patient to drink prescribed fluid amounts. If oral fluids are


tolerated, provide oral fluids patient prefers. Provide fresh water and a straw.
Be creative in selecting fluid sources (e.g., flavored gelatin, frozen juice bars,
sports drink)

6. Weigh daily.

7. Describe or teach causes of fluid losses or decreased fluid intake. Explain


to the parents importance of maintaining proper nutrition and hydration.

Dependent:

1. Administer Oral hydrating solutions/ORESOL as prescribed by the


physician.

Evaluation:

After 4 hours of nursing interventions the goal was partially met as manifested by the patient’s
ability to maintain adequate fluid volume as evidenced by:
> Patient was relaxed
>Maintained good skin turgor 2 seconds
>Maintained normal capillary refill 2 seconds
>had moist mucous membrane
>Urine output of 30-40 cc/ per hour via diaper
>Stable vital signs:
BP: 90/60 mmHg
PR: 88 bpm
T: 36.0 C

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