Problem 3: RISK FOR FLUID VOLUME DEFICIT Cues Diagnosis Scientific Explanation Vomiting is defined as the discharge of the

contents of the stomach up into the mouth by force. Vomiting can be an attempt removing toxins from the gastrointestinal tract such as diarrhea, lower gastrointestinal tract. These may lead to fluid volume deficit. Planning Maintain fluid volume at functional level as evidenced by stable vital signs,, good skin turgor and prompt capillary refill. Intervention
>Assess vital signs, noting low blood pressure, severe hypotension, rapid heartbeat, and thread peripheral pulses. >Administer IV fluids, as indicated. Replace blood products; administer plasma expanders, as ordered. >Provide frequent oral as well as eye care >Measure and record intake and output.

Rationale

Risk for fluid Subjective cues: volume deficit matas ne lagnat related to active at 3 days neng fluid loss as mamanyuka ya as associated with verbalized by the vomiting S.O. secondary to dengue fever. Objective cues: Upon assessment the client appeared : - Irritable and weak - Skin is dry and warm to touch - Lips is pale and dry With a temperature of 38.6C Low platelet count

Expected Outcomes >These changes in At the end of the vital signs are nursing care the associated with fluid objectives were volume loss and/or met and the client hypovolemia. achieved normal fluid volume as evidenced by stable vital signs,, > Maintaining the good skin turgor balance of fluid / and prompt electrolyte. capillary refill.

>To prevent injury from dryness

> Accurate documentation helps identify fluid losses/replacement needs and influences choice of interventions.