Acute Gastroenteritis
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| Assessment data (subjective and objective findings relevant to THIS diagnosis) | Goals / expected outcomes | Nursing intervention | Rationale | Evaluation |
|---|---|---|---|---|
| Patient reports frequent diarrhea and vomiting; dry mouth and tongue; decreased urine output; poor skin turgor; reports feeling thirsty; possible dizziness on standing | Patient will maintain adequate hydration as evidenced by moist mucous membranes, stable vital signs, and urine output of at least 30 mL/hr within 24 hours | Monitor vital signs including blood pressure, pulse, and temperature every 4 hours to detect signs of hypovolemia | Vital signs changes can indicate fluid volume deficit and help detect early hypovolemia | Vital signs remain stable or improve, indicating adequate hydration status |
| Assess mucous membranes, skin turgor, and urine output regularly to monitor hydration status | Physical signs provide direct evidence of fluid volume status and effectiveness of interventions | Improvement in mucous membranes moisture, skin turgor, and urine output observed | ||
| Encourage oral rehydration with electrolyte solutions as tolerated to replace fluid and electrolyte losses | Oral rehydration helps restore fluid and electrolyte balance and prevents worsening dehydration | Patient tolerates fluids and shows signs of improved hydration | ||
| Provide intravenous fluids as ordered if oral intake is insufficient or patient shows signs of severe dehydration | IV fluids rapidly restore circulating volume and correct electrolyte imbalances | Patient’s hydration status improves with IV therapy as evidenced by vital signs and lab results | ||
| Educate patient and family about importance of fluid replacement and signs of dehydration to report | Education promotes patient participation in care and early recognition of dehydration | Patient verbalizes understanding of hydration needs and signs to report |
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