Brian, age 12, has food poisoning. His mother describes the buffet-style restaurant they had eaten in the previous night. Brian became ill about 2 hours after eating. He has severe diarrhea, vomiting that has stopped at present, and a low-grade temperature of 100.2°F orally. His cheeks are flushed, skin is hot and dry, skin turgor is fair, and lips are dry and cracked. ?
Devise a nursing care plan for Brian. Include assessment data to observe, nursing diagnosis, goals, and nursing interventions.
Assessment data to observe: general appearance and behavior, poor skin turgor, decreased urinary output, sunken fontanel (in infant), decreased weight, increased pulse and respiration, decreased blood pressure, prolonged capillary refill.
Nursing diagnosis: altered nutrition-less than body requirements related to diarrhea losses and inadequate intake; fluid volume deficit related to excessive GI losses in stool or emesis.
Goals: child will maintain adequate hydration as evidenced by absence of above symptoms; child will maintain appropriate nutrition for age as evidenced by eating and retaining foods; child will not spread the infection to others; the family will receive appropriate support and education, especially home care and prevention.
Nursing interventions:
administer rehydration liquids, beginning with small amounts and gradually increasing to a regular diet; administer IV fluids as ordered; strict intake and output; weigh daily; assess vital signs, skin turgor, mucous membranes, mental status; discourage intake of carbonated beverages, fruit juices, and gelatin (these are high in carbohydrates, low in electrolytes, and have a high osmosis level); instruct family in providing appropriate therapy, monitoring intake and output, and assessing for signs of dehydration.
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