Concept Care Plan Mapping: Eva Madison Case Study

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Nursing History

Patient: Eva Madison; Informant: Her mother and self; Age: 5 years; Gender: Female

Admitting diagnosis: dehydration

Children belong to a group of people who are vulnerable to dehydration due to their age and the lack of knowledge about major sanitation rules. Children are not able to identify and explain their concerns or meet their basic needs properly. Pediatric dehydration is a result of gastroenteritis that is usually characterized by vomiting and diarrhea (Anigilaje, 2018). The negative fluid balance causes dehydration and provokes fluid shifts that have to be monitored and controlled (Anigilaje, 2018). Dry mouth, sunken eyes, and listlessness are the main signs.

Chief complaint: vomiting and nausea

History of present illness: inability to keep fluids down during the last three days

Allergies: no known

Medications: none

Past medical history: no information

Immunization: no information

Psychosocial history: no information

Family history: no information

Assessment	Nursing Diagnosis	Goals/Outcomes	Nursing Interventions	Rationale	Evaluation
As evidenced by vomiting and diarrhea during the last three days, weight loss, dry mucous membrane, and no urination since yesterday	At risk for fluid volume deficit	Short-term: capillary refill in less than three seconds; stabilized vital signs Long-term: adequate fluid balance; dehydration prevention in the next year	1. Monitoring of vital signs 2. Education of family members on how to manage dehydration at home	1. Changes in vital signs (elevated temperature) say about infection 2. The child suffered from vomiting and diarrhea for several days, and the parents did nothing.		Both goals are met: electrolyte balance is restored, and Eva’s family are aware of how to manage dehydration problems. It is predicted that Eva’s parents should know how to help the child with vomiting at home.
As evidenced by low blood pressure (80/65), tachycardia, nausea, and pain (2 on 0-5 scale)	Decreased cardiac output	Short-term: dysrhythmia absence; pulse is within normal limits Long-term: adequate cardiac output, stable blood pressure in hospital	1. Monitor fluid intake 2. Monitor lab results	1. Patients with similar symptoms could have poorly functioning ventricles that do not tolerate increased fluid 2. Routine blood or urine analysis shows the etiology of the condition and indicates critical changes	Both goals are met: Eva’s pulse and blood pressure are restored. It is expected that Eva’s parents pay attention to her vitals and report on changes, if any.

Reference

Anigilaje, E. A. (2018). Management of diarrhoeal dehydration in childhood: A review for clinicians in developing countries. Frontiers in Pediatrics, 6.

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