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    Fdar - Sandra - Pyloric Stenosis - Final

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    Cheryl Moana Marie Fedelis
    The nurse documented caring for an infant patient named Sandra B. who was experiencing deficient fluid volume related to frequent projectile vomiting and dehydration. After nursing interventions like encouraging breastfeeding, monitoring intake and output, and IV/PO fluid administration, the patient's fluid volume improved within 6 hours. Later, the nurse noted the patient had imbalanced nutrition from inability to retain food, appearing lethargic and skinny. Further interventions like supplemental feeding and thickened formula helped the patient's feeding pattern and ability to retain food improve within 6 hours.

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    Fdar - Sandra - Pyloric Stenosis - Final

    Uploaded by

    Cheryl Moana Marie Fedelis
    34 views3 pages
    The nurse documented caring for an infant patient named Sandra B. who was experiencing deficient fluid volume related to frequent projectile vomiting and dehydration. After nursing interventions like encouraging breastfeeding, monitoring intake and output, and IV/PO fluid administration, the patient's fluid volume improved within 6 hours. Later, the nurse noted the patient had imbalanced nutrition from inability to retain food, appearing lethargic and skinny. Further interventions like supplemental feeding and thickened formula helped the patient's feeding pattern and ability to retain food improve within 6 hours.

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    FDAR - SANDRA - PYLORIC STENOSIS - FINAL

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    The nurse documented caring for an infant patient named Sandra B. who was experiencing deficient fluid volume related to frequent projectile vomiting and dehydration. After nursing interventions like encouraging breastfeeding, monitoring intake and output, and IV/PO fluid administration, the patient's fluid volume improved within 6 hours. Later, the nurse noted the patient had imbalanced nutrition from inability to retain food, appearing lethargic and skinny. Further interventions like supplemental feeding and thickened formula helped the patient's feeding pattern and ability to retain food improve within 6 hours.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    34 views3 pages

    Fdar - Sandra - Pyloric Stenosis - Final

    Uploaded by

    Cheryl Moana Marie Fedelis
    The nurse documented caring for an infant patient named Sandra B. who was experiencing deficient fluid volume related to frequent projectile vomiting and dehydration. After nursing interventions like encouraging breastfeeding, monitoring intake and output, and IV/PO fluid administration, the patient's fluid volume improved within 6 hours. Later, the nurse noted the patient had imbalanced nutrition from inability to retain food, appearing lethargic and skinny. Further interventions like supplemental feeding and thickened formula helped the patient's feeding pattern and ability to retain food improve within 6 hours.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    Student Nurse Name: Cheryl Moana Marie Fedelis Date: April 26, 2022

    Patient’s Name: Sandra B. Age:

    FDAR

    DATE AND TIME FOCUS PROGRESS NOTES


    04/26/2022 Deficient Fluid Volume related to projectile D: Patient’s mother verbalized that her child breast fed well for the first couple of weeks but since then
    9:00 am and frequent vomiting throws up all the time like he’s forcing all his feedings out.

    Objective cues:
    - Looks skinny
    - Look sick
    - Cries all the time
    - Presence of tears
    - Looks fussy

    Planning:
    Within 6 hours of nursing intervention the client will increase feeding and fluid intake and absence of
    dehydration.

    A: Assessed blood pressure and heart rate frequently.


    Assessed in changes in patient’s mental status such as fatigue, irritability, restlessness and confusion.
    Assessed for signs of dehydration such as thirst, non-elastic skin-turgor, dry, cracked mucous membranes
    and sunken eyes.
    Checked skin turgor on areas of the body that does not have loose skin, such as the forehead or shins.
    Assessed patient’s weight regularly at the same time and clothing.
    Recorded amount and source of output.
    Monitored intake.
    Encouraged fluids IV/PO.
    Provided mouth care 3 times, 2 hours interval.
    Encouraged the mother to breastfed frequently.
    Instructed the mother if the child vomit 3 times to stop breastfeed and administer oral rehydration
    solution.
    Monitored laboratory studies as indicated: ABGs/pH, serum electrolytes (especially potassium), and BUN.
    Administered medications as ordered by physician.
    Encouraged the mother to breastfeed or provide food in small but frequent intervals.
    Encouraged the mother to assist the child in feeding through proper position.

    R: Goal Met.
    After 6 hours of nursing intervention the client increased feeding and fluid intake and absence of
    dehydration.

    04/26/2022 Imbalanced nutrition less than body D: Patient’s mother verbalized that her child breast fed well for the first couple of weeks but since then
    11:00 am requirements related to inability to retain throws up all the time like he’s forcing all his feedings out. The patient looks skinny, sick and he cries and
    food fussy all the time.

    Objective cues:
    - Look sick
    - Lethargy
    - Look skinny
    - Looks fussy
    - Weight loss

    Planning:
    Within 6 hours of nursing interventions the client will improve feeding pattern, increase the ability to
    retain food and absence of frequent vomiting.

    A: Noted real, exact weight.


    Assessed nutritional history with the participation of significant others.
    Assessed for physical signs of poor nutritional intake.
    Ascertained etiological factors for decreased nutritional intake.
    Ascertained healthy body weight for age and height.
    Reviewed laboratory values that indicate well-being or deterioration.
    Referred to a dietitian for complete nutrition assessment and methods for nutritional support.
    Recorded amount and source of output.
    Administered medications as ordered by physician.
    Encouraged the mother to breastfeed or provide food in small but frequent intervals.
    Encouraged the mother to assist the child in feeding through proper position.
    Instructed the mother to feed the infant slowly while he or she is sitting in an infant seat or being held
    upright.
    Instructed the mother to make feedings of formula thickened with infant cereal and fed through a large-
    holed nipple to improve nutrition.
    Instructed the mother to give pacifier to the child to satisfy the baby’s need for sucking because of the
    interruption in normal feeding and sucking habits.

    R: Goal Met.
    After 6 hours of nursing interventions the client improved feeding pattern, increased the ability to retain
    food and absence of frequent vomiting.

    References:
    Wayne, G. (2022, March 19). Deficient fluid volume (dehydration) nursing care plan. Nurses Labs. Retrieved from https://nurseslabs.com/deficient-fluid-volume/

    Mange K, Matsuura D, Cizman B, Soto H, Ziyadeh FN, Goldfarb S, Neilson EG. Language guiding therapy: the case of dehydration versus volume depletion. Ann Intern Med. 1997;127:848–853. Retrieved from
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6354080

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