F3 · Dehydration
Actual Food and fluids
Definition
The body has too little water, shown by thirst, dry mouth, dark urine, or low blood pressure.- Vomiting
- diarrhea
- poor drinking
- fever
- diuretics
- burns
- Thirst
- dry mouth
- dark urine
- low blood pressure
- fast pulse
- sunken eyes
📋 Scenario
A child with diarrhea has dry lips, sunken eyes, and no tears.
Subjective (S): "I'm so thirsty and tired."
Objective (O): Dry mucous membranes; sunken eyes; heart rate 126/min in a child; reduced skin elasticity; dark scant urine; weight down 0.5 kg.
Assessment tools for this scenario: CP-FLUID Fluid Balance & Nutrition Score CP-SKIN Skin & Wound Score CP-ELIM Elimination Check
Validated scales to consider: MUST, fluid chart, glucose, Braden Scale, TIME wound chart, Bristol Stool Chart, bladder scan
**CarePath diagnosis:** Dehydration related to diarrhea, as evidenced by dry mucous membranes, sunken eyes, a fast heart rate, and dark scant urine.
**Interventions and rationale**
| Intervention | Rationale |
|---|---|
| Measure intake and output. | Measuring intake and output shows whether fluid losses are being replaced and how the kidneys are coping. |
| Give oral rehydration or intravenous fluids as ordered. | Oral rehydration solution replaces water and salts, and intravenous fluids are used when drinking is not enough or not safe. |
| Weigh. | Weight changes, especially in a child, reflect fluid loss or gain accurately. |
| Report low urine output. | Low urine output signals that fluid is still too low and the kidneys are not getting enough blood, so stronger treatment may be needed. |
**Expected outcomes**
- Within 12 hours: urine pale and normal in amount, mucous membranes moist, heart rate and blood pressure normal for age.
- Drinks fluids willingly.
**Linking the data to the diagnosis**
The child has diarrhea, dry lips, sunken eyes and no tears. The nurse finds dry mucous membranes, heart rate 126/min, reduced skin elasticity, dark scant urine and weight down 0.5 kg. The patient says they are very thirsty and tired. This is an actual problem because fluid loss is already shown by these signs, so a risk statement would be wrong. Fluid build-up in the body is the opposite problem and does not apply. The plan aims for pale urine in normal amounts, moist mucous membranes and a normal heart rate and blood pressure for age within 12 hours, with the child drinking willingly.
CarePath diagnosis
Dehydration related to diarrhea, as evidenced by dry mucous membranes, sunken eyes, a fast heart rate, and dark scant urine.
Interventions and rationale
Listed in priority order.
| Intervention | Rationale |
|---|---|
| 1. Measure intake and output. | Measuring intake and output shows whether fluid losses are being replaced and how the kidneys are coping. |
| 2. Give oral rehydration or intravenous fluids as ordered. | Oral rehydration solution replaces water and salts, and intravenous fluids are used when drinking is not enough or not safe. |
| 3. Weigh. | Weight changes, especially in a child, reflect fluid loss or gain accurately. |
| 4. Report low urine output. | Low urine output signals that fluid is still too low and the kidneys are not getting enough blood, so stronger treatment may be needed. |
Expected outcomes
- Within 12 hours: urine pale and normal in amount, mucous membranes moist, heart rate and blood pressure normal for age.
- Drinks fluids willingly.
Linking the data to the diagnosis
The child has diarrhea, dry lips, sunken eyes and no tears. The nurse finds dry mucous membranes, heart rate 126/min, reduced skin elasticity, dark scant urine and weight down 0.5 kg. The patient says they are very thirsty and tired. This is an actual problem because fluid loss is already shown by these signs, so a risk statement would be wrong. Fluid build-up in the body is the opposite problem and does not apply. The plan aims for pale urine in normal amounts, moist mucous membranes and a normal heart rate and blood pressure for age within 12 hours, with the child drinking willingly.