Care Plan for Dehydration

Category / Primary Body System

• Renal / Urinary System

Problem

• Resident is at risk for dehydration.

Goal

• Resident will maintain adequate hydration and avoid dehydration for 90 days.

Plan/Approach

1. Monitoring and Assessment

   • Assess for signs and symptoms of dehydration, such as poor skin turgor, dry mucous membranes, and dry conjunctiva.
   • Monitor for changes in mental status, reduced urine output, and changes in urine characteristics (color, odor, concentration).

2. Documentation and Communication

   • Document findings related to hydration status.
   • Notify MD/RNP/PA of any concerns regarding dehydration.

3. Dietary and Fluid Management

   • Consult with dietary services as needed to ensure appropriate fluid and electrolyte intake.
   • Encourage fluid intake with and between meals, if not contraindicated.
   • Incorporate activities that promote fluid intake during programs.

4. Medication and Laboratory Monitoring

   • Administer medications as ordered to manage underlying conditions contributing to dehydration.
   • Monitor lab results to assess hydration status and overall health.

Rationale

1. Monitoring and Assessment

   • Regular assessment for dehydration helps identify early signs and allows for timely interventions.
   • Monitoring mental status and urine output provides additional indicators of hydration status.

2. Documentation and Communication

   • Accurate documentation and timely communication with healthcare providers ensure that any changes in hydration status are addressed promptly.

3. Dietary and Fluid Management

   • Dietary consultations can help develop a plan that ensures adequate fluid and electrolyte intake.
   • Encouraging regular fluid intake and integrating fluid-rich activities prevent dehydration and promote overall health.

4. Medication and Laboratory Monitoring

   • Administering medications as prescribed addresses underlying conditions that may contribute to dehydration.
   • Regular lab monitoring provides data to guide adjustments in the care plan and ensure adequate hydration.

Actions

1. Monitoring and Assessment

   • Assess the patient for signs of dehydration daily, noting skin turgor, mucous membranes, and conjunctiva.
   • Monitor mental status and urine output, documenting any changes in behavior, alertness, or urine characteristics.

2. Documentation and Communication

   • Document all findings related to hydration status in the patient’s medical record.
   • Notify the MD/RNP/PA immediately if any signs of dehydration are detected or if there are changes in the patient's condition.

3. Dietary and Fluid Management

   • Arrange a dietary consult to develop a nutrition plan that includes adequate fluids and electrolytes.
   • Encourage the patient to drink fluids regularly, offering water, juice, and other hydrating options with and between meals.
   • Incorporate fluid-rich activities into daily routines and programs to promote regular hydration.

4. Medication and Laboratory Monitoring

   • Administer medications as prescribed, monitoring for effectiveness and any side effects that may affect hydration.
   • Conduct and review lab tests as ordered, such as serum electrolytes, blood urea nitrogen (BUN), and creatinine, to assess hydration status and kidney function.