Cues/Needs
Nursing Diagnosis Subjective data: Risk for fluid volume deficit Objective data: related to >Oral Fluid Intake of decreased fluid 30cc for 8 hours intake.
>Concentrated urinedark yellow in color >Dry skin, Dry mucous membranes >Weakness, Changes in mental status (restlessness, irritability) >pale conjunctiva >pale nailbeds Vital signs taken as follows: BP: 90/60 mmHg PR: 98 bpm T: 36° C Weight: 55 lbs
Rationale
Goals and Interventions objectives Short term goal: Independent: Fluid volume deficit occurs After 4 hours of 1.Continue monitoring from a loss of nursing intake and output body fluid or the interventions, the (accurately), character, and shift of fluids patient will amount of stools, vomiting into the third maintain adequate and bleeding. space, or from a fluid volume at a reduced fluid functional level as 2.Monitor for neurologic intake. One evidenced by: and neuromascular common source individually manifestations of of fluid loss is adequate fluid hypokalemia (e.g., muscle nausea and volume and weakness, lethargy, altered vomiting, electrolyte balance level of consciousness). bleeding and as evidenced by excessive urine output greater 3. Continue assessing vital urination. In than 30 ml/hr, stable signs (BP, pulse, Dengue vital signs, moist temperature). Hemorrhagic mucous membranes, Fever signs and good skin turgor symptoms that and balance intake could manifest and output. are vomiting and Long term goal: frequent bleeding from After 3 days of 4.Provide oral hygiene. By gastrointestinal health teaching and means of teaching patient to tract in the form nursing brush teeth thrice a day or of hematemesis interventions: every after meal. (Use soft or melena that 1. Gain weight. bristle to prevent bleeding may lead to fluid 2. Show Showss no episodes) loss. sign of 5.Encourage patient to drink dehydration
Rationale
1.Indicates excessive fluid loss or resultant of dehydration. Accurate records are critical in assessing the patient’s fluid balance. 2.Potassium is vital electrolyte for skeletal and smooth muscle activity.
Evaluation
After 4 hours of nursing interventions the goal was partially met as manifested by the patient’s ability to maintain adequate fluid volume as evidenced by: > patient was relaxed >Maintained good skin turgor 2 seconds
3. Vital signs changes such as increased heart rate, decreased blood pressure, and increased temperature indicate hypovolemia. Hypotensive and increased pulse rate can be an indication that patient is dehydrated. 4. Oral hygiene can increase patient’s appetite for eating and interest in drinking essential amount of fluid.
5.Oral fluid replacement is indicated for mild fluid deficit.
>Maintained normal capillary refill 2 seconds >had moist mucous membrane >Urine output of 30-40 cc per hour >Stable vital signs: BP: 90/60 mmHg PR: 88 bpm T:36.0 C
prescribed fluid amounts. If oral fluids are tolerated, provide oral fluids patient prefers. Provide fresh water and a straw. Be creative in selecting fluid sources (e.g., flavored gelatin, frozen juice bars, sports drink)
Elderly patients have a decreased sense of thirst and may need ongoing reminders to drink. Increasing fluid intake can maintain patient dehydrated.
6. Weigh daily.
6. To determine weight loss which can be due to severe dehydration.
7.Describe or teach causes of fluid losses or decreased fluid intake. Explain importance of maintaining proper nutrition and hydration.
7.Excessive intestinal loss may lead to electrolyte imbalance. Patients need to understand the importance of drinking extra fluid during bouts of fever, and other conditions causing fluid deficits.
Dependent: 1.Administer Oral hydrating solutions/ORESOL as prescribed by the physician.
Oral rehydration replaces and maintains fluids and electrolytes balance which is loss in the body.
References: Handbook of Common Communicable and infectious Disease by Dionesia Monjejar-Navales, RN, MAEd Lippincott Review Series Medical Surgical Nursing 4th Ed
