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Deficient Fluid Volume (Isotonic) : Anxiety Fear

This document provides information on the nursing diagnosis of deficient fluid volume related to excessive vascular loss. It describes potential related signs such as changes in mentation, decreased pulse pressure, decreased or concentrated urine, decreased venous filling, and hypotension or tachycardia. Desired outcomes include improvement in fluid balance as evidenced by stable vital signs and adequate urine output. Nursing interventions include assessing history of blood loss, monitoring uterine activity and fetal status, auscultating breath sounds, recording intake and output, and discouraging rectal or vaginal examinations to prevent further hemorrhage. The rationale for interventions helps determine the nature and severity of hemorrhage and maintains adequate fluid volume and renal perfusion.

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Vincent Paul Santos
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42 views2 pages

Deficient Fluid Volume (Isotonic) : Anxiety Fear

This document provides information on the nursing diagnosis of deficient fluid volume related to excessive vascular loss. It describes potential related signs such as changes in mentation, decreased pulse pressure, decreased or concentrated urine, decreased venous filling, and hypotension or tachycardia. Desired outcomes include improvement in fluid balance as evidenced by stable vital signs and adequate urine output. Nursing interventions include assessing history of blood loss, monitoring uterine activity and fetal status, auscultating breath sounds, recording intake and output, and discouraging rectal or vaginal examinations to prevent further hemorrhage. The rationale for interventions helps determine the nature and severity of hemorrhage and maintains adequate fluid volume and renal perfusion.

Uploaded by

Vincent Paul Santos
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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During an emergency

Assess client’s/couple’s psychological stress and situation, anxiety may hasten the


emotional response to an event. degree of discomfort due to the fear-
tension-pain syndrome.

Information, knowing what to expect


Educate client about the condition and
can help lower the anxiety level which
treatment. Encourage expression of concerns.
can enhance the perception of pain.

Provide a quiet environment and diversional


activities. Instruct client in relaxation methods Decreases stimuli, refocus attention,
such as meditation, guided imagery, and deep hence lowering the level of discomfort.
breathing.

Administer narcotics or sedatives as prescribed. Promotes rest/alleviates pain.

Prepare for surgical procedure, administer Treatment of underlying disorder


preoperative medications if indicated. should alleviate pain.

Deficient Fluid Volume (Isotonic)


Nursing Diagnosis

 Deficient Fluid Volume


May be related to

 Excessive vascular loss


Possibly evidenced by

 Change in mentation
 Decreased pulse pressure
 Decreased/concentrated urine
 Decreased venous filling,
 Hypotension
 Tachycardia
Desired Outcomes

 Client will demonstrate improvement in fluid balance as evidenced by stable vital signs, good capillary refill, absence
of alteration sensorium, and individually adequate urine output and specific gravity.
Nursing Interventions Rationale

Assess client history of blood loss


Estimation of the volume of blood loss aids in the
(amount, duration, characteristics,
differential diagnosis. A one gram of pad weight
and presence of clot). Instuct pad
is equal to approximately 1 ml of blood loss.
count; weigh pads/underpad.

Helps determine nature of the hemorrhage


Monitor uterine activity, fetal status, and possible outcome of a hemorrhagic episode.
and any abdominal tenderness. Tenderness is usually present in ruptured ectopic
pregnancy or abruptio placentae.
Adventitious breath sounds suggest an excessive
Auscultate breath sounds.
replacement.

Reflects the extent of blood loss,


Monitor vital signs, capillary refill,
although cyanosis and changes in BP and pulse
color of mucous membranes/skin.
are late signs of circulatory loss and developing
Measure CVP, if feasible.
shock.

Record intake/output. Obtain hourly


Determines the degree of fluid losses and reflects
urine samples; measure specific
the adequacy of renal perfusion.
gravity.

Promotes the occurrence of hemorrhage,


Discourage rectal or vaginal
especially if marginal or total placenta previa is
examination.
considered.

Ascertain religious practices and May prohibit use of blood products and establish
preferences. need for alternative therapy.

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