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Nursing Fluid Deficit Management

The patient presented with signs of dehydration including pale conjunctiva and hyperactive bowel sounds. The nursing diagnosis was deficient fluid volume related to frequent vomiting. Short term outcomes were that within 30 minutes to 1 hour and 24-48 hours the patient would demonstrate lifestyle changes to avoid progression of dehydration and verbalize awareness of causative factors. Interventions included providing a comfortable environment, preventing electrolyte and fluid loss, assisting with feedings if needed, encouraging fluid intake, and educating on preventing future episodes. The rationale was that early detection and treatment can decrease complications from dehydration.

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Arian May Marcos
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44 views3 pages

Nursing Fluid Deficit Management

The patient presented with signs of dehydration including pale conjunctiva and hyperactive bowel sounds. The nursing diagnosis was deficient fluid volume related to frequent vomiting. Short term outcomes were that within 30 minutes to 1 hour and 24-48 hours the patient would demonstrate lifestyle changes to avoid progression of dehydration and verbalize awareness of causative factors. Interventions included providing a comfortable environment, preventing electrolyte and fluid loss, assisting with feedings if needed, encouraging fluid intake, and educating on preventing future episodes. The rationale was that early detection and treatment can decrease complications from dehydration.

Uploaded by

Arian May Marcos
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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EXPLANATION OF

ASSESSMENT OUTCOMES INTERVENTIONS RATIONALE EVALUATION


THE PROBLEM

Subjective: STO: Within 30 Dx: Monitor for the Early detection of risk STO: (Goal Met)
Fluid volume minutes – 1 hour of existence of factors factors and early Within 30 minutes – 1
 “Agsarsarwa met deficit (FVD) or effective nursing causing deficient fluid intervention can decrease hour of effective
jay anak ko” as hypovolemia is a state interventions, the volume (e.g., the occurrence and nursing interventions,
verbalized by the or condition where the patient’s will be able to gastrointestinal losses, severity of complications the patient was able to
mother. fluid output exceeds the demonstrate lifestyle difficulty maintaining from deficient fluid demonstrates lifestyle
fluid intake. It occurs changes to avoid oral intake, fever, volume. The changes to avoid
Objective: when the body loses progression uncontrolled type II gastrointestinal system is progression
both water of dehydration. diabetes mellitus, a common site of of dehydration.
 Hyperactive and electrolytes from diuretic therapy). abnormal fluid loss.
bowel sounds. the ECF in similar LTO: Within 24 – 48
 Pale conjunctiva. proportions. Common hours of effective Alteration in LTO: (Goal Met)
 Vital signs: sources of fluid loss are nursing interventions, mentation/sensorium may
T-36.5 the gastrointestinal tract, the patient will Assess alteration in be caused by abnormally Within 24 – 48 hours of
P-98 polyuria, and increased verbalize awareness of mentation/sensorium high or low glucose, effective nursing
R-18 perspiration. causative factors and (confusion, agitation, electrolyte abnormalities, interventions, the
BP-110/90 behaviors essential to slowed responses) acidosis, decreased patient verbalized
Source: correct fluid deficit. cerebral perfusion, or Patient verbalizes
Nursing Diagnosis https://nurseslabs.com/d developing hypoxia. awareness of causative
eficient-fluid-volume/ Impaired consciousness factors and behaviors
 Deficient fluid can predispose patient to essential to correct fluid
volume  related aspiration regardless of deficit.
to frequent the cause.
vomiting. Drop situations where
patient can experience
overheating to prevent
further fluid loss.
Tx:Provide comfortable
environment by Fluid losses from
covering patient with diarrhea should be
light sheets. concomitantly treated
with antidiarrheal
medications, as
Provide measures to prescribed. Antipyretics
prevent excessive can decrease fever and
electrolyte loss (e.g., fluid losses from
resting the GI tract, diaphoresis.
administering
antipyretics as ordered Dehydrated patients may
by the physician). be weak and unable to
meet prescribed intake
independently.

Aid the patient if he or


she is unable to eat
without assistance, and Patient may have
encourage the family or restricted oral intake in an
SO to assist with attempt to control urinary
feedings, as necessary. symptoms, reducing
homeostatic reserves and
Edx: Encourage to increasing risk of
drink bountiful amounts dehydration or
of fluid as tolerated or hypovolemia.
based on individual
needs. Patient needs to
understand the value of
drinking extra fluid
during bouts of diarrhea,
fever, and other
conditions causing fluid
Enumerate deficits.
interventions to prevent
or minimize future An accurate measure of
episodes of dehydration fluid intake and output is
an important indicator of
patient’s fluid status.

Teach family members


how to monitor output
in the home. Instruct
them to monitor both
intake and output..

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