Student Nurses Community

NURSING CARE PLAN Hypovolemia (Fluid Volume Deficit) ASSESSMENT SUBJECTIVE: Limang araw na akong nagtatae at suka (I have been
vomiting and having diarrhea for 5 days)

DIAGNOSIS Deficient fluid volume may be related to active fluid loss (hemorrhage, vomiting, gastric intubation, diarrhea, burns, wounds, fistulas).

INFERENCE Inadequate water intake, loss through vomiting, diarrhea, gastrointestinal obstruction, fever or sweating, hemorrhage, burns, third space fluid shifting.

PLANNING After 24 hours of nursing interventions, the Patient will maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor, and prompt capillary refill.

INTERVENTION Independent Monitor urinary output.

RATIONALE Fluid replacement needs are based on correction of current deficits and ongoing losses. Measurement provides useful data for comparison. Impaired gag and swallow reflexes and change in level of consciousness are among the factors that affect clients ability to replace fluids orally. Relieves thirst and discomfort of dry mucous membranes and augments parenteral replacement. Tissues are susceptible to breakdown because of vasoconstriction and increased fragility. Skin and mucous

EVALUATION After 24 hours of nursing interventions, the Patient was able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor, and prompt capillary refill.

as verbalized by the patient.

Weigh daily and compare with 24hour fluid balance. Evaluate clients ability to manage own hydration.

OBJECTIVE: Dry mucous membranes Cold, clammy skin Restlessness V/S taken as follows T: 36.3C P: 88 R: 17 BP: 110/ 80

Ascertain clients beverage preferences, and set up a 24-hour schedule for fluid intake. Turn frequently, gently massage skin, and protect bony prominences.

Provide skin and

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mouth care. membranes are dry with decreased elasticity because of vasoconstriction and reduced intracellular water. Decreased cerebral tissue perfusion frequently results in changes in mentation. Refer to listing of predisposing or contributing factors to determine treatment needs. Depending on the avenue of fluid loss, differing electrolyte and metabolic imbalances may be present and require correction.

Provide safety precautions.

Collaborative Assist with identification and treatment of underlying cause. Monitor laboratory studies.