NCP - Hypovolemia (Fluid Volume Deficit)

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:

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

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

After 8 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.

Independent Monitor urinary output. Weigh daily and compare with 8-hour fluid balance. Evaluate clients ability to manage own hydration Ascertain clients beverage preference s, and set up a 24hour schedule for fluid intake. Turn frequently, gently massage skin, and protect bony prominenc es.

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

After 8 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.

Limang araw na akong nagtatae at suka (I have been

vomiting and having diarrhea for 5 days) as

verbalized by the patient.

OBJECTIVE: Dry mucous membranes Cold, clammy skin Restlessness

V/S taken as follows T: 36.5C P: 78 R: 20 BP: 120/ 80

Provide skin and mouth care.

vasoconstrictio n and increased fragility. Skin and mucous membranes are dry with decreased elasticity because of vasoconstrictio n 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 precaution s.

Collaborative: Assist with identificati on and treatment of underlying cause. Monitor laboratory studies.