Mr. Bryson, 32 years old, reporter. He always do jogging every morning together with his dog named Bark. Bark is a Alaskan Malamute who loves to go outside so he always exited about going out with Mr. Bryson to do jogging or shopping or visiting his colleagues. Mr. Bryson also loves to go out with his dog because he feels comfortable and he likes when people are looking at his dog saying good things. Below is a sample of nursing care plan about deficient fluid volume of Mr. Bryson.
ASSESSMENT
Subjective:
Objectives:
The patient is pale, has dry mouth, dry skin and dry mucous membrane. Other objectives for the patient are decrease urine output, experiencing weight loss and confusion. Vital signs are taken and noted as follows: Body temperature is 38.1 degrees Celsius, blood pressure is 90/70 mmHg, pulse rate is 129 beats per minute, and respiratory rate is 20 cycles per minute. The client has fever as manifested by his/her body temperature which is above normal.
DIAGNOSIS
Deficient fluid volume related to exhaustion
as manifested by increased pulse rate and dry skin and mucous membranes. (Exhaustion in this diagnosis refers to extreme physical tiredness.)
PLANNING
After 4 hours of nursing intervention, the
patient will maintain fluid volume at functional level as evidenced by stable
vital signs, moist mucous membrane and good skin turgor. (We need to regain his/her fluid deficiency as soon as possible to prevent continuous fluid lossy may lead to severe dehydration that can cause more severe complications.)
INTERVENTION
- Evaluate nutritional status of Mr. Bryson and note his current intake and weight changes. Remember that Mr. Bryson is an elderly patient who are often have his decreased thrist reflex and may not aware of his water needs.
- Monitor Mr. Bryson's vital signs regularly especially his blood pressure, take blood pressure with him lying, sitting, and standing when possible. Also, monitor confusion of his loss of ability to carry out usual activity, lethargy and dizziness. Confusion is caused by sufficient dehydration due to his poor cerebral perfusion and electrolyte imbalances. Check acute confusion.
- Monitor Mr. Bryson's urinary output so that you could accurately determine the fluid replacement he needs. Administer him fluids and electrolytes as indicated, oral fluid intake is indicated in patients like him with mild dehydration. Provide Mr. Bryson beverages and fluids with high fluid content and encourage him to limit intake of alcohol and caffeinated beverages that tend to exert a diuretic effect. Severe fluid deficiency can be manage through intravenous fluid infusion, administer blood products as prescribe by physician and regulate the intravenous flow rate. If symptoms of fluid overload manifest to Mr. Bryson, stop or lower his infusion and notify the physician. Maintain accurate input and output and instruct Mr. Bryson and his relatives in how to measure and record the input and output.
- If diarrhea is present, administer anti-diarrheal medication as indicated. If vomiting is present, administer anti-emetic medication as prescribe. If Mr. Bryson has regional enteritis, liquids and food containing sodium is restricted.
EVALUATION
After 4 hours of nursing intervention, the patient has maintained fluid volume at functional level as evidenced by stable vital signs, moist mucous membrane and good skin turgor.
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