Deficient fluid volume is a condition where the fluid output exceeds the fluid intake and body electrolytes became imbalance as a result of dehydration, blood loss, vomiting or diarrhea which causes cells in our body to not function properly. Below is an example of nursing care plan for patients with deficient fluid volume.
ASSESSMENT
Subjective:
“I feel
exhausted, I’m thirsty.” as verbalized by the patient.
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 and note the current intake and weight changes. Remember that clients with very young age cannot describe or verbalized thirst. While elderly patients are often have a decreased thrust relax and may not aware of water needs.
Monitor client's vital signs regularly especially blood pressure, take blood pressure with the client lying, sitting, and standing when possible. Also, monitor confusion of his/her loss of ability to carry out usual activity, lethargy and dizziness. Confusion is caused by sufficient dehydration due to poor cerebral perfusion and electrolyte imbalances.
Monitor urinary output so that you could accurately determine the fluid replacement needs. Administer fluids and electrolytes as indicated, oral fluid intake is indicated in patients with mild dehydration. Provide beverages and fluids with high fluid content and encourage the patient 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, stop or lower the infusion and notify the physician. Maintain accurate input and output and instruct the client and 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 the patient 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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