Mr. Shull, a 22 year old
soccer player, even with his young age he achieved a lot of champion
trophies and MVP awards in different barangay leagues and nearby city
soccer competitions. Mr. Shull started playing soccer when he was 5 years
old. His first trainer and coach was his Father who was a popular soccer player
in his time. His father thought him well that he said that his son surpasses
him. One day, Mr. Shull is absent in his finals league due to abdominal
disturbances. He can't even watch the game since it is not televise. His doctor
asks several questions to identify the cause of his problem. He took some test
for examination. After several hours, the doctor found out the cause
of Mr. Shull's abdominal disturbance. Below is a sample of risk for
imbalanced fluid volume nursing care plan of Mr. Shull.
Assessment:
Subjective:
“I had excessive bowel elimination this day”, patient said.
Objectives:
- Specific client’s fluid findings
- Dry mouth
- Dry eyes
- Weight gain
Vital signs taken as follows:
BP: 110/80 mmHG
PR: 45 bpm
RR: 25 cpm
Temp: 36.2 ‘C
Diagnosis:
Risk for imbalanced
fluid volume related to excessive bowel elimination as manifested by dry mouth
and dry eyes.
Planning:
In 4 hours of nursing
intervention, the patient will understand the factors causing risk for
imbalanced fluid volume and what behaviors and appropriate lifestyle must be
done in order to prevent them.
Intervention:
Discuss with Mr.
Shull about his individual risk factors or potential problems related to
fluid volume imbalanced like having diarrhea. Discuss also how to prevent the
risk by preventing the factors. Teach Mr. Shull on how to measure his
I/O or the input and output by recording his amount of fluid volume intake and
his amount of urine output. Instruct Mr. Shull on other necessary
self-interventions like routinely measuring his weight to serve as a basis for
his fluid volume balance. Encourage Mr. Shull to make a diary about
his daily urine elimination, his fecal elimination, his fluid intake and his
weight.
Evaluation:
After 4 hours of nursing intervention, the patient understood the factors
causing risk for imbalanced fluid volume and what behaviors and appropriate
lifestyle must be done in order to prevent them.
Above is just a sample of nursing care plan in clients with risk for imbalanced
fluid like Mr. Shull. In some cases, clients must be confined in the
hospital for many days so there are other nursing interventions for that.
However treating fluid imbalanced in its early stage is the best option like we
did in Mr. Shull's case and to reduce his chances of possible
complications. Just remember these factors that can cause fluid imbalanced:
- Diarrhea
- Vomiting
- Heat exhaustion
- Inadequate potassium diet
- Kidney illness
- Taking certain medications such as diuretics
- Blood loss or fluid loss
- High fever
- And even excessive alcohol consumption
For more samples of nursing care plan you are free to check it out in our NCP LIST page.
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