Nursing Care plan for Deficient fluid volume

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nursing care plan for deficient fluid volume
nursing care plan for deficient fluid volume
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Example of Nursing Care plan for Deficient fluid volume

Nursing Diagnosis:

Deficient fluid volume related to vomiting and diaphoresis as evidenced by tachycardia, urine concentration and poor skin turgor.

Assessment Cues:

Subjective data:

  • “ I feel very thirsty all day but I can’t tolerate fluids because of nausea and vomiting that I have”
  • “ My urine become dark yellow ”

Objective Data:

  • Tachycardia: 105 beats/min
  • Tachypnea: 30 cycle/min
  • Poor skin turgor
  • K+: 2.9 mEq/l
  • Increased Urea level: 0.77 mg/dL
  • Increased Creatinine level: 22mg/L
  • Concentrated urine
  • Urine output > 60ml/h

Planning and Outcome:

Short term:

  • The patient will experience relief from nausea and vomiting in 2-4 hours
  • The clients’ fluid intake and output will be balanced in 12 to 24 hours.

Long term:

  • The patient lab value will be within normal limits prior to discharge.

Nursing Interventions and Rationale:

NURSING INTERVENTIONS RATIONALE
Independent:
– Assess and document amount, color, and characteristics of vomitus. – Determine fluid replacement
– Measure and document vital signs every hour – Monitor patient’s status
– Assess skin turgor – Indicates hydration status
Dependent:
– Administer antiemetic drugs – Prevent further fluid loss
– Administer IV fluids with flow rate as prescribed – Insure a good solution replacement and prevent over rehydration
– Administer IV potassium as prescribed – Low potassium levels are dangerous and the patient has hypokalemia

Evaluation:

Goal met:

  • The patient’s nausea and vomiting stopped after administering antiemetics.
  • The patient’s vital signs improved HR=80, RR= 17 and urine output > 60ml/h.

 

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