Home Care Plans Nursing Care Plan Example for Deficient fluid volume

Nursing Care Plan Example for Deficient fluid volume

nursing care plan for deficient fluid volume
nursing care plan for deficient fluid volume

Example of a 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.

Read Also: Deficient fluid volume Nursing Diagnosis & Nursing Care Plan
Read also : Excess fluid volume Nursing Diagnosis & Nursing Care plan.

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.