Example of a Nursing Care plan for Deficient fluid volume
Deficient fluid volume related to vomiting and diaphoresis as evidenced by tachycardia, urine concentration and poor skin turgor.
- “ 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 ”
- 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:
- 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.
- The patient lab value will be within normal limits prior to discharge.
Nursing Interventions and Rationale:
|– 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|
|– 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|
- 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.