Fluid Volume Deficit (Dehydration) : Ateneo de Naga University College of Nursing Nursing Care Plan

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ATENEO DE NAGA UNIVERSITY

COLLEGE OF NURSING
NURSING CARE PLAN
FLUID VOLUME DEFICIT (DEHYDRATION)

ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION


lterations in mental After 1hr of nursing
-Urge the patient to drink -Oral fluid After 1hr of nursing
state Fluid Volume Fluid volume intervention the patient
intervention the patient
will be : prescribed amount of replacement is
Patient complaints of deficit (FVD) or was :
Deficit -normovolemic as fluid. indicated for mild
weakness and thirst hypovolemia is -normovolemic as
evidenced by systolic BP fluid deficit and is a
that may or may not evidenced by systolic BP
a state or greater than or equal to -Aid the patient if he or she
cost-effective method greater than or equal to
be accompanied by condition 90 mm HG (or patient’s is unable to eat without
90 mm HG (or patient’s
tachycardia or weak where the fluid baseline), absence of assistance, and encourage for replacement baseline), absence of
pulse orthostasis, HR 60 to 100 the family or SO to assist treatment orthostasis, HR 60 to 100
output exceeds
Weight loss beats/min, urine output with feedings, as Dehydrated patients beats/min, urine output
the fluid intake. greater than 30 mL/hr
(depending on the necessary. may be weak and greater than 30 mL/hr
severity of fluid It occurs when and normal skin turgor.
unable to meet and normal skin turgor.
the body loses -able to demonstrate -If patient can tolerate
volume deficit) -able to demonstrate
lifestyle changes to prescribed intake
Concentrated urine, both water and oral fluids, give what lifestyle changes to
avoid progression of independently. avoid progression of
decreased urine electrolytes oral fluids patient
dehydration
dehydration
output from the ECF in -able to verbalize prefers. Provide fluid -Most patients may -able to verbalize
Dry mucous similar awareness of causative and straw at bedside have reduced sense awareness of causative
membranes, sunken proportions
factors and behaviors within easy reach. of thirst and may factors and behaviors
eyeballs essential to correct fluid
Provide fresh water and require continuing essential to correct fluid
deficit
Weak pulse, a straw. deficit
-able to explains reminders to drink. -able to explain
tachycardiaDecrease
measures that can be -Educate patient about measures that can be
d skin turgor taken to treat or prevent -Enough knowledge aids
possible cause and taken to treat or prevent
Decreased blood fluid volume loss the patient to take part in
pressure, effect of fluid losses or his or her plan of care. fluid volume loss

hemoconcentration decreased fluid intake.

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