Nursing Care Plan for Risk for Deficient Fluid Volume

Nursing Diagnosis for Risk for Deficient Fluid Volume


Risk for Deficient Fluid Volume

Definition: The decrease intravascular fluid, interstitial, and / or intrasellular. This leads to dehydration, loss of fluids with sodium expenditure.

Characteristics :
  • Weakness

  • Thirst

  • Decreased skin turgor / tongue

  • Mucous membrane / dry skin

  • Increased pulse rate, decreased blood pressure, decrease in volume / pulse pressure

  • Completion of decreased venous

  • Changes in the mental position

  • The concentration of urine increased

  • Increased body temperature

  • Elevated hematocrit

  • Weight loss immediately (except on third spacing)

Related Factors :
  • Loss of active fluid volume

  • Failure of regulatory mechanisms


NOC :
  • Fluid balance
  • Hydration
  • Nutritional Status: Food and Fluid Intake

Results Criteria :
  • Maintain urine output in accordance with age and body weight, urine specific gravity normal, normal HT
  • Blood pressure, pulse, body temperature within normal limits
  • There are no signs of dehydration, good skin turgor, mucous membranes moist, no excessive thirst
NIC :

Fluid Management
  • Weigh nappies / pads if necessary
  • Maintain a record intake and output accurately
  • Monitor position hydration (moisture of mucous membranes, adequate pulse, blood pressure orthostatic), if necessary
  • Monitor vital signs
  • Monitor the input of food / fluids and calculate daily calorie intake
  • Perform IV therapy
  • Monitor nutrition position
  • Give fluids
  • Give IV fluids at room temperature
  • Encourage oral input
  • Encourage families to help patients eat
  • Offer a snack (fruit juice, fresh fruit)
  • Collaboration doctor if signs of excessive fluid appears worse
  • Set possible transfusion
  • Preparations for transfusion

Source : http://nandanursingdiagnosis.blogspot.com/2011/06/risk-for-deficient-fluid-volume.html

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