Nanda Nursing Diagnosis

Nursing Diagnosis for Dehydration Fluid volume deficit related to excessive output, less intake. Risk for ineffective tissue perfusion related to decreased blood flow. Risk for impaired skin integrity related to decreased skin turgor. Activity intolerance related to physical weakness. Risk for Decreased cardiac output related to a decrease in systemic vascular resistance. Nursing Care Plan for Dehydration Nursing Interventions for Dehydration 1. Fluid volume deficit related to excessive output, less intake. Goal: adequate fluid volume so that fluid volume deficiency can be overcome. Expected outcomes: Maintain fluid balance. Vital signs (pulse = 80-100 beats / min, temperature = 36-37oC) Capillary refill less than 3 seconds. Akral warm. Urine output: 1-2 cc / kg body weight / hour. Intervention: Monitor vital signs, capillary refill, the status of the mucous membranes. Discuss strategies to stop vomiting and use of laxatives / diuretics. Identification of a plan to increase the optima...

Dehydration Definition Dehydration is a condition in which a person who is not fasting experiencing or at risk of dehydration vascular, interstitial or intra-vascular (Sell Lynda Carpenito, 2000: 139). Classification Classification of dehydration by Donna D. Ignatavicus there are 3 types: a. Isotonic dehydration Isotonic dehydration is lost water followed by the electrolyte so that the density remained normal, then this type of dehydration is usually not result in ECF fluid move to the ICF. b. Hypotonic dehydration Hypotonic dehydration is the loss of solvent from the ECF exceeds fluid loss, resulting in blood vessels become more concentrated. ECF osmotic pressure decreases, resulting in fluid moves from the ECF to ICF. Vascular volume also decreased, as well as cell swelling occurs. c. Hypertonic dehydration Hypertonic dehydration is ECF fluid loss exceeds the solvent is non-osmotic dehydration ECF decreased, resulting in fluid moves from ICF to ECF. Etiology Various causes dehydratio...