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
- 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
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
