Nursing Care Plan

Nursing Diagnosis for Dehydration

1. Fluid volume deficit related to excessive output, less intake.
2. Risk for ineffective tissue perfusion related to decreased blood flow.
3. Risk for impaired skin integrity related to decreased skin turgor.
4. Activity intolerance related to physical weakness.
5. 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 optimal fluid balance.
• Assess the results of the test function electrolyte / kidney.
• Give / supervise administration of IV fluids.
• Additional potassium, oral or N as indicated.

2. Risk for ineffective tissue perfusion related to decreased blood flow.

Goal: Maintain / improve tissue perfusion.

Expected outcomes:

• Vital signs are stable BP = 120/80 mmHg, pulse = 80-100 beats / min, no pale skin.
• Warm skin.
• Palpable peripheral pulses.
• Adequate urine output from 0.5 to 1.5 cc / kg / body weight.
• CRT is less than 2 seconds.
• Composmentis consciousness.
• No chest pain.

Intervention:

• Assess changes in the level of consciousness, dizziness complaints.
• Auscultation apical pulse, watch heart rate / rhythm.
• Assess the skin against the cold, pale, sweating.
• Record output and urine specific gravity.
• Observation pale skin, redness, change positions frequently.
• Keep an eye on pulse oximetry.
• Give IV fluids as indicated.

3. Risk for impaired skin integrity related to decreased skin turgor.

Goal: Identify and maintain the skin smooth, supple, intact.

Expected outcomes:

• Good skin turgor, skin intact, no blisters, no redness.

Intervention:

• Observation reddish, pale.
• Use skin cream.
• Discuss the importance of changes in position, it is necessary to maintain the activity.
• Emphasize the importance of nutrient input / adequate fluid.

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 dehydration determine the types of dehydration (According to Donna D. Ignatavicus, 1991: 253).

1. Dehydration

• Bleeding.
• Vomiting.
• Diarrhea.
• Hypersalivation.
• Fistula.
• Ileustomy (cutting intestine).
• Diaporesis (excessive sweating).
• Burns.
• Fasting.
• Hypotonic therapy.
• Suction gastrointestinal (stomach wash).

2. Hypotonic Dehydration

• DM disease.
• Excess fluid rehydration.
• Severe and chronic malnutrition.

3. Hypertonic Dehydration

• Hyperventilation.
• Diarrhea water.
• Diabetes Insipedus (ADH hormone decreases).
• Excessive fluid rehydration.
• Dysphagia.
• Impaired thirst.
• Disorders of consciousness.
• Systemic infection: increased body temperature.

Clinical Manifestations

Here are the symptoms or signs of dehydration based on its level (Nelson, 2000):
1. Mild dehydration (loss of fluid 2-5% of its original weight)

• Thirsty, restless.
• Pulse rate 90 -110 x / minute, normal breath.
• Normal skin turgor.
• Urine output (1300 ml / day).
• Good awareness.
• Heart rate increased.

2. Moderate Dehydration (loss of fluid 5% of its original weight)

• Increased thirst.
• Rapid and weak pulse.
• Dry skin turgor, dry mucous membranes.
• Reduced urine output.
• Increased body temperature.

3. Severe dehydration (loss of fluids 8% of its original weight)

• Loss of consciousness.
• Weak, lethargic.
• Tachycardia.
• Sunken eyes.
• No urine output.
• Hypotension.
• Rapid pulse and smooth.
• Cold extremities.

Nursing Diagnosis and Interventions for Dehydration