Nursing Care Plan

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