NURSING DIAGNOSIS: Fluid Volume, risk for deficient
Risk factors may include
- Excessive losses through vomiting and diarrhea, third-space shift
- Altered clotting process
Possibly evidenced by
- [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
- Maintain adequate hydration, as evidenced by stable vital signs, good skin turgor, capillary refill, strong peripheral pulses, and individually appropriate urinary output.
Coagulation Status (NOC)
- Be free of signs of hemorrhage with clotting times WNL.
7 Hepatitis Nursing Care Plan (NCP)
- Imbalanced Nutrition — Hepatitis Nursing Care Plan (NCP)
- Deficient Fluid Volume — Hepatitis Nursing Care Plan (NCP)
- Low Self-Esteem — Hepatitis Nursing Care Plan (NCP)
- Risk for Infection — Hepatitis Nursing Care Plan (NCP)
- Fatigue — Hepatitis Nursing Care Plan (NCP)
- Impaired Skin Integrity — Hepatitis Nursing Care Plan (NCP)
- Knowledge Deficit — Hepatitis Nursing Care Plan (NCP)
Deficient Fluid Volume — Hepatitis Nursing Care Plan (NCP): Nursing Interventions & Rationale
|Monitor I&O, compare with periodic weight. Note enteric losses, e.g., vomiting and diarrhea.||Provides information about replacement needs/effects of therapy. Note: Diarrhea may be due to transient flulike response to viral infection or may represent a more serious problem of obstructed portal blood flow with vascular congestion in the GI tract, or it may be the intended result of medication use (neomycin, lactulose) to decrease serum ammonia levels in the presence of hepatic encephalopathy.|
|Assess vital signs, peripheral pulses, capillary refill, skin turgor, and mucous membranes.||Indicators of circulating volume/perfusion.|
|Check for ascites for edema formation. Measure abdominal girth as indicated.||Useful in monitoring progression/resolution of fluid shifts (edema/ascites).|
|Use small-gauge needles for injections, applying pressure for longer than usual after venipuncture.||Reduces possibility of bleeding into tissues.|
|Have patient use cotton/sponge swabs and mouthwash instead of toothbrush.||Avoids trauma and bleeding of the gums.|
|Observe for signs of bleeding, e.g., hematuria/melena, ecchymosis, oozing from gums/puncture sites||Prothrombin levels are reduced and coagulation times prolonged when vitamin K absorption is altered in GI tract and synthesis of prothrombin is decreased in affected liver.|
|Monitor periodic laboratory values, e.g., Hb/Hct, Na, albumin, and clothing times.||Reflects hydration and identifies sodium retention/protein deficits, which may lead to edema formation. Deficits in clotting potentiate risk of bleeding/hemorrhage.|
|Administer antidiarrheal agents, e.g., diphenoxylate with atropine (Lomotil).||Reduces fluid/electrolyte loss from GI tract.|
|Provide IV fluids (usually glucose), electrolytes.
|Provides fluid and electrolyte replacement in acute toxic state.|
|Administer medications as indicated, e.g.:Vitamin K;
Antacids or H2-receptor antagonists, e.g., cimetidine (Tagamet).
Infuse fresh frozen plasma, as indicated.
| Correction of albumin/protein deficits can aid in return of fluid from tissues to the circulatory system.Because absorption is altered, supplementation may prevent coagulation problems, which may occur if clotting factors/prothrombin time (PT) is depressed.
Neutralize/reduce gastric secretions to lower risk of gastric irritation/bleeding.
May be required to replace clotting factors in the presence of coagulation defects.
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