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NURSING DIAGNOSIS: Fluid Volume, risk for deficient
Risk factors may include
- Excessive losses through normal routes, e.g., preoperative emesis and diarrhea; high-volume ileostomy output
- Losses through abnormal routes, e.g., NG/intestinal tube, perineal wound drainage tubes
- Medically restricted intake
- Altered absorption of fluid, e.g., loss of colon function
- Hypermetabolic states, e.g., inflammation, healing process
Possibly evidenced by
- [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
Desired Outcomes
Hydration (NOC)
- Maintain adequate hydration as evidenced by moist mucous membranes, good skin turgor and capillary refill, stable vital signs, and individually appropriate urinary output.
10 Ileostomy & Colostomy Nursing Care Plan (NCP)
- Risk for Impaired Skin Integrity — Ileostomy & Colostomy Nursing Care Plan (NCP)
- Disturbed Body Image — Ileostomy & Colostomy Nursing Care Plan (NCP)
- Acute Pain — Ileostomy & Colostomy Nursing Care Plan (NCP)
- Impaired Skin Integrity — Ileostomy & Colostomy Nursing Care Plan (NCP)
- Deficient Fluid Volume — Ileostomy & Colostomy Nursing Care Plan (NCP)
- Imbalanced Nutrition — Ileostomy & Colostomy Nursing Care Plan (NCP)
- Sexual Dysfunction — Ileostomy & Colostomy Nursing Care Plan (NCP)
- Disturbed Sleep Pattern — Ileostomy & Colostomy Nursing Care Plan (NCP)
- Constipation/Diarrhea — Ileostomy & Colostomy Nursing Care Plan (NCP)
- Knowledge Deficit — Ileostomy & Colostomy Nursing Care Plan (NCP)
Deficient Fluid Volume — Ileostomy & Colostomy Nursing Care Plan (NCP)
| Nursing Interventions | Rationale |
| Monitor intake and output (I&O) carefully, measure liquid stool. Weigh regularly. | Provides direct indicators of fluid balance. Greatest fluid losses occur with ileostomy, but they generally do not exceed 500–800 mL/day. |
| Monitor vital signs, noting postural hypotension, tachycardia. Evaluate skin turgor, capillary refill, and mucous membranes. | Reflects hydration status/possible need for increased fluid replacement. |
| Limit intake of ice chips during period of gastric intubation. | Ice chips can stimulate gastric secretions and wash out electrolytes. |
| Monitor laboratory results, e.g., Hct and electrolytes | Detects homeostasis or imbalance, and aids in determining replacement needs |
| Administer IV fluid and electrolytes as indicated. | May be necessary to maintain adequate tissue perfusion/organ function. |
Found through:
impaired skin integrity care plan interventions, colostomy nursing diagnosis, risk of impaired skin integrity care plan, ileostomy nursing diagnosis, nursing diagnosis ileostomy, list the signs and symptoms of deficient fluid volume, impaired sleep pattern care plan
