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NURSING DIAGNOSIS: Risk for Deficient Fluid Volume
Risk factors may include
- Excessive losses through normal routes (severe frequent diarrhea, vomiting)
- Hypermetabolic state (inflammation, fever)
- Restricted intake (nausea/anorexia)
Desired Outcomes
Hydration (NOC)
- Maintain adequate fluid volume as evidenced by moist mucous membranes, good skin turgor, and capillary refill; stable vital signs; balanced I&O with urine of normal concentration/amount.
7 Inflammatory Bowel Disease Nursing Care Plan (NCP)
- Diarrhea — Inflammatory Bowel Disease Nursing Care Plan (NCP)
- Risk for Deficient Fluid Volume — Inflammatory Bowel Disease Nursing Care Plan (NCP)
- Anxiety — Inflammatory Bowel Disease Nursing Care Plan (NCP)
- Acute Pain — Inflammatory Bowel Disease Nursing Care Plan (NCP)
- Ineffective Coping — Inflammatory Bowel Disease Nursing Care Plan (NCP)
- Imbalanced Nutrition — Inflammatory Bowel Disease Nursing Care Plan (NCP)
- Knowledge Deficit — Inflammatory Bowel Disease Nursing Care Plan (NCP)
Risk for Deficient Fluid Volume — Inflammatory Bowel Disease Nursing Care Plan (NCP): Nursing Interventions & Rationale
| Nursing Interventions | Rationale |
| Monitor I&O. Note number, character, and amount of stools; estimate insensible fluid losses, e.g., diaphoresis. Measure urine specific gravity; observe for oliguria. | Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement. |
| Assess vital signs (BP, pulse, temperature). | Hypotension (including postural), tachycardia, fever can indicate response to and/or effect of fluid loss. |
| Observe for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill. | Indicates excessive fluid loss/resultant dehydration. |
| Weigh daily. | Indicator of overall fluid and nutritional status. |
| Maintain oral restrictions, bedrest; avoid exertion. | Colon is placed at rest for healing and to decrease intestinal fluid losses. |
| Observe for overt bleeding and test stool daily for occult blood. | Inadequate diet and decreased absorption may lead to vitamin K deficiency and defects in coagulation, potentiating risk of hemorrhage. |
| Note generalized muscle weakness or cardiac dysrhythmias. | Excessive intestinal loss may lead to electrolyte imbalance, e.g., potassium, which is necessary for proper skeletal and cardiac muscle function. Minor alterations in serum levels can result in profound and/or life-threatening symptoms. |
| Administer parenteral fluids, blood transfusions as indicated. | Maintenance of bowel rest requires alternative fluid replacement to correct losses/anemia. Note: Fluids containing sodium may be restricted in presence of regional enteritis. |
| Monitor laboratory studies, e.g., electrolytes (especially potassium, magnesium) and ABGs (acid-base balance). | Determines replacement needs and effectiveness of therapy. |
