Nurseslabs » deficient fluid volume

3 Placenta Previa Nursing Care Plans

NursesLabs — Wed, 01 Feb 2012 11:00:55 +0000

Placenta praevia (placenta previa AE) is an obstetric complication in which the placenta is attached to the uterine wall close to or covering the cervix. It can sometimes occur in the later part of the first trimester, but usually during the second or third. It is a leading cause of antepartum hemorrhage (vaginal bleeding). It affects approximately 0.5% of all labors.

Read our Placenta Previa Nursing Care Plans below

1 Deficient Fluid Volume

Fluid volume deficit is a state in which an individual is experiencing decreased intravascular, interstitial and/or intracellular fluid. Active Blood Loss or Hemorrhage due to disrupted placental implantation during pregnancy may manifest signs and symptoms of fluid vol. deficient that may later lead to hypovolemic shock and cause maternal and fetal death.

Assessment

Nursing Dx

Planning

Nursing Interventions

Rationale

Expected Outcome

S-O-> Bleeding Episodes (amount, duration)

> Facial Grimace due of Pain

> Complaint of pain

Abdomen soft/hard when palpated

> Manifest Body Weakness

> Low BP

Increased HR

Decreased RR

Fetal HR >120-160 bpm

> Decreased Urine Out

> Increased Urine Concentration

> Pale, Cool Skin

>Increased Capillary Refill

Deficient Fluid Volume r/t Active Blood Loss Secondary to Disrupted Placental Implantation

Short Term:After 4 hours of NI, the pt will verbalize understanding of causative factors.Long Term:

After 4 days of NI, the pt will maintain fluid volume at a functional level AEB individually adequate urinary output and stable vital signs.

1. Establish Rapport2. Monitor Vital Signs3. Assess color, odor, consistency and amount of vaginal bleeding; weigh pads

4. Assess hourly intake and output.

5. Assess baseline data and note changes. Monitor FHR.

6. Assess abdomen for tenderness or rigidity- if present, measure abdomen at umbilicus (specify time interval)

7. Assess SaO2, skin color, temp, moisture, turgor, capillary refill (specify frequency)

8. Assess for changes in LOC: note for complaints of thirst or apprehension

9. Provide supplemental O2 as ordered via facemask or nasal cannula @ 10-12 L/min.

10. Initiate IV fluids as ordered (specify fluid type and rate).

11. Position Pt. in supine with hips elevated if ordered or left lateral position.

12. Monitor lab. Work as obtained: Hgb & Hct, Rh and type, cross match for 2 units RBCs, urinalysis, etc. Scheduled for ultrasound as ordered.

1. To gain patient’s trust2. To obtain baseline data3. Provides information about active bleeding versus old blood, tissue loss and degree of blood loss

4. Provides information about maternal and fetal physiologic compensation to blood loss

5. Assessment provides information about possible infection, placenta previa or abruption. Warm, moist, bloody environment is ideal for growth of microorganisms.

6. Detecting increased in measurement of abdominal girth suggests active abruption

7. Assessment provides information about blood vol., O2 saturation and peripheral perfusion

8. To detect signs of cerebral perfusion

9. Intervention increases available O2 to saturate decreased hemoglobin

10. For replacement of fluid vol. loss

11. Position decreases pressure on placenta and cervical os. Left lateral position improves placental perfusion

12. Lab. Work provides information about degree of blood loss; prepares for possible transfusion. Ultra sound provides info about the cause of bleeding

Short Term:The pt shall have verbalized understanding of causative factors.Long Term:

The pt shall have maintained fluid volume at a functional level AEB individually adequate urinary output and stable vital signs.

3 Placenta Previa Nursing Care Plans Original source at: Nurseslabs

3 Diabetes Insipidus Nursing Care Plans

NursesLabs — Tue, 24 Jan 2012 17:32:46 +0000

Diabetes Insipidus (DI) is a disorder in which there is an abnormal increase in urine output, fluid intake and often thirst.

It causes symptoms such as urinary frequency, nocturia (frequent awakening at night to urinate) or enuresis (involuntary urination during sleep or “bedwetting”).

Urine output is increased because it is not concentrated normally.

Consequently, instead of being a yellow color, the urine is pale, colorless or watery in appearance and the measured concentration (osmolality or specific gravity) is low (1).

1. Deficient Fluid Volume

Common Related Factors

Defining Characteristics

Compromised endocrine regulatory mechanismNeurohypophyseal dysfunctionHypopituitarismHypophysectomyNephrogenic DI

PolyuriaOutput exceeds intakePolydipsia (increased thirst)Sudden weight lossUrine specific gravity less than 1.005Urine osmolality less than 300 mOsm/LHypernatremia (sodium greater than 145 mEq/L)

Altered mental status

Requests for cold or ice water

Common Expected OutcomePatient experiences normal fluid volume as evidenced by absence of thirst, normal serum sodium level, and stable weight.

NOC OutcomesFluid Balance; Electrolyte and Acid-Base BalanceNIC InterventionsFluid Monitoring; Fluid Management; Electrolyte Management

Ongoing Assessment

Actions/Interventions	Rationale
Monitor intake and output. Report urine volume greater than 200 mL for each of 2 consecutive hours or 500 mL in a 2-hour period.	With DI, the patient voids large urine volumes independent of the fluid intake. Urine output ranges from 2 to 3 L/day with renal DI to greater than 10 L/day with central DI.
Monitor for increased thirst (polydipsia).	If the patient is conscious and the thirst center is intact, thirst can be a reliable indicator of fluid balance. Polyuria and polydipsia strongly suggest DI. Also, the DI patient prefers ice water.
Weigh daily.	Weight loss occurs with excessive fluid loss.
Monitor urine specific gravity.	This may be 1.005 or less.
Monitor serum and urine osmolality.	Urine osmolality will be decreased and serum osmolality will increase.
Monitor urine and serum sodium levels.	The patient with DI has decreased urine sodium levels and hypernatremia.
Monitor serum potassium.	Hypokalemia may result from the increase in urinary output of potassium.
Monitor for signs of hypovolemic shock (e.g., tachycardia, tachypnea, hypotension).	Frequent assessment can detect changes early for rapid intervention. Polyuria causes decreased circulatory blood volume.

Therapeutic Interventions

Actions/Interventions	Rationale
Allow the patient to drink water at will.	Patients with intact thirst mechanisms may maintain fluid balance by drinking huge quantities of water to compensate for the amount they urinate. Patients prefer cold or ice water.
Provide easily accessible fluid source, keeping adequate fluids at bedside.	This encourages fluid intake.
Administer intravenous (IV) fluids:	IV fluids are indicated if the patient cannot take in sufficient fluids orally.
5% dextrose in water or 0.45% sodium chloride	Hypotonic IV fluids provide free water and help lower serum sodium levels gradually.
0.9% sodium chloride	Isotonic fluids may be indicated for the patient who has sustained significant fluid loss and is hemodynamically unstable. Once circulatory volume has been restored, hypotonic IV fluids can be given.
Administer medication as prescribed.	Aqueous vasopressin is usually used for DI of short duration (e.g., postoperative neurosurgery or head trauma). Pitressin tannate (vasopressin) in oil (the longer-acting vasopressin) is used for longer-term DI. Patients with milder forms of DI may use chlorpropamide (Diabinese), clofibrate (Atromid), or carbamazepine (Tegretol) to stimulate release of ADH from the posterior pituitary and enhance its action on the renal tubules. Hydrochlorothiazide (HydroDIURIL) may also be used for nephrogenic DI.
If vasopressin is given, monitor for water intoxication or rebound hyponatremia.	Overmedication can result in volume excess.

2. Risk for Impaired Skin Integrity

Common Risk Factor
Urinary frequency with high volume output and the potential for incontinence
Common Expected OutcomePatient’s skin remains intact.	NOC OutcomesTissue Integrity: Skin and Mucous Membranes; Risk Control; Risk DetectionNIC InterventionsSkin Surveillance; Skin Care: Topical Treatments

Ongoing Assessment

Actions/Interventions	Rationale
Inspect skin; document condition and changes in status.	Early detection and intervention may prevent occurrence or progression of impaired skin integrity. Fluid loss from polyuria contributes to decreased skin turgor and dryness.
Assess for continence or incontinence. Evaluate need for an indwelling urinary catheter.	Excessive moisture on the skin increases the risk of skin breakdown.
Assess other factors that may risk the patient’s skin integrity (e.g., immobility, nutritional status, altered mental status).	Excessive moisture from urinary incontinence can add to the risk for skin breakdown from other sources.

Therapeutic Interventions

Actions/Interventions	Rationale
Provide easy access to the bathroom, urinal, or bedpan.	Both polyuria and polydipsia disrupt the patient’s normal activities (including sleep). Easy access to void will decrease inconvenience and frustration.
Use skin barriers as needed.	These prevent redness or excoriation from urinary frequency.
Keep bed linen clean, dry, and wrinkle-free.	This prevents shearing forces.

3. Deficient Knowledge

Common Related Factors	Defining Characteristics
New conditionUnfamiliarity with disease and treatment	QuestionsRequests for more informationVerbalized misconceptions or misinterpretation
Common Expected OutcomePatient verbalizes correct understanding of DI and the medications used in treatment.	NOC OutcomesKnowledge: Disease Process; Knowledge: MedicationNIC InterventionsTeaching: Disease Process; Teaching: Prescribed Medication

Ongoing Assessment

Actions/Interventions	Rationale
Assess level of knowledge of DI cause and treatment.	An individualized teaching plan is based on the patient’s current knowledge and desire for additional information.
Assess readiness to learn.	Rapid fluid loss from polyuria can lead to impaired cognitive function. This change in mental status can limit the patient’s ability to learn new information.

Therapeutic Interventions

Actions/Interventions	Rationale
Give written information concerning the diagnosis and treatment of DI:
Water deprivation ADH stimulation test	This test may be done to differentiate nephrogenic causes from neurogenic causes of DI. The patient is instructed to take nothing by mouth (NPO) for 12 hours before a blood sample is drawn to measure ADH levels. The ADH level is increased in nephrogenic DI and decreased in neurogenic (central) DI. Vasopressin may be given to evaluate renal response. There is no response to the drug in nephrogenic DI.
Computed tomography scan or magnetic resonance imaging	These scans may be ordered if a pituitary tumor is suspected.
Desmopressin acetate (DDAVP)	This is the drug of choice for the management of DI. This medication is a synthetic form of ADH and is administered intranasally.
Aqueous form of ADH (vasopressin)	This drug has a shorter half-life than DDAVP and therefore requires more frequent daily administration. Vasopressin is usually given parenterally and is not recommended for the long-term management of chronic DI.
Other drugs used in combination to manage DI, including chlorpropamide (Diabinese), clofibrate (Atromid), carbamazepine (Tegretol), and hydrochlorothiazide	These secondary drugs work on the kidney or the posterior pituitary gland to increase pituitary release of ADH or increase renal response to ADH.
Teach the patient the necessity of closely monitoring fluid balance, including daily weights (same time of day with same amount of clothing), fluid intake and output, and measurement of urine specific gravity.	This assists the patient in monitoring the condition so that adjustments can be made accordingly, helping prevent undertreatment or overtreatment with the medication,.
Discuss when to seek further medical attention (at signs of underdosage or overdosage of medications).	Patients with chronic disease need to be able to recognize important changes in their condition to avert complications and possible hospitalization.
Instruct the patient to wear a medical alert bracelet, listing DI and the medications that the patient is using.	This allows for prompt intervention in the event of an emergency.

Sources: (1) (2)

3 Diabetes Insipidus Nursing Care Plans Original source at: Nurseslabs

Deficient Knowledge | Diabetes Insipidus Nursing Care Plans

NursesLabs — Thu, 12 Jan 2012 14:49:27 +0000

Common Related Factors

New condition
Unfamiliarity with disease and treatment

Defining Characteristics

Questions
Requests for more information
Verbalized misconceptions or misinterpretation

Common Expected Outcomes

Patient verbalizes correct understanding of DI and the medications used in treatment.

NOC Outcomes

Knowledge: Disease Process;
Knowledge: Medication

NIC Interventions

Teaching: Disease Process;
Teaching: Prescribed Medication

Ongoing Assessment

Assess level of knowledge of DI cause and treatment. An individualized teaching plan is based on the patient’s current knowledge and desire for additional information.
Assess readiness to learn. Rapid fluid loss from polyuria can lead to impaired cognitive function. This change in mental status can limit the patient’s ability to learn new information.

Nursing Interventions

Give written information concerning the diagnosis and treatment of DI:
- Water deprivation ADH stimulation test
  - This test may be done to differentiate nephrogenic causes from neurogenic causes of DI. The patient is instructed to take nothing by mouth (NPO) for 12 hours before a blood sample is drawn to measure ADH levels. The ADH level is increased in nephrogenic DI and decreased in neurogenic (central) DI. Vasopressin may be given to evaluate renal response. There is no response to the drug in nephrogenic DI.
- Computed tomography scan or magnetic resonance imaging
  - These scans may be ordered if a pituitary tumor is suspected.
- Desmopressin acetate (DDAVP)
  - This is the drug of choice for the management of DI. This medication is a synthetic form of ADH and is administered intranasally.
- Aqueous form of ADH (vasopressin)
  - This drug has a shorter half-life than DDAVP and therefore requires more frequent daily administration. Vasopressin is usually given parenterally and is not recommended for the long-term management of chronic DI.
- Other drugs used in combination to manage DI, including chlorpropamide (Diabinese), clofibrate (Atromid), carbamazepine (Tegretol), and hydrochlorothiazide
  - These secondary drugs work on the kidney or the posterior pituitary gland to increase pituitary release of ADH or increase renal response to ADH.

Teach the patient the necessity of closely monitoring fluid balance, including daily weights (same time of day with same amount of clothing), fluid intake and output, and measurement of urine specific gravity. This assists the patient in monitoring the condition so that adjustments can be made accordingly, helping prevent undertreatment or overtreatment with the medication.
Discuss when to seek further medical attention (at signs of underdosage or overdosage of medications). Patients with chronic disease need to be able to recognize important changes in their condition to avert complications and possible hospitalization.
Instruct the patient to wear a medical alert bracelet, listing DI and the medications that the patient is using. This allows for prompt intervention in the event of an emergency.

Deficient Knowledge | Diabetes Insipidus Nursing Care Plans Original source at: Nurseslabs

4 Diabetes Mellitus Nursing Care Plans

NursesLabs — Fri, 06 Jan 2012 23:00:18 +0000

Diabetes mellitus is a metabolic disease characterized by dysregulation of carbohydrate, protein, and lipid metabolism. The primary feature of this disorder is elevation in blood glucose levels (hyperglycemia), resulting from either a defect in insulin secretion from the pancreas, a change in insulin action, or both. Sustained hyperglycemia has been shown to affect almost all tissues in the body and is associated with significant complications of multiple organ systems, including the eyes, nerves, kidneys, and blood vessels.

Here you view 4 Diabetes Mellitus Nursing Care Plans

1. Deficient Fluid Volume

Glucose appears in the urine (glycosuria) because the kidney excretes the excess glucose to make the blood glucose level normal. Glucose excreted in the urine acts as osmotic diuretic and causes excretion of increased amount of water, resulting in fluid volume deficit or polyuria.

Assessment

Nursing Diagnosis

Planning

Nursing
Interventions

Rationale

Evaluation

Subjective:(none)Objective:

elevated temperature of 38.4°C/axilla
increased urine output.
sweating of the skin
thirst
exhaustion
weight loss
dry skin or mucous membrane

Deficient Fluid Volume r/t intracellular DHN 2° the DM II

Short Term:After 3° of NI, patient shall have verbalized understanding of causative factors and purpose of individual therapeutic interventions and medications.Long Term:After 2 days of NI, the patient shall have maintained fluid volume at a functional level as evidenced by individual good skin turgor, moist mucous membrane and stable vital signs.

Establish rapportTake and record vital signsMonitor the temperatureAssess skin turgor and mucous membranes for signs of dehydrationEncourage the patient to increase fluid intake

Administer IVF as ordered by the Doctor

Administer anti-pyretic as prescribed by the Doctor.

Friendly relationship with patient and to be able to each other’s concernTo obtain baseline dataTo monitor changes in temperatureDry skin and mucous membranes are signs of dehydrationTo replace fluid loss and prevent dehydration

To replace electrolytes and fluid loss

To decrease body temperature and will have less occurrence of dehydration.

Short Term:After 3° of NI, patient will have verbalized understanding of causative factors and purpose of individual therapeutic interventions and medications.Long Term:After 2 days of NI, the patient will have maintained fluid volume at a functional level as evidenced by individual good skin turgor, moist mucous membrane and stable vital signs

4 Diabetes Mellitus Nursing Care Plans Original source at: Nurseslabs

Deficient Fluid Volume | Diabetes Insipidus Nursing Care Plans

NursesLabs — Fri, 16 Dec 2011 02:18:40 +0000

Common Related Factors

Compromised endocrine regulatory mechanism
Neurohypophyseal dysfunction
Hypopituitarism
Hypophysectomy
Nephrogenic DI

Defining Characteristics

Polyuria
Output exceeds intake
Polydipsia (increased thirst)
Sudden weight loss
Urine specific gravity less than 1.005
Urine osmolality less than 300 mOsm/L
Hypernatremia (sodium greater than 145 mEq/L)
Altered mental status
Requests for cold or ice water

Common Expected Outcomes

Patient experiences normal fluid volume as evidenced by absence of thirst, normal serum sodium level, and stable weight.

NOC Outcomes

Fluid Balance; Electrolyte and Acid-Base Balance

NIC Interventions

Fluid Monitoring; Fluid Management; Electrolyte Management

Ongoing Assessment

Monitor intake and output. Report urine volume greater than 200 mL for each of 2 consecutive hours or 500 mL in a 2-hour period. With DI, the patient voids large urine volumes independent of the fluid intake. Urine output ranges from 2 to 3 L/day with renal DI to greater than 10 L/day with central DI.
Monitor for increased thirst (polydipsia). If the patient is conscious and the thirst center is intact, thirst can be a reliable indicator of fluid balance. Polyuria and polydipsia strongly suggest DI. Also, the DI patient prefers ice water.
Weigh daily. Weight loss occurs with excessive fluid loss.
Monitor urine specific gravity. This may be 1.005 or less.
Monitor serum and urine osmolality. Urine osmolality will be decreased and serum osmolality will increase.
Monitor urine and serum sodium levels. The patient with DI has decreased urine sodium levels and hypernatremia.
Monitor serum potassium. Hypokalemia may result from the increase in urinary output of potassium.
Monitor for signs of hypovolemic shock (e.g., tachycardia, tachypnea, hypotension). Frequent assessment can detect changes early for rapid intervention. Polyuria causes decreased circulatory blood volume.

Nursing Interventions

Allow the patient to drink water at will. Patients with intact thirst mechanisms may maintain fluid balance by drinking huge quantities of water to compensate for the amount they urinate. Patients prefer cold or ice water.
Provide easily accessible fluid source, keeping adequate fluids at bedside. This encourages fluid intake.
Administer intravenous (IV) fluids: IV fluids are indicated if the patient cannot take in sufficient fluids orally.

5% dextrose in water or 0.45% sodium chloride. Hypotonic IV fluids provide free water and help lower serum sodium levels gradually.
0.9% sodium chloride. Isotonic fluids may be indicated for the patient who has sustained significant fluid loss and is hemodynamically unstable. Once circulatory volume has been restored, hypotonic IV fluids can be given.

Administer medication as prescribed. Aqueous vasopressin is usually used for DI of short duration (e.g., postoperative neurosurgery or head trauma). Pitressin tannate (vasopressin) in oil (the longer-acting vasopressin) is used for longer-term DI. Patients with milder forms of DI may use chlorpropamide (Diabinese), clofibrate (Atromid), or carbamazepine (Tegretol) to stimulate release of ADH from the posterior pituitary and enhance its action on the renal tubules. Hydrochlorothiazide (HydroDIURIL) may also be used for nephrogenic DI.
If vasopressin is given, monitor for water intoxication or rebound hyponatremia. Overmedication can result in volume excess.

Deficient Fluid Volume | Diabetes Insipidus Nursing Care Plans Original source at: Nurseslabs

7 Gastroenteritis Nursing Care Plans

NursesLabs — Fri, 04 Nov 2011 12:00:28 +0000

Gastroenteritis is an inflammation of the stomach and intestinal tract that primarily affects the small bowel.

The major clinical manifestations are diarrhea of varying degrees and abdominal pain and cramping. Associated clinical manifestations are nausea, vomiting, fever anorexia, distention, tenesmus, and borborygmi.

The nursing goals for patients with Acute Gastroenteritis are toward: avoiding dehydration and management of diarrhea. This post contains 4 nursing care plans.

1. Diarrhea

Diarrhea is defined as an increase in the frequency, volume and fluid content of stool. Rapid propulsion of intestinal contents through the small bowel results in diarrhea. Diarrhea is a hallmark sign of gastroenteritis.

Diarrhea- AGE

7 Gastroenteritis Nursing Care Plans Original source at: Nurseslabs