Nurseslabs » deficient fluid volume

Deficient Fluid Volume — Anorexia & Bulimia Nervosa Nursing Care Plans

Nurseslabs — Sat, 05 May 2012 10:25:37 +0000

NURSING DIAGNOSIS: Fluid Volume actual or risk for deficient

May be related to

Inadequate intake of food and liquids
Consistent self-induced vomiting
Chronic/excessive laxative/diuretic use

Possibly evidenced by (actual)

Dry skin and mucous membranes, decreased skin turgor
Increased pulse rate, body temperature, decreased BP
Output greater than input (diuretic use); concentrated urine/decreased urine output (dehydration)
Weakness
Change in mental state
Hemoconcentration, altered electrolyte balance

Desired Outcomes

Maintain/demonstrate improved fluid balance, as evidenced by adequate urine output, stable vital signs, moist mucous membranes, good skin turgor.
Verbalize understanding of causative factors and behaviors necessary to correct fluid deficit.

Nursing Interventions & Rationale

Nursing Interventions	Rationale
Monitor vital signs, capillary refill, status of mucous membranes, skin turgor.	Indicators of adequacy of circulating volume. Orthostatic hypotension may occur with risk of falls/injury following sudden changes in position.
Monitor amount and types of fluid intake. Measure urine output accurately.	Patient may abstain from all intake, with resulting dehydration; or substitute fluids for caloric intake, disturbing electrolyte balance.
Discuss strategies to stop vomiting and laxative/diuretic use.	Helping patient deal with the feelings that lead to vomiting and/or laxative/diuretic use will prevent continued fluid loss. Note: Patient with bulimia has learned that vomiting provides a release of anxiety.
Identify actions necessary to regain/maintain optimal fluid balance, e.g., specific fluid intake schedule.	Involving patient in plan to correct fluid imbalances improves chances for success.
Review electrolyte/renal function test results.	Fluid/electrolyte shifts, decreased renal function can adversely affect patient’s recovery/prognosis and may require additional intervention.
Administer/monitor IV, TPN; electrolyte supplements, as indicated.	Used as an emergency measure to correct fluid/electrolyte imbalance and prevent cardiac dysrhythmias.

Deficient Fluid Volume — Anorexia & Bulimia Nervosa Nursing Care Plans Original source at: Nurseslabs

Risk for Deficient Fluid Volume — Cholecystitis Nursing Care Plans

Nurseslabs — Sat, 28 Apr 2012 16:50:59 +0000

NURSING DIAGNOSIS: Fluid Volume, risk for deficient

Risk factors may include

Excessive losses through gastric suction; vomiting, distension, and gastric hypermotility
Medically restricted intake
Altered clotting process

Possibly evidenced by

[Not applicable; presence of signs and symptoms and establishes an actual diagnosis.]

Desired Outcomes

Demonstrate adequate fluid balance evidenced by stable vital signs, moist mucous membranes, good skin turgor, capillary refill, individually appropriate urinary output, absence of vomiting.

Nursing Interventions	Rationale
Maintain accurate record of I&O, noting output less than intake, increased urine specific gravity. Assess skin/mucous membranes, peripheral pulses, and capillary refill.	Provides information about fluid status/circulating volume and replacement needs.
Monitor for signs/symptoms of increased/continued nausea or vomiting, abdominal cramps, weakness, twitching, seizures, irregular heart rate, paresthesia, hypoactive or absent bowel sounds, depressed respirations.	Prolonged vomiting, gastric aspiration, and restricted oral intake can lead to deficits in sodium, potassium, and chloride.
Eliminate noxious sights/smells from environment.	Reduces stimulation of vomiting center.
Perform frequent oral hygiene with alcohol-free mouthwash; apply lubricants.	Decreases dryness of oral mucous membranes; reduces risk of oral bleeding.
Use small-gauge needles for injections and apply firm pressure for longer than usual after venipuncture.	Reduces trauma, risk of bleeding/hematoma formation.
Assess for unusual bleeding, e.g., oozing from injection sites, epistaxis, bleeding gums, ecchymosis, petechiae, hematemesis/melena.	Prothrombin is reduced and coagulation time prolonged when bile flow is obstructed, increasing risk of bleeding/hemorrhage.
Keep patient NPO as necessary.	Decreases GI secretions and motility.
Insert NG tube, connect to suction, and maintain patency as indicated.	To rest the GI Tract

Risk for Deficient Fluid Volume — Cholecystitis Nursing Care Plans Original source at: Nurseslabs

Risk for Deficient Fluid Volume — AIDS Nursing Care Plans

Nurseslabs — Mon, 26 Mar 2012 00:41:17 +0000

Nursing Diagnosis: Risk for Deficient Fluid Volume

Risk factors may include

Excessive losses: copious diarrhea, profuse sweating, vomiting
Hypermetabolic state, fever
Restricted intake: nausea, anorexia; lethargy

Desired outcomes

Maintain hydration as evidenced by moist mucous membranes, good skin turgor, stable vital signs, individually adequate urinary output.

Nursing Interventions	Rationale
Monitor vital signs, including CVP if available. Note hypotension, including postural changes.	Indicators of circulating fluid volume.
Note temperature elevation and duration of febrile episode. Administer tepid sponge baths as indicated. Keep clothing and linens dry. Maintain comfortable environmental temperature.	Fever is one of the most frequent symptoms experienced by patients with HIV infections (97%). Increased metabolic demands and associated excessive diaphoresis result in increased insensible fluid losses and dehydration.
Assess skin turgor, mucous membranes, and thirst.	Indirect indicators of fluid status.
Measure urinary output and specific gravity. Measure/estimate amount of diarrheal loss. Note insensible losses.	Increased specific gravity/decreasing urinary output reflects altered renal perfusion/circulating volume. Note:Monitoring fluid balance is difficult in the presence of excessive GI/insensible losses.
Weigh as indicated.	Although weight loss may reflect muscle wasting, sudden fluctuations reflect state of hydration. Fluid losses associated with diarrhea can quickly create a crisis and become life-threatening.
Monitor oral intake and encourage fluids of at least 2500 mL/day.	Maintains fluid balance, reduces thirst, and keeps mucous membranes moist.
Make fluids easily accessible to patient; use fluids that are tolerable to patient and that replace needed electrolytes	Enhances intake. Certain fluids may be too painful to consume (e.g., acidic juices) because of mouth lesions.
Eliminate foods potentiating diarrhea	May help reduce diarrhea. Use of lactose-free products helps control diarrhea in the lactose-intolerant patient.
Encourage use of live culture yogurt or OTC Lactobacillus acidophilus(lactaid).	Antibiotic therapies disrupt normal bowel flora balance, leading to diarrhea. Note: Must be taken 2 hr before or after antibiotic to prevent inactivation of live culture.
Administer fluids/electrolytes via feeding tube/IV, as appropriate.	May be necessary to support/augment circulating volume, especially if oral intake is inadequate, nausea/vomiting persists.
Monitor laboratory studies as indicated, e.g.: Serum/urine electrolytes; BUN/Cr; Stool specimen collection.	Alerts to possible electrolyte disturbances and determines replacement needs. Evaluates renal perfusion/function. Bowel flora changes can occur with multiple or single antibiotic therapy.
Maintain hypothermia blanket if used.	May be necessary when other measures fail to reduce excessive fever/insensible fluid losses.

Risk for Deficient Fluid Volume — AIDS Nursing Care Plans Original source at: Nurseslabs

Deficient Fluid Volume — Diabetes Nursing Care Plans

Nurseslabs — Sun, 25 Mar 2012 01:47:38 +0000

Nursing Diagnosis: Deficient Fluid Volume

May be related to

Osmotic diuresis (from hyperglycemia)
Excessive gastric losses: diarrhea, vomiting
Restricted intake: nausea, confusion

Possibly evidenced by:

Increased urinary output, dilute urine
Weakness; thirst; sudden weight loss
Dry skin/mucous membranes, poor skin turgor
Hypotension, tachycardia, delayed capillary refill

Desired Outcomes:

Demonstrate adequate hydration as evidenced by stable vital signs, palpable peripheral pulses, good skin turgor and capillary refill, individually appropriate urinary output, and electrolyte levels within normal range.

Nursing Interventions	Actions
Obtain history from patient/SO related to duration/intensity of symptoms such as vomiting, excessive urination.	Assists in estimation of total volume depletion. Symptoms may have been present for varying amounts of time (hours to days). Presence of infectious process results in fever and hypermetabolic state, increasing insensible fluid losses.
Monitor vital signs: Note orthostatic BP changes; Respiratory pattern, e.g., Kussmaul’s respirations, acetone breath; Respiratory rate and quality; use of accessory muscles, periods of apnea, and appearance of cyanosis; Temperature, skin color/moisture.	Hypovolemia may be manifested by hypotension and tachycardia. Estimates of severity of hypovolemia may be made when patient’s systolic BP drops more than 10 mm Hg from a recumbent to a sitting/standing position. Note: Cardiac neuropathy may block reflexes that normally increase heart rate.Lungs remove carbonic acid through respirations, producing a compensatory respiratory alkalosis for ketoacidosis. Acetone breath is due to breakdown of acetoacetic acid and should diminish as ketosis is corrected.Correction of hyperglycemia and acidosis will cause the respiratory rate and pattern to approach normal. In contrast, increased work of breathing; shallow, rapid respirations; and presence of cyanosis may indicate respiratory fatigue and/or that patient is losing ability to compensate for acidosis.Although fever, chills, and diaphoresis are common with infectious process, fever with flushed, dry skin may reflect dehydration.
Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes.	Indicators of level of hydration, adequacy of circulating volume.
Monitor I&O; note urine specific gravity.	Provides ongoing estimate of volume replacement needs, kidney function, and effectiveness of therapy.
Weigh daily.	Provides the best assessment of current fluid status and adequacy of fluid replacement.
Maintain fluid intake of at least 2500 mL/day within cardiac tolerance when oral intake is resumed.	Maintains hydration/circulating volume.
Promote comfortable environment. Cover patient with light sheets.	Avoids overheating, which could promote further fluid loss.
Investigate changes in mentation/sensorium.	Changes in mentation can be due to abnormally high or low glucose, electrolyte abnormalities, acidosis, decreased cerebral perfusion, or developing hypoxia. Regardless of the cause, impaired consciousness can predispose patient to aspiration.
Insert/maintain indwelling urinary catheter.	Provides for accurate/ongoing measurement of urinary output, especially if autonomic neuropathies result in neurogenic bladder (urinary retention/overflow incontinence). May be removed when patient is stable to reduce risk of infection.

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

3 Placenta Previa Nursing Care Plans

Nurseslabs — Wed, 29 Feb 2012 16:48:54 +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.

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

Assessment

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

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 pads4. 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 loss4. 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. Deficient Fluid Volume - Diabetes Insipidus Nursing Care Plans

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 statusRequests 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 - Diabetes Insipidus Nursing Care Plans

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 - Diabetes Insipidus Nursing Care Plans

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.

3 Diabetes Insipidus Nursing Care Plans Original source at: Nurseslabs

4 Diabetes Mellitus Nursing Care Plans

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

This post contains nursing care plans for Diabetes Mellitus.

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.

Other Diabetes Mellitus Nursing Care Plans

Here are 4 Diabetes Mellitus Nursing Care Plans

1. Deficient Fluid Volume - Diabetes Mellitus Nursing Care Plans

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.

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

Assessment

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

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 rapport
Take and record vital signs
Monitor the temperature
Assess skin turgor and mucous membranes for signs of dehydration
Encourage 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 concern
To obtain baseline data
To monitor changes in temperature
Dry skin and mucous membranes are signs of dehydration
To 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 Plan

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.

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 Plan Original source at: Nurseslabs

5 Neonatal Sepsis Nursing Care Plans

Nurseslabs — Sat, 12 Nov 2011 12:37:34 +0000

Neonatal Sepsis is an infection in the blood that spreads throughout the body and occurs in a neonate. Here are 5 Neonatal Sepsis Nursing Care Plans.

Neonatal Sepsis is also termed as Neonatal Septicemia and Sepsis Neonatorum.

Neonatal Sepsis has 2 types: The one that is seen in the first week of life is termed as Early- onset sepsis and most often appears in the first 24 hours of life.

The infection is often acquired from the mother. This can be cause by a bacteria or infection acquired by the mother during her pregnancy, a Preterm delivery, Rupture of membranes (placenta tissue) that lasts longer than 24 hours, Infection of the placenta tissues and amniotic fluid (chorioamnionitis) and frequent vaginal examinations during labor. The second type or the Late-onset Sepsis is acquired after delivery. This can be cause by contaminated hospital equipment, exposure to medicines that lead to antibiotic resistance, having a catheter in a blood vessel for a long time, staying in the hospital for an extended period of time.

Signs and symptoms of Neonatal Sepsis includes but is not limited to: body temperature changes, breathing problems, diarrhea, low blood sugar, reduced movements, reduced sucking, seizures, slow heart rate, swollen belly area, vomiting, yellow skin and whites of the eyes (jaundice). Possible complications are disability and worst is death of the neonate.

This post has 5 Neonatal Sepsis Nursing Care Plans

1. Hyperthermia - Neonatal Sepsis Nursing Care Plans

NDx: Hyperthermia related to inflammatory process/ hypermetabolic state as evidenced by an increase in body temperature, warm skin and tachycardia

Due to the presence of an infectious agents, stimulation of the monocytes triggers the release of the pyrogenic cytokines that stimulate anterior hypothalamus which results in elevated thermoregulatory set point that leads to an increased heat conservation (Vasoconstriction) and increased heat production which results to fever.

Assessment

Planning

Intervention

Rationale

Expected Outcome

Subjective:

May manifest:

Irritability
Weakness

Objective:

The patient may manifest one or more of the following:

Temperature above normal level (36 ^oC)
Skin warm to touch
Presence of tachycardia (above 160 bpm)
Presence of tachypnea (above 60 bpm)
WBC elevated

Short-term:

After 30 minutes of nursing intervention the patient will maintain normal core temperature as evidenced by vital signs within normal limits and normal WBC level

Long Term:

After 3 days of NI, pt will still maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.

Independent

1. Monitor neonate’s condition.

2. Monitor Vital signs

3. Provide TSB

Interdependent

4. Ensure that all equipment used for infant is sterile, scrupulously clean. Do not share equipment with other infants

Dependent

5. Administer Anti-pyretics as ordered

1. To determine the need for intervention and the effectiveness of therapy.

2. To have a baseline data

3. Helps in lowering down the temperature

4. this would prevent the spread of pathogens to the infant from equipment

5. aids in lowering down temperature

The patient shall maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.

5 Neonatal Sepsis 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 — Gastroenteritis Nursing Care Plans

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