Nursing Care Plans | 10/31/2011, 2:17 pm

8 TAHBSO Nursing Care Plans


8 Risk for Deficient Fluid Volume

Decrease intravascular, interstitial, or intracellular fluid refers to dehydration. Fluid volume deficit or hypovolemia occurs from a loss of body fluid or the shift of fluids into the third space or reduced fluid intake. Common sources for fluid loss are the gastrointestinal tract, polyuria and increased perspiration. It also occurs to patient who undergone surgery. In an operation the patient is losing too much body fluid through blood loss that can lead to deficient fluid.

AssessmentPlanningNursing
Interventions		RationaleEvaluation
  • thirst
  • weakness
  • decrease urine output
  • sudden weight loss
  • decrease skin turgor
  • dry mucous membranes
  • sunken eyeballs
  • change in mental state
Short term:After 4 hours of nursing interventions the patient will identify risk factors and appropriate interventionsLong term:After 3 day of nursing interventions the patients will demonstrate behaviors or lifestyle changes to prevent development of fluid volume deficit
  1. Establish rapport
  2. Monitor vital signs
  3. Encourage increase oral fluid intake
  4. Provide supplemental fluids as ordered
  5. Monitor intake and output
  6. Provide safety measures
  7. Encourage the use of oresol
  1. To gain trust
  2. To obtain maintenance data
  3. To replace loss fluids
  4. Prevents peak in fluid level
  5. To ensure accurate picture of fluid status
  6. Confusion can lead to accidents
  7. To replace loss electrolyte.
Short term:The patient identified risk factors and appropriate interventionsLong term:The patient demonstrated behaviors or lifestyle changes to prevent development of fluid volume deficit

Navigation
  1. Acute Pain
  2. Hypothermia
  3. Hyperthermia
  4. Anxiety
  5. Fatigue
  6. Sexual Dysfunction
  7. Risk for Infection
  8. Risk for Deficient Fluid Volume
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