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Medical Diagnoses: Fluid Volume Deficient 

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

   

Client has a pacemaker, history of CHF and ARF, and her labs showed her WBC count @ 30,000.

She coded at 4am

   

   

Objective

RP’s vitals were pulse 80, BP 81/40, and her temperature was 95.3. She had a gallbladder drain and was on the ventilator. She had sluggish reactive pupils, bilateral rhoncci, abdominal distention, and no edema. Her skin was cool, dry, pale. 

Problem

Fluid volume deficient

   

   

Long Term:

Client will be able to describe symptoms of fluid loss and certain measures that can be taken to treat or prevent fluid volume loss following hospital stay.


-Watch for early signs of hypovolemia, including restlessness, weakness, muscle cramps, headaches, inability to concentrate, and postural hypotension.

Rationale: A study of healthy volunteers restricted their fluid for up to 37 hours and reported symptoms of headache, decreased alertness, and inability to concentrate (Shirreffs, 2004).

-Encourage fluid intake by offering fluids regularly to cognitively impaired clients.

Rationale: Dehydration results in impaired alertness; in older individuals it also results in slower psychomotor processing speed and impaired memory performance (Ritz &, Berrut, 2005).

   

   

Client stated that headaches, restlessness, and inability to concentrate are signs of hypovolemia and that she should contact her health care provider if this happens. Client will also increase her fluid intake.

   

R/T

Excessive removal of fluid during dialysis and failure of regulatory mechanisms (kidneys r/t toxins)

   

   

   

   

   

   

Short Term:

Client’s blood pressure, pulse, and temperature will remain within normal limits within one day.


-Monitor vital signs of clients with deficient fluid volume every 15 minutes to 1 hour for the unstable client. Observe for tachycardia, tachypnea, and decreased pulse pressure first, and then hypotension, decreased pulse volume, and increased or decreased body temperature.

Rational: A systemic review demonstrated that hypotension and tachycardia, and occasionally fever, are clinical signs of dehydration (Ferry, 2005).

-If the client required IV fluid replacement, maintain patent IV access, set an appropriate IV infusion flow rate, and administer at a constant flow rate as ordered.

Rationale: Isotonic IV fluids such as 0.9% normal saline or Ringer’s lactate allow replacement of intravascular volume (Kasper, 2005).

-Monitor elderly clients for excess fluid volume during the treatment of deficient fluid volume: listen to lung sounds, watch for edema, and not vital signs. Rationale: The elderly client has a decreased ability to adapt to raid increased in intravascular volume and can quickly develop fluid overload (Allison & Lobo, 2004).

   

The client’s blood pressure stayed within normal limits consistently, her pulse decreased from 80 to 60 as a baseline, and her temperature increased from 95.3 to a normal 98.9. 


   

AEB

Inelastic, dry skin, decreased blood pressure, abdominal distention, tachycardia, change in mental status, decreased urine output, and decreased temperature

   

   

   

   

   

   

   

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*I = Implementation.  Check those interventions/actions/orders that were implemented.


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