Nursing Care Plan

Fluid Volume Deficit - Nanda Nursing Diagnosis

Nursing Diagnoses 2015-17:
Definitions and Classification
(NANDA Nursing Diagnoses)

Nursing Care Plan Fluid Volume Deficit

The state in which an individual who did not undergo a period of fasting or at risk of dehydration vascular, interstitial, or intravascular.

Related Factor:

Pathophysiology
Dealing with excessive urine output
Uncontrolled diabetes.
Related to increased capillary permeability and evaporative loss to the road because it burns
Related to increased fluid loss
Fever
Drainage abnormal
Peritonitis
Diarrhea
Situational
Related to nausea / vomiting
Related to decreased motivation to drink fluids
Depression
Fatigue
Related to this diet
Related to food through a tube with a high dissolved
Related to difficulty swallowing or eating alone
Mouth pain, sore throat
Related to heat / excessive sunlight, drought.
Related to lose through:
Indwelling catheter
Drein
Related to insufficient fluid for the efforts sport or weather conditions.
Related to the excessive use of:
Laxative or enema
Diuretics or alcohol.
Maturisional
(Baby / child)
Related to increased vulnerability of the body
The decline acceptance fluid
Decrease in urine concentration
(Elderly)
Related to increased vulnerability of the body
The decline acceptance fluid
Decrease in thirst sensation

Major data

  • Insufficient oral fluid intake
  • Negative balance between input and output
  • Weight loss
  • Skin / mucous membranes dry
Minor data
  • Increased serum natriun
  • Decreased urine output or the output of redundant
  • Concentrated urine or frequent urination
  • Decreased skin turgor
  • thirst / nausea / anokresia
Expected outcomes

Individuals will:
1. Increasing fluid intake at least 2000 ml / day (unless contraindicated)
2. Telling the need to increase fluid intake during heat stress or
3. Retaining urine specific gravity within normal limits
4. Show no signs and symptoms of dehydration

Intervention

1. Assess the likes and dislikes; give a favorite drink within the diet
2. Plan your fluid intake goals for each turn (eg, 1000 ml during the morning, afternoon 800 ml, and 200 ml of the evening)
3. Assess the individual's understanding of the reasons to maintain adequate hydration and methods for achieving goals fluid intake.
4. For children, offering:
a. Liquid forms an interesting (popsicle, chilled juices, ice cone)
b. Unusual Containers (colored cups, straws)
c. A game or activity (tell kids to drink when the time came for the child)
5. Encourage the individual to maintain a written report of fluid intake and urine output, if necessary.
6. Monitor input; make sure at least 1500 ml orally every 24 hours.
7. Monitor the output of; make sure at least 1000-1500 ml per 24 hours.
8. Monitor urine specific gravity
9. Measure your weight every day with the same kind of clothes, weight loss of 2% -4% indicates mild dehydration, 5% -9% moderate dehydration.
10. Teach that coffee, tea, and juice grapes cause diuresis and can increase fluid loss.
11. Consider additional fluid loss associated with vomiting, diarrhea, fever, drein hose.
12. Monitor blood electrolyte levels, blood urea nitrogen, urine and serum osmolality, creatinine, hematocrit, and hemoglobin.
13. For wound drainage:
a. Maintain accurate records on the number and type of drainage.
b. Weigh bandage, if necessary, to estimate fluid loss.
c. Dressing the wound to minimize fluid loss.

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