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NCP Risk For Deficient Fluid Volume Potential

The document discusses a patient presenting with nausea, vomiting, and fever, leading to a nursing diagnosis of risk for deficient fluid volume. Interventions included assessing vital signs and skin turgor, encouraging oral fluid intake, administering antipyretics and antiemetics, and providing IV fluids as needed to replenish fluid losses. The patient was educated on factors causing fluid deficit, behaviors to correct it, and the importance of monitoring intake and output to maintain fluid balance.

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Arian May Marcos
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5K views

NCP Risk For Deficient Fluid Volume Potential

The document discusses a patient presenting with nausea, vomiting, and fever, leading to a nursing diagnosis of risk for deficient fluid volume. Interventions included assessing vital signs and skin turgor, encouraging oral fluid intake, administering antipyretics and antiemetics, and providing IV fluids as needed to replenish fluid losses. The patient was educated on factors causing fluid deficit, behaviors to correct it, and the importance of monitoring intake and output to maintain fluid balance.

Uploaded by

Arian May Marcos
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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EXPLANATION OF

ASSESSMENT OUTCOMES INTERVENTIONS RATIONALE EVALUATION


THE PROBLEM
STO Dx: Elevated temperature and STO: (Goal Met)
Subjective: Assess vital prolonged fever increases
“ang init ng Fluid volume deficit Within 30 minutes – 1 sign changes: metabolic rate and fluid
anak ko at (FVD) or hypovolemia hour of effective increasing loss through evaporation. Within 30 minutes – 1
palagi siyang is a state or condition nursing interventions, temperature, Orthostatic BP changes hour of effective
sumusuka” where the fluid output the patient’s will be prolonged and increasing nursing interventions,
as verbalized exceeds the fluid intake. able to demonstrates fever, tachycardia may indicate the patient was able to
by the It occurs when the body fluid balance evidenced orthostatic systemic fluid deficit. maintain demonstrates
mother. loses both water and by individually hypotension, fluid balance evidenced
electrolytes from the appropriate parameters tachycardia. Indirect indicators of by individually
Objective: ECF in similar like moist mucous adequacy of fluid appropriate parameters
 Loss of proportions. Common membranes, good skin volume, although oral like moist mucous
appetite. sources of fluid loss are turgor, prompt capillary mucous membranes may membranes, good skin
 Warm to the gastrointestinal tract, refill, and stable vital be dry because of mouth turgor, prompt capillary
touch. polyuria, and increased signs. breathing and refill, and stable vital
 Dry mouth perspiration. Risk Assess skin supplemental oxygen. signs.
and skin. factors for FVD are as turgor,
Nausea. follows: vomiting, moisture of Provides information
 Vital signs: diarrhea, GI suctioning, LTO mucous about adequacy of fluid
>PR- sweating, decreased membranes. volume and replacement
140bpm intake, nausea, and etc. Within 24 – 48 hours needs.
>RR- 69bpm Fluid volume deficit of effective nursing
interventions, the LTO: (Goal Met)
Nursing Diagnosis may be an acute or
 Risk for chronic condition patient will verbalize
deficient fluid managed in the hospital, awareness of causative Within 24 – 48 hours of
volume related to outpatient center, or factors and behaviors effective nursing
nausea and vomiting. home setting. essential to correct fluid interventions, the
deficit. Monitor intake patient verbalized
Source: and output Patient may have awareness of causative
https://nurseslabs.com/d (I&O), noting restricted oral intake in an factors and behaviors
eficient-fluid-volume/ color, character attempt to control urinary essential to correct fluid
of urine. symptoms, reducing deficit.
Calculate fluid homeostatic reserves and
balance. Be increasing risk of
aware of dehydration or
insensible hypovolemia.
losses. Weigh
as indicated. To reduce fluid losses.

Tx:

Encourage to
drink bountiful
amounts of In presence of reduced
fluid as intake and/or excessive
tolerated or loss, use of parenteral
based on route may correct
individual deficiency.
needs.
Fluid losses from
diarrhea should be
concomitantly treated
with antidiarrheal
medications, as
Administer prescribed. Antipyretics
medications as can decrease fever and
indicated: fluid losses from
antipyretics, diaphoresis.
antiemetics.

Provide Enough knowledge aids


supplemental the patient to take part in
IV fluids as his or her plan of care.
necessary
Patient needs to
understand the value of
Provide drinking extra fluid
measures to during bouts of diarrhea,
prevent fever, and other
excessive conditions causing fluid
electrolyte loss deficits.
(e.g., resting
the GI tract, An accurate measure of
administering fluid intake and output is
antipyretics as an important indicator of
ordered by the patient’s fluid status.
physician).

Edx:
Educate patient
about possible
cause and
effect of fluid
losses or
decreased fluid
intake.

Enumerate
interventions to
prevent or
minimize
future episodes
of dehydration.
Teach family members
how to monitor output
in the home. Instruct
them to monitor both
intake and output.

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