- Actual
- Risk for (Potential)
Related To: [Check those that apply]
- Inadequate fluid intake
- Active fluid loss (diuresis, abnormal drainage or bleeding, diarrhea)
- Electrolyte and acid-base imbalances
- Failure of regulatory mechanisms
- Increased metabolic rate (fever, infection)
- Fluid shifts (edema or effusions)
As evidenced by: [Check those that apply]
- Decreased urine output
- Concentrated urine
- Output greater than intake
- Sudden weight loss
- Decreased venous filling
- Hemoconcentration
- Increased serum sodium
- Hypotension
- Thirst
- Increased pulse rate
- Decreased skin turgor
- Dry mucous membranes
- Weakness
- Possible weight gain
- Changes in mental status
Patient’s Diagnosis: –
Date:-
CLICK HERE for Free NCLEX –RN & CGFNS Practice Questions
CLICK HERE for Free Anatomy & Physiology Practice Questions
- experiences adequate fluid volume and electrolyte balance as evidenced by: urine output greater than 30 ml per hr, normotensive blood pressure (BP), heart rate (HR) 100 beats per min, consistency of weight, and normal skin turgor.
- Others
Note: you need to indicate time frame/target as objective must be measurable.
| Nursing Interventions | Scientific Rationale |
|---|---|
| Obtain patient history to ascertain the probable cause of the fluid disturbance. | This will help to guide interventions. |
| Assess or instruct patient to monitor weight daily and consistently, with same scale, and preferably at the same time of day. | To facilitate accurate measurement and follow trends. |
| Evaluate fluid status in relation to dietary intake. Determine if patient has been on a fluid restriction. | Most fluid enters the body through drinking, water in foods, and water formed by oxidation of foods. |
| Monitor and document vital signs. | Sinus tachycardia may occur with hypovolemia to maintain an effective cardiac output. |
| Assess skin turgor and mucous membranes for signs of dehydration. | The skin in elderly patients loses its elasticity; therefore skin turgor should be assessed over the sternum or on the inner thighs. Longitudinal furrows may be noted along the tongue. |
| Assess color and amount of urine. Report urine output less than 30 ml per hr for 2 consecutive hours. | Concentrated urine denotes fluid deficit. |
| Monitor temperature. | Febrile states decrease body fluids through perspiration and increased respiration. |
| Monitor serum electrolytes and urine osmolality and report abnormal values. | Elevated hemoglobin and elevated blood urea nitrogen (BUN) suggest fluid deficit. Urine-specific gravity is likewise increased. |
| Document baseline mental status and record during each nursing shift. | Dehydration can alter mental status. |
| Evaluate whether patient has any related heart problem before initiating parenteral therapy. | Cardiac and elderly patients often have precarious fluid balance and are prone to develop pulmonary edema. |
| Encourage patient to drink prescribed fluid amounts. | Oral fluid replacement is indicated for mild fluid deficit. |
| Provide oral hygiene. | To promote interest in drinking. |
| Obtain and maintain a large-bore intravenous (IV) catheter. | Parenteral fluid replacement is indicated to prevent shock. |
| Maintain IV flow rate. | Elderly patients are especially susceptible to fluid overload. |
CLICK HERE for more Free Nursing Care Plans
___________________________________
Patient/Significant other signature
___________________________________
RN Signature
