Deficient Fluid Volume Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis Deficient Fluid Volume related to active fluid volume loss.

Deficient Fluid Volume NANDA Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium

Characteristics
  • 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

Goal:
To identify interventions to improve the balance of fluid and minimize the inflammatory process to improve comfort.

Expected outcomes:
  • Adequate urine output with normal specific gravity,
  • Stable vital signs
  • Mucous membranes moist
  • Good skin turgor
  • The capillary rise
  • Weight within the normal range.

Nursing Interventions Deficient Fluid Volume Nursing Care Plan for Peritonitis

Independent:

1. Monitor vital signs, note the presence of hypotension (including postural changes), tachycardia, tachypnea, fever. Measure CVP if any.
Rational: To assist in the evaluation of the degree of fluid deficit / effectiveness of fluid replacement therapy and response to treatment.

2. Maintain adequate intake and output and then connect with the body weight daily.
Rationale: Demonstrates overall hydration status.

3. Rehydration / resuscitation fluid
Rationale: To meet the need of fluid in the body (homeostasis).

4. Measure specific gravity of urine
Rationale: Demonstrates changes in hydration status and renal function.

5. Observation of skin / mucous membranes for dryness, turgor, note peripheral edema / sacral.
Rational: Hypovolemia, fluid displacement, and lack of nutrition aggravate skin turgor, adding tissue edema.

6. Eliminate the danger signs / smells from environment. Limit intake of ice cubes.
Rational: Lowering the gastric stimulation and vomiting response.

7. Change positions frequently give skin care with often, and keep the bed dry and free of folds.
Rational: tissue edema and circulatory disturbance tends to damage the skin.

Collaboration:

1. Monitor laboratory examinations, eg Hb / hematocrit, electrolytes, protein, albumin, BUN, creatinine.
Rationale: Provides information about hydration and organ function.

2. Give the plasma / blood, fluids, electrolytes.
Rational: Charge / maintain circulating volume and electrolyte balance. Colloid (plasma, blood) to help move the water into the area by increasing intravascular osmotic pressure.

3. Keep fasting with nasogastric aspiration / intestinal
Rational: Lowering intestinal hyperactivity, and loss from diarrhea.

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