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