Crispy Chicken, age 49, presented with acute appendicitis as evidenced by loose bowel movements, vomiting, weakness, and fever. He had a fluid volume deficit due to active fluid loss from diarrhea. The nursing care plan aimed to (1) evaluate the degree of fluid deficit, (2) correct fluid losses to reverse dehydration, and (3) provide measures to rest the GI tract such as nothing by mouth and bed rest. Interventions included assessing vital signs, monitoring intake and output, administering IV fluids and medications, and advancing diet from ice chips to clear liquids as tolerated.
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Crispy Chicken, age 49, presented with acute appendicitis as evidenced by loose bowel movements, vomiting, weakness, and fever. He had a fluid volume deficit due to active fluid loss from diarrhea. The nursing care plan aimed to (1) evaluate the degree of fluid deficit, (2) correct fluid losses to reverse dehydration, and (3) provide measures to rest the GI tract such as nothing by mouth and bed rest. Interventions included assessing vital signs, monitoring intake and output, administering IV fluids and medications, and advancing diet from ice chips to clear liquids as tolerated.
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sample nursing care plan for nursing diagnosis of fluid volume deficit
Crispy Chicken, age 49, presented with acute appendicitis as evidenced by loose bowel movements, vomiting, weakness, and fever. He had a fluid volume deficit due to active fluid loss from diarrhea. The nursing care plan aimed to (1) evaluate the degree of fluid deficit, (2) correct fluid losses to reverse dehydration, and (3) provide measures to rest the GI tract such as nothing by mouth and bed rest. Interventions included assessing vital signs, monitoring intake and output, administering IV fluids and medications, and advancing diet from ice chips to clear liquids as tolerated.
Copyright:
Attribution Non-Commercial (BY-NC)
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Download as DOC, PDF, TXT or read online from Scribd
Crispy Chicken, age 49, presented with acute appendicitis as evidenced by loose bowel movements, vomiting, weakness, and fever. He had a fluid volume deficit due to active fluid loss from diarrhea. The nursing care plan aimed to (1) evaluate the degree of fluid deficit, (2) correct fluid losses to reverse dehydration, and (3) provide measures to rest the GI tract such as nothing by mouth and bed rest. Interventions included assessing vital signs, monitoring intake and output, administering IV fluids and medications, and advancing diet from ice chips to clear liquids as tolerated.
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NURSING CARE PLAN: FLUID VOLUME DEFICIT
Name of Patient: Crispy Chicken
Age: 49 years old Chief Complaint: Loose Bowel Movement (LBM) and vomiting Diagnosis: Acute Appendicitis
ANALYSIS/ NURSING GOAL AND NURSING CUES HEALTH RATIONALE EVALUATION DIAGNOSIS OBJECTIVES INTERVENTIONS IMPLICATION
INTERACTION: Fluid Volume IMMEDIATE GOAL
According to the Deficit related to CAUSE After 8 hours of EFFECTIVENESS client: active fluid Active fluid nursing 1. Was the client able to “Tatlo o apat o volume loss (e.g volume loss (e.g intervention, the be evaluated in the kaya minsan diarrhea) diarrhea) client will be able to degree of fluid deficit? limang beses ako maintain fluid __yes __no why? dumudumi INTERMEDIATE volume at a simula kaninang CAUSE functional level 2. Was the client’s 7am (November Decreases condition able to be 8, 2006), matubig mucosal OBJECTIVES corrected/ replaced siya hindi siya absorption losses to reverse buo” (1) Evaluate a. Assess vital signs Provides baseline pathophysiologic “Dalawang beses ROOT CAUSE degree of fluid for assessing and mechanism? lang ako umiihi Bacterial deficit evaluating __yes __no why? simula kaninang infection interventions. 7am (November (Smeltzer & Bare, 3. Was the client able to 8, 2006) HEALTH Medical Surgical do the measures “Nanghihina ako” IMPLICATION Nursing, 10th ed., designed provided to “May kinain lang Complications of pp.245) allow the GI tract to ako, di ko na diarrhea include rest? matandaan kung the potential for b. Note physical Predictors of fluid __yes __no why? ano un, tapos cardiac signs of dehydration balance that should makalipas ng dysrythmias be in client’s usual (4) Was the client able ilang oras because of range in a healthy to return to a regular nahihilo na ako significant fluid state. (Nurse’s diet? tapos medyo and electrolyte Pocket Guide, 9th __yes __no why? nilalagnat tapos loss. (Smeltzer edition by nagususka tapos & Bare, Medical Doenges, et al EFFICIENCY nanghihina” Surgical page 240) Was the interventions ANALYSIS/ NURSING GOAL AND NURSING CUES HEALTH RATIONALE EVALUATION DIAGNOSIS OBJECTIVES INTERVENTIONS IMPLICATION Nursing, 10th (2) Correct/replace a. Administer To limit done within the time According to ed., pp. 1032) losses to reverse medications gastric/intestinal frame? client’s son Complications of pathophysiologic (antiemetics or losses; to treat __yes __no why? “Nagsusuka siya regional enteritis mechanism antidiarrheals or bacteria (Nurse’s tapos maputla. include intestinal antibiotics) Pocket Guide, 9th APPROPRIATENESS Minsan sinasabi obstruction or edition by Were the interventions niya na masakit stricture Doenges, et al pp. suitable to the client? ang kanyang formation, 248) __yes __no why? tiyan.” perianal disease, fluid b. Encouraged fluid To detect early ACCESSIBILITY OBSERVATION and electrolyte intake and signs of Were the interventions Pale in color imbalance, monitoring of daily dehydration acceptable to the Appeared weak malnutrition from fluid intake and (Smeltzer & Bare, client? malabsorptiuon, output Medical Surgical __yes __no why? MEASUREMENT and fistula and Nursing, 10th ed., 3x loose stool abscess pp 1014) ADEQUACY Decreased urine formation. Were the interventions output (2x since Smeltzer & (3) Provide a Administer nothing Allowing the gastric adequate to meet the 7am) Bare, Medical measures by mouth—possibly mucosa to heal client’s needs? Surgical designed to allow for days—until acute (Smeltzer & Bare, __yes __no why? Laboratory Nursing, 10th the GI tract to rest symptoms subside Medical Surgical Results: ed., pp.1042) Nursing, 10th ed., Sodium: 129 b. Maintain bed rest pp. 1012) mmol/L (132- 142mmol/L) (4) Promote return a. Offer the client Fluid electrolyte WBC: 15.19/L to a regular diet ice chips followed replacement (4.5-11.0x109/L) by clear liquids provides oral replacement therapy (Medical- Surgical Nursing, 4th edition by Lippincott pp. 204)
