Create
Learn
Share

Deficient Fluid Volume

rename
taddio's version from 2017-06-19 22:25

Section

Deficient Fluid VolumeNext
Assessment 1 - skin turgorAssessment 2 - oral fluid consumption
Assessment 2 - oral fluid consumptionAssessment 3 - knowledge deficit
Assessment 3 - knowledge deficitAssessment 4 - patient states, “I feel dizzy and lightheaded”
Assessment 4 - patient states, “I feel dizzy and lightheaded”Assessment 5 - patient has depressed fontanelle
Assessment 5 - patient has depressed fontanelleAssessment 6 - patients vital signs showed hypotension of 88/52
Assessment 6 - patients vital signs showed hypotension of 88/52Rationale Opening - Inadequate fluid intake affects all systems.
Rationale Opening - Inadequate fluid intake affects all systems.Rationale 1 - alterations in skin integrity
Rationale 1 - alterations in skin integrityRationale 2 - alterations in bowel / kidney function
Rationale 2 - alterations in bowel / kidney functionRationale 3 - electrolyte imbalance
Rationale 3 - electrolyte imbalanceRationale 4 - decreased tissue perfusion
Rationale 4 - decreased tissue perfusionRationale 4 - complications such as pneumonia or alterations in cognition
Rationale 4 - complications such as pneumonia or alterations in cognitionRelated to 1 - diarrhea
Related to 1 - diarrheaRelated to 2 - blood loss
Related to 2 - blood lossRelated to 3 - active fluid loss
Related to 3 - active fluid lossOutcome 1 - The patient will consume 90 mL's of the preferred fluid during the PCS
Outcome 1 - The patient will consume 90 mL's of the preferred fluid during the PCSOutcome 2 - Maintain elastic skin turgor; moist mucous membranes, flat fontanelle after the interventions during the PCS
Outcome 2 - Maintain elastic skin turgor; moist mucous membranes, flat fontanelle after the interventions during the PCSOutcome 3 - Achieve elastic skin turgor; moist mucous membranes, flat fontanelle after the interventions during the PCS
Outcome 3 - Achieve elastic skin turgor; moist mucous membranes, flat fontanelle after the interventions during the PCSInterventions 1 - administer IV fluid of 5% Dextrose in 0.45% Normal saline with 10 mEq of Potassium Chloride at 35 mL per hour (or whatever is ordered) (Administering IV fluid of 5% Dextrose in 0.45% Normal saline with 10 mEq of Potassium Chloride at 35 mL per hour will allow for an increase in vascular hydration thereby resulting in elastic skin turgor; moist mucous membranes, flat fontanelle)
Interventions 1 - administer IV fluid of 5% Dextrose in 0.45% Normal saline with 10 mEq of Potassium Chloride at 35 mL per hour (or whatever is ordered) (Administering IV fluid of 5% Dextrose in 0.45% Normal saline with 10 mEq of Potassium Chloride at 35 mL per hour will allow for an increase in vascular hydration thereby resulting in elastic skin turgor; moist mucous membranes, flat fontanelle)Interventions 2 - Encourage Fluids throughout PCS (Having _patient name__ drink more fluids will allow for systemic hydration thereby resulting in elastic skin turgor; moist mucous membranes, flat fontanelle)
Interventions 2 - Encourage Fluids throughout PCS (Having _patient name__ drink more fluids will allow for systemic hydration thereby resulting in elastic skin turgor; moist mucous membranes, flat fontanelle)Interventions 3 - encourage the mother to breast feed ad lib
Interventions 3 - encourage the mother to breast feed ad libCollaborations 1 - Nutritionist can provide food and drink choices to help with fluid losses
Collaborations 1 - Nutritionist can provide food and drink choices to help with fluid lossesCollaborations 2 - UAP can assist with oral care as needed
Collaborations 2 - UAP can assist with oral care as neededlast
memorize