Definition:
Decreased intravascular fluid, interstitial, and or intracellular. This leads to dehydration, loss of fluid with sodium output.
Defining characteristics:
Weakness.
Decreased skin or tongue turgor.
Increased pulse rate, decreased blood pressure, decrease in volume or pulse pressure.
Charging vein decreased.
Changes in mental status. Increased urine concentration.
Increased body temperature.
| NOC
- Fluid balance
- Hydration
- Nutritional Status: Food and Fluid Intake
Goal:
After the provision of nursing care within 2x24 hours clients do not experience significant lack of fluid volume.
Expected outcomes:
- The amount of hemoglobin in normal circumstances.
- Blood pressure, pulse, body temperature within normal limits.
- No signs of dehydration.
- Elasticity good skin turgor, mucous membranes moist, no excessive thirst.
| Fluid Management
- Monitor nutritional status.
- Monitor the status of hydration (moisture mucous membranes, adequate pulse, orthostatic blood pressure), if necessary.
- Monitor vital signs.
- Monitor input food / liquid and calculate daily calorie intake.
- Measure diapers / pads if necessary.
- Maintain records accurate intake and output.
- Perform IV therapy.
- Give fluids.
- Give IV fluids at room temperature.
- Push the oral input.
- Provide appropriate replacement nasogastric output.
- Encourage families to help patients eat.
- Offer snacks (fruit juices, fresh fruit).
- Collaboration with your doctor if signs of excess fluid appears to worsen.
- Set the possibility of transfusion.
- Preparation for transfusion.
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