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  • NCP FVD

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    The patient was at risk for fluid volume imbalance due to oral intake restriction prior to surgery, blood loss during the procedure, and osmotic diuresis from contrast agent. The short term goal was for vital signs to fall within normal limits after 4 hours of nursing intervention. Interventions included monitoring vital signs, documenting mental status, observing skin and mucous membranes for dryness, and monitoring fluid intake and output to prevent further fluid deficit. The long term goal was for the patient to maintain fluid volume at a functional level for 8 hours prior to surgery through IV fluid administration before and during the procedure.

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    The patient was at risk for fluid volume imbalance due to oral intake restriction prior to surgery, blood loss during the procedure, and osmotic diuresis from contrast agent. The short term goal was for vital signs to fall within normal limits after 4 hours of nursing intervention. Interventions included monitoring vital signs, documenting mental status, observing skin and mucous membranes for dryness, and monitoring fluid intake and output to prevent further fluid deficit. The long term goal was for the patient to maintain fluid volume at a functional level for 8 hours prior to surgery through IV fluid administration before and during the procedure.

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    113 views1 page

    NCP FVD

    Uploaded by

    krizzia_ancheta
    The patient was at risk for fluid volume imbalance due to oral intake restriction prior to surgery, blood loss during the procedure, and osmotic diuresis from contrast agent. The short term goal was for vital signs to fall within normal limits after 4 hours of nursing intervention. Interventions included monitoring vital signs, documenting mental status, observing skin and mucous membranes for dryness, and monitoring fluid intake and output to prevent further fluid deficit. The long term goal was for the patient to maintain fluid volume at a functional level for 8 hours prior to surgery through IV fluid administration before and during the procedure.

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    ASSESSMENT  OBJECTIVE: o Nothing per orem prior to surgery o RRincreased o PRincreased o Irritability o With indwelling catheter

    NURSING DIAGNOSIS  Risk for fluid volume imbalance related to restriction of oral intake prior to surgery, blood loss at the access site and via catheter, osmotic dieresis due to the contrast agent

    PLANNING  SHORT TERM GOAL: y After 4 hours of nursing intervention patient s vital signs will fall within the normal level; RR 1220brpm, PR 60-100bpm

    INTERVENTION INDEPENDENT y Monitor vital signs such as temperature, pulse rate, respiratory rate, blood pressure

    RATIONALE y Vital sign changes such as increased heart rate, decreased blood pressure, and elevated temperature is present in condition with fluid volume deficit. Fluid volume deficit can alter mental status due to decrease cerebral perfusion Indicates excessive fluid loss and result of dehydration

    EVALUATION GOAL MET

    y  LONG TERM GOAL: y During 8 hours of nursing intervention patient will be able to maintain fluid volume at a functional level as evidenced by: o Adequate urinary output o vital signs fall within normal limit ( RR 1220brpm, PR 60100bpm) o moist skin and mucous membrane o <3 seconds capillary refill Patient will be able to maintain fluid restriction for 8 hours prior to surgery Regulated IV fluid before and during surgery y

    Document baseline mental status and monitor mental status throughout the procedure Observe for excessively dry skin and mucous membranes, decrease skin turgor, slowed capillary refill Observe for excessive bleeding on the incision site Monitor and record fluid intake and output balance

    To prevent even greater fluid volume deficit Decreased urinary output may indicate fluid deficit and may require fluid replacement through IV fluid To prevent fluid volume deficit

    Monitor IV flow rate regularly

    DEPENDENT y maintain patent IV access, set an


    appropriate IV infusion flow rate, and administer at a constant flow rate as ordered

    IV fluid is given to prevent dehydration secondary to oral fluid restriction

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