CU 4 LABORATORY

FOR NUTRIENT AND

DIET THERAPY
NCP OF RISK FOR
DEFICIENT FLUID
VOLUME
ASSESSMENT
Subjective:
“Tatlo or apat na beses pi ako sa isang araw dumudumi. Lagi rin po ako nauuhaw nauuhaw.
Basa rin po lagi tae ko. Nauuhaw ako. Tsaka lagi pong sumasakit ung sa pangibabaw kong
tiyan

Objective Cues:
Thirst Vital Signs: T: 36.5
Decreased skin turgor BP: 110/90 mmHg
Weakness RR: 19 CPM
Weight loss PR: 90 BPM
pallor
NURSING DIAGNOSIS
Risk for deficient fluid volume related to Inadequte Fluid
Intake
PLANNING
Short Term:
After 1-2 hours of continuous nursing care ang proper health teachings the patient
will manifest.
 Decrease risk for complications of Fluid Volume Deficit
 Significant others will have the proper knowledge regarding thediseas.
 Significant others will know the proper intervention of the problem.
PLANNING
Long term:
After 2 days of continuous nursing care and proper healtyh teaching the client will
maintain fluid volume at functional label as evidenced by:
 Normalized Bowel Movement
 Moist mucous membrane and good skin turgor.
INTERVENTION AND
RATIONALE
Independent
 Monitor intake and output, character and amount of stools; estimate insensible fluid
losses. Measure urine specific gravity and observe for oliguria.
o Provides information about overall fluid balance, renal function, and bowel
disease control, as well as guidelines for fluid replacement ( pg. 328-343 Nurses
Pocket Guide Edition 14)
 Assess vital signs ( BP- pulse, temperature
o Decrease in circulating blood volume can cause hypotension and tachycardia
( pg. 328-343 Nurses Pocket Guide Edition 14)
INTERVENTION AND
RATIONALE
 Note for excessively dry skin and mucous membranes, decreased skin turgor,
slowed capillary refill.
o Indicates excessive fluid loss or resultant of dehydration (pg. 328-343 Nurses
Pocket Guide Edition 14)
 Weigh patient daily.
o Indicator of overall fluid and nutritional status ( pg. 328-343 Nurses Pocket
Guide Edition 14)
• Maintain oral restrictions, bed rest and avoidance of exertion,.
o Colon is placed at rest for healing and to decrease intestinal fluid losses.
( pg. 328-343 Nurses Pocket Guide Edition 14)
INTERVENTION AND
RATIONALE
• Monitor usual mentation, behavior or functional abilitie.
o Those signs indicate sufficient dehydration to cause poor cerebral perfusion
or electrolyte imbalance. ( pg. 328-343 Nurses Pocket Guide Edition 14)
EVALUATION
Short Term Goal:
GOAL SUCCESSFULLY MET:
After 2hrs of continuous nursing care and proper health teachings the patient
manifested:
• Decreased risk for complications of Fluid volume deficit
• Significant others acquired proper knowledge regarding the disease.
• Significant others understand the intervention of the problem.
EVALUATION
Long Term:
After 2 days of continuous nursing care and proper health teachings the client will
maintain fluid volume at functional level as evidenced by:
• Normalized Bowel Movement
•Moist mucous membrane and skin turgor