Fluid Volume Deficit | Nursing Care Plan for Peritonitis

Nursing diagnosis: deficient Fluid Volume related to Fluid shifts from extracellular, intravascular, and interstitial compartments into intestines and/or peritoneal space, Vomiting; medically restricted intake; nasogastric (NG) or intestinal aspiration, Fever, hypermetabolic state

Possibly evidenced by
Dry mucous membranes, poor skin turgor, delayed capillary refill, weak peripheral pulses
Diminished urinary output; dark, concentrated urine
Hypotension; tachycardia

Desired Outcomes/Evaluation Criteria—Client Will
Fluid Balance
Demonstrate improved fluid balance as evidenced by adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor, prompt capillary refill, and weight within acceptable range.

Nursing intervention with rationale:
1. Monitor vital signs, noting presence of hypotension (including postural changes), tachycardia, tachypnea, and fever. Measure central venous pressure (CVP) if available.
Rationale: Aids in evaluating degree of fluid deficit, effectiveness of fluid replacement therapy, and response to medications.

2. Maintain accurate intake and output (I&O) and correlate with daily weights. Include measured and estimated losses, such as with gastric suction, drains, dressings, Hemovacs, diaphoresis, and abdominal girth for third spacing of fluid.
Rationale: Reflects overall hydration status. Urine output may be diminished because of hypovolemia and decreased renal perfusion, but weight may still increase, reflecting tissue edema or ascites accumulation (third spacing). Gastric suction losses may be large, and a great deal of fluid can be sequestered in the bowel and peritoneal space (ascites).

3. Measure urine specific gravity.
Rationale: Reflects hydration status and changes in renal function, which may warn of developing acute renal failure in response to hypovolemia and effect of toxins. Note: Many antibiotics also have nephrotoxic effects that may further affect kidney function and urine output.

4. Observe skin and mucous membrane dryness and turgor. Note peripheral and sacral edema.
Rationale: Hypovolemia, fluid shifts, and nutritional deficits contribute to poor skin turgor and taut edematous tissues.

5. Eliminate noxious sights or smells from environment. Limit intake of ice chips.
Rationale: Reduces gastric stimulation and vomiting response. Note: Excessive use of ice chips during gastric aspiration can increase gastric washout of electrolytes.

6. Change position frequently, provide frequent skin care, and maintain dry, wrinkle-free bedding.
Rationale: Edematous tissue with compromised circulation is prone to breakdown.

7. Monitor laboratory studies: Hgb/Hct, electrolytes, protein, albumin, BUN, and creatinine (Cr).
Rationale: Provides information about hydration and organ function. Significant consequences to systemic function are possible mas a result of fluid shifts, hypovolemia, hypoxemia, circulating toxins, and necrotic tissue products.

8. Administer plasma, blood, fluids, electrolytes, and diuretics, as indicated.
Rationale: Replenishes and maintains circulating volume and electrolyte balance. Colloids, such as plasma or blood, help move water back into intravascular compartment by increasing osmotic pressure gradient. Diuretics may be used to assist in excretion of toxins and to enhance renal function.

9. Maintain NPO status with NG or intestinal aspiration.
Rationale: Reduces vomiting caused by hyperactivity of bowel; manages stomach and intestinal fluids.