Risk for Deficient Fluid Volume | Nursing Care Plan for Appendectomy

Nursing diagnosis: risk for deficient Fluid Volume

Risk factors may include
Preoperative vomiting, postoperative restrictions—nothing by mouth (NPO)
Hypermetabolic state—fever, healing process
Inflammation of peritoneum with sequestration of fluid

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Hydration
Maintain adequate fluid balance as evidenced by moist mucous membranes, good skin turgor, stable vital signs, and individually adequate urinary output.

Nursing intervention with rationale:
1. Monitor blood pressure (BP) and pulse.
Rationale: Variations help identify fluctuating intravascular volumes or changes in vital signs associated with immune response to inflammation.

2. Inspect mucous membranes; assess skin turgor and capillary refill.
Rationale: Indicators of adequacy of peripheral circulation and cellular hydration.

3. Monitor intake and output (I&O); note urine color and concentration and specific gravity.
Rationale: Decreasing output of concentrated urine with increasing specific gravity suggests dehydration and need for increased fluids.

4. Auscultate bowel sounds. Note passing of flatus and bowel movement.
Rationale: Indicators of return of peristalsis and readiness to begin oral intake. Note: This may not occur in the hospital if client has had a laparoscopic procedure and been discharged in less than 24 hours.

5. Provide clear liquids in small amounts when oral intake is resumed, and progress diet as tolerated.
Rationale: Reduces risk of gastric irritation and vomiting to minimize fluid loss.

6. Give frequent mouth care with special attention to protection of the lips.
Rationale: Dehydration results in drying and painful cracking of the lips and mouth.

7. Maintain nasogastric (NG) and intestinal suction, as indicated.
Rationale: Although not frequently needed, an NG tube may be inserted preoperatively and maintained in immediate postoperative phase to decompress the bowel, promote intestinal rest, and prevent vomiting.

8. Administer intravenous (IV) fluids and electrolytes.
Rationale: The peritoneum reacts to irritation and infection by producing large amounts of intestinal fluid, pulling fluid from the vascular space and possibly reducing the circulating blood volume, resulting in dehydration and relative electrolyte imbalances.