Risk for Deficient Fluid Volume | Nursing Care Plan (NCP) for Inflammatory Bowel Disease for I

Nursing diagnosis: risk for deficient Fluid Volume

Risk factors may include

Excessive losses through normal routes—severe frequent diarrhea, vomiting

Hypermetabolic state—inflammation, fever

Restricted intake—nausea, anorexia

Possibly evidenced by

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

Desired Outcomes/Evaluation Criteria—Client Will

Hydration

Maintain adequate fluid volume as evidenced by moist mucous membranes, good skin turgor, and capillary refill; stable vital signs; and balanced intake and output (I&O) with urine of normal concentration and amount.

Nursing intervention with rationale:

1. Monitor I&O. Note number, character, and amount of stools; estimate insensible fluid losses (e.g., diaphoresis). Measure urine specific gravity and observe for oliguria.

Rationale: Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement.

2. Assess vital signs (blood pressure [BP], pulse, temperature).

Rationale: Hypotension (including postural), tachycardia, and fever can indicate response to and effect of fluid loss.

3. Observe for excessively dry skin and mucous membranes, decreased skin turgor, and slowed capillary refill.

Rationale: Indicates excessive fluid loss and resultant dehydration.

4. Weigh daily.

Rationale: Indicator of overall fluid and nutritional status.