Risk for Deficient Fluid Volume | Nursing Care Plan for Peritoneal Dialysis

Nursing diagnosis: risk for deficient Fluid Volume

Risk factors may include
Use of hypertonic dialysate with excessive removal of fluid from circulating volume

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

Desired Outcomes/Evaluation Criteria—Client Will
Systemic Toxin Clearance: Dialysis
Achieve desired alteration in fluid volume and weight with BP and electrolyte levels within acceptable range.
Experience no symptoms of dehydration.

Nursing intervention with rationale:
1. Maintain record of inflow and outflow volumes and individual and cumulative fluid balance.
Rationale: Provides information about the status of client’s loss or gain at the end of each exchange.

2. Adhere to schedule for draining dialysate from abdomen.
Rationale: Prolonged dwell times, especially when 4.5% glucose solution is used, may cause excessive fluid loss.

3. Weigh when abdomen is empty, following initial 6 to 10 runs, then as indicated.
Rationale: Detects rate of fluid removal by comparison with baseline body weight.

4. Monitor BP lying and sitting and pulse. Note level of jugular pulsation.
Rationale: Decreased BP, postural hypotension, and tachycardia are early signs of hypovolemia.

5. Note reports of dizziness, nausea, and increasing thirst.
Rationale: May indicate hypovolemia or hyperosmolar syndrome.

6. Inspect mucous membranes, evaluate skin turgor, peripheral pulses, and capillary refill.
Rationale: Dry mucous membranes, poor skin turgor, and diminished pulses and capillary refill are indicators of dehydration and need for increased intake or changes in strength of dialysate.

7. Monitor laboratory studies, as indicated, such as: Serum sodium and glucose levels
Rationale: Hypertonic solutions may cause hypernatremia by removing more water than sodium. In addition, dextrose may be absorbed from the dialysate, thereby elevating serum glucose.

8. Monitor laboratory studies, as indicated, such as: Serum potassium levels
Rationale: Hypokalemia may occur and can cause cardiac dysrhythmias.

Risk for Deficient Fluid Volume | Nursing Diagnosis for Renal Failure

Nursing diagnosis: risk for deficient Fluid Volume

Risk factors may include
Excessive loss of fluid (diuretic phase of ARF, with rising urinary volume and delayed return of tubular reabsorption capabilities)

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

Desired Outcomes/Evaluation Criteria—Client Will
Fluid Balance
Display I&O near balance, good skin turgor, moist mucous membranes, palpable peripheral pulses, stable weight and vital signs, and electrolytes within normal range.

Nursing intervention with rationale:
1. Measure I&O accurately. Weigh daily. Calculate insensible fluid losses.
Rationale: Helps estimate fluid replacement needs. Fluid intake should approximate losses through urine, nasogastric (NG) or wound drainage, and insensible losses—diaphoresis and metabolism. Note: Some sources believe that fluid replacement should not exceed two-thirds of the previous day’s output to prevent prolonging the diuresis.

2. Encourage fluid intake. Provide allowed fluids throughout 24-hour period.
Rationale: Diuretic phase of ARF may revert to oliguric phase if fluid intake is not maintained or nocturnal dehydration occurs.

3. Monitor BP, noting postural changes, and heart rate.
Rationale: Orthostatic hypotension and tachycardia suggest hypovolemia.

4. Note signs and symptoms of dehydration, such as dry mucous membranes, thirst, dulled sensorium, and peripheral vasoconstriction.
Rationale: In diuretic or postobstructive phase of renal failure, urine output can exceed 3 L/day. Extracellular fluid (ECF) volume depletion activates the thirst center, and sodium depletion causes persistent thirst, unrelieved by drinking water. Continued fluid losses and inadequate replacement may lead to hypovolemic state.

5. Control environmental temperature; limit bed linens, as indicated.
Rationale: May reduce diaphoresis, which contributes to overall fluid losses.

6. Monitor laboratory studies, such as sodium.
Rationale: In nonoliguric ARF or in diuretic phase of ARF, large urine losses may result in sodium wasting, while elevated urinary sodium acts osmotically to increase fluid losses. Restriction of sodium may be indicated to break the cycle.

Risk for Deficient Fluid Volume | Nursing Diagnosis for Leukemia

Nursing diagnosis: risk for deficient Fluid Volume

Risk factors may include
Excessive losses—vomiting, hemorrhage, diarrhea
Decreased fluid intake—nausea, anorexia
Increased fluid need—hypermetabolic state, fever, predisposition for kidney stone formation and tumor lysis syndrome

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

Desired Outcomes/Evaluation Criteria—Client Will
Hydration
Demonstrate adequate fluid volume, as evidenced by stable vital signs; palpable pulses; urine output, specific gravity, and pH within normal limits.
Risk Control
Identify individual risk factors and appropriate interventions.
Initiate behaviors or lifestyle changes to prevent development of dehydration.

Nursing intervention with rationale:
1. Monitor intake and output (I&O). Calculate insensible losses and fluid balance. Note decreased urine output in presence of adequate intake. Measure urine specific gravity and pH.
Rationale: Tumor lysis syndrome occurs when destroyed cancer cells release toxic levels of potassium, phosphorus, and uric acid. Elevated phosphorus and uric acid levels can cause crystal formation in the renal tubules, impairing filtration and leading to renal failure.

2. Weigh daily.
Rationale: Measure of adequacy of fluid replacement and kidney function. Continued intake greater than output may indicate renal insult or obstruction.

3. Monitor blood pressure (BP) and heart rate.
Rationale: Changes may reflect effects of hypovolemia associated with bleeding or dehydration.

4. Evaluate skin turgor, capillary refill, and general condition of mucous membranes.
Rationale: Indirect indicators of fluid status.

5. Note presence of nausea or fever.
Rationale: Affects intake, fluid needs, and route of replacement.

6. Encourage fluids of up to 3 to 4 L/day when oral intake is resumed.
Rationale: Promotes urine flow, prevents uric acid precipitation, and enhances clearance of antineoplastic drugs.

7. Inspect skin and mucous membranes for petechiae and ecchymotic areas; note bleeding gums, frank or occult blood in stools and urine, and oozing from invasive line sites.
Rationale: Suppression of bone marrow and platelet production places client at risk for spontaneous or uncontrolled bleeding.

8. Implement measures to prevent tissue injury and bleeding: gentle brushing of teeth or gums with soft toothbrush, cotton swab, or sponge-tipped applicator; using electric razor instead of sharp razors when shaving; avoiding forceful nose blowing and needlesticks when possible; and using sustained pressure such as sandbags or pressure dressings on oozing puncture or intravenous (IV) sites.
Rationale: Fragile tissues and altered clotting mechanisms increase the risk of hemorrhage following even minor trauma.

9. Limit oral care to mouth rinse, if indicated, such as a mixture of 1/4 tsp baking soda and 1/8 tsp salt in 8 oz water, or may use hydrogen peroxide in water or saline for bleeding or infected oral tissue. Avoid mouthwashes with alcohol.
Rationale: When bleeding is present, even gentle brushing may cause more tissue damage. Alcohol has a drying effect and may be painful to irritated tissues.

10. Administer medications, as indicated, for example: Antiemetics: 5-HT3 receptor antagonist drugs, such as ondansetron (Zofran) or granisetron (Kytril)
Rationale: Relieves nausea and vomiting associated with administration of chemotherapy agents and may enhance oral intake.

Risk for Deficient Fluid Volume | Nursing Diagnosis for Sickle Cell Disease

Nursing diagnosis: risk for deficient Fluid Volume

Risk factors may include
Increased fluid needs—hypermetabolic state or fever, inflammatory processes
Renal parenchymal damage or infarctions limiting the kidney’s ability to concentrate urine (hyposthenuria)

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 individually appropriate urine output with a near-normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor, and prompt capillary refill.

Nursing intervention with rationale:
1. Maintain accurate intake and output (I&O). Weigh daily.
Rationale: Client may reduce fluid intake during periods of crisis because of malaise and anorexia. Dehydration from vomiting, diarrhea, and fever may reduce urine output and precipitate a vaso-occlusive crisis.

2. Note urine characteristics and specific gravity.
Rationale: The kidney can lose its ability to concentrate urine, resulting in excessive losses of dilute urine and fixation of the specific gravity.

3. Monitor vital signs, comparing with client’s usual or previous readings. Take BP in lying, sitting, and standing positions, if possible.
Rationale: Reduction of circulating blood volume can occur from increased fluid loss, resulting in hypotension and tachycardia.

4. Observe for fever, changes in level of consciousness, poor skin turgor, dryness of skin and mucous membranes, and pain.
Rationale: Symptoms are reflective of dehydration and hemoconcentration with consequent vaso-occlusive state.

5. Monitor vital signs closely during blood transfusions and note presence of dyspnea, crackles, rhonchi, wheezes, diminished breath sounds, cough, frothy sputum, and cyanosis.
Rationale: Client’s heart may already be weakened and prone to failure because of chronic demands placed on it by the anemic state. Heart may be unable to tolerate the added fluid volume from transfusions or rapid IV fluid administered to treat crisis or shock.

6. Administer IV fluids, as indicated.
Rationale: Replaces fluid deficits; may reverse renal concentration of RBCs and reduce potential for kidney failure. Fluids must be given immediately, especially in CNS involvement, to decrease hemoconcentration and prevent further infarction.

7. Monitor laboratory studies, for example: Hgb/Hct
Rationale: Elevations may indicate hemoconcentration. Post-transfusion Hgb level of 8 to 9 g/dL is generally recommended to avoid the risk of hyperviscosity that may occur several days after transfusion when RBCs sequestered in the spleen may return to the circulation and increase the Hgb levels.

8. Serum and urine electrolytes
Rationale: Kidneys’ loss of ability to concentrate urine may result in serum depletions of Na+, K–, and Cl–, necessitating replacement.

Risk for Deficient Fluid Volume/Bleeding | Nursing Care Plan for Pancreatitis

Nursing diagnosis: risk for deficient Fluid Volume/Bleeding

Risk factors may include
Excessive losses—vomiting, gastric suctioning
Increase in size of vascular bed (vasodilation effects of kinins)
Third-space fluid transudation, ascites formation
Alteration of clotting process, hemorrhage

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

Desired Outcomes/Evaluation Criteria—Client Will
Hydration
Maintain adequate hydration as evidenced by stable vital signs, good skin turgor, prompt capillary refill, strong peripheral pulses, and individually appropriate urinary output.

Nursing intervention with rationale:
1. Auscultate heart sounds; note rate and rhythm. Monitor and document rhythm and changes.
Rationale: Cardiac changes and dysrhythmias may reflect hypovolemia or electrolyte imbalance, commonly hypokalemia and hypocalcemia. Hyperkalemia may occur related to tissue necrosis, acidosis, and renal insufficiency and may precipitate lethal dysrhythmias if uncorrected. Note: Cardiovascular complications are common in severe pancreatitis and include myocardial infarction (MI), pericarditis, and pericardial effusion with or without tamponade.

2. Monitor blood pressure (BP), noting trends. Measure central venous pressure (CVP), if available.
Rationale: Fluid sequestration with shifts into third space, bleeding, and release of vasodilators (kinins) and cardiac depressant factor triggered by pancreatic ischemia may result in profound hypotension. Reduced cardiac output and poor organ perfusion can precipitate widespread systemic complications. Systemic infection (septic shock) is also possible, exacerbating hypovolemic status.

3. Investigate changes in sensorium: confusion and slowed responses.
Rationale: Changes may be related to hypovolemia, hypoxia, electrolyte imbalance, or impending delirium tremens (in client with acute pancreatitis secondary to excessive alcohol intake). Severe pancreatic disease may cause toxic psychosis.

4. Measure intake and output (I&O), including vomiting or gastric aspirate, and diarrhea. Calculate 24-hour fluid balance.
Rationale: Indicators of replacement needs and effectiveness of therapy.

5. Note decrease in urine output (less than 400 mL/24 hours).
Rationale: Oliguria may occur, signaling renal impairment or acute tubular necrosis (ATN), related to increase in renal vascular resistance or altered renal blood flow.

6. Record color and character of gastric drainage, measure pH, and note presence of occult blood.
Rationale: Risk of gastric hemorrhage is high.

7. Weigh, as indicated; correlate with calculated fluid balance.
Rationale: Weight loss may suggest hypovolemia; however, edema, fluid retention, and ascites may be reflected by increased or stable weight, even in the presence of muscle wasting.

8. Note poor skin turgor, dry skin and mucous membranes, or reports of thirst.
Rationale: Further physiological indicators of dehydration.

9. Observe and record peripheral and dependent edema. Measure abdominal girth if ascites present.
Rationale: Edema and fluid shifts occur as a result of increased vascular permeability, sodium retention, and decreased colloid osmotic pressure in the intravascular compartment.

10. Inspect skin for petechiae, hematomas, and unusual wound or venipuncture bleeding. Note hematuria, mucous membrane bleeding, and bloody gastric contents.
Rationale: Disseminated intravascular coagulation (DIC) may be initiated by release of active pancreatic proteases into the circulation. The most frequently affected organs are the kidneys, skin, and lungs.

Risk for Deficient Fluid Volume/Bleeding | Nursing Care Plan for Hepatitis

Nursing diagnosis: risk for deficient Fluid Volume/Bleeding

Risk factors may include
Excessive losses through vomiting and diarrhea, third-space shift
Altered clotting process

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

Desired Outcomes/Evaluation Criteria—Client Will
Hydration
Maintain adequate hydration, as evidenced by stable vital signs, good skin turgor, capillary refill, strong peripheral pulses, and individually appropriate urinary output.
Coagulation Status
Be free of signs of hemorrhage with clotting times WNL.

Nursing intervention with rationale:
1. Monitor intake and output (I&O) and compare with periodic weight. Note enteric losses, such as vomiting and diarrhea.
Rationale: Provides information about replacement needs and effects of therapy. Note: Diarrhea may be due to transient flulike response to viral infection or may represent a more serious problem of obstructed portal blood flow with vascular congestion in the gastrointestinal (GI) tract. Or, it may be the intended result of medication use, such as neomycin or lactulose, to decrease serum ammonia levels in the presence of hepatic encephalopathy.

2. Assess vital signs, peripheral pulses, capillary refill, skin turgor, and mucous membranes.
Rationale: Indicators of circulating volume and perfusion.

3. Check for ascites for edema formation. Measure abdominal girth, as indicated.
Rationale: Useful in monitoring progression and resolution of fluid shifts associated with edema and ascites.

4. Use small-gauge needles for injections, applying pressure for longer than usual after venipuncture.
Rationale: Reduces possibility of bleeding into tissues.

5. Have client use cotton or sponge swabs and alcohol-free mouthwash instead of toothbrush.
Rationale: Avoids trauma and bleeding of the gums. Note: Alcohol-based mouthwash may be irritating to dry mucosa.

6. Observe for signs of bleeding—hematuria and melena, ecchymosis, and oozing from gums or puncture sites.
Rationale: Prothrombin levels are reduced and coagulation times prolonged when vitamin K absorption is altered in GI tract, and synthesis of prothrombin is decreased in affected liver.

7. Monitor periodic laboratory values, such as Hgb/Hct, sodium, albumin, and clotting times.
Rationale: Reflects hydration status and identifies sodium retention and protein deficits, which may lead to edema formation. Deficits in clotting potentiate risk of bleeding.

8. Administer antidiarrheal agents, such as diphenoxylate with atropine (Lomotil).
Rationale: Reduces fluid and electrolyte loss from GI tract.

9. Provide intravenous (IV) fluids (usually glucose) and electrolytes
Rationale: Provides fluid and electrolyte replacement in acute toxic state.

10. Administer medications, as indicated, for example: Vitamin K
Rationale: Because absorption is altered, supplementation may prevent coagulation problems, which may occur if clotting factors are decreased.

Deficient Fluid Volume | Nursing Care Plan for Diabetes Mellitus

Nursing diagnosis: deficient Fluid Volume related to Osmotic diuresis from hyperglycemia, Excessive gastric losses—diarrhea, vomiting, Restricted intake—nausea, confusion

Possibly evidenced by
Increased urinary output, dilute urine
Weakness, thirst, sudden weight loss
Dry skin and mucous membranes, poor skin turgor
Hypotension, tachycardia, delayed capillary refill

Desired Outcomes/Evaluation Criteria—Client Will
Fluid Balance
Demonstrate adequate hydration as evidenced by stable vital signs, palpable peripheral pulses, good skin turgor and capillary refill, individually appropriate urinary output, and electrolyte levels within normal range.

Nursing intervention with rationale:
1. Obtain history from client and significant other (SO) related to duration and intensity of symptoms, such as vomiting and excessive urination.
Rationale: Helps estimate total volume depletion. Symptoms may have been present for varying amounts of time—hours to days. Presence of infectious process results in fever and hypermetabolic state, increasing insensible fluid losses.

2. Monitor vital signs: Note orthostatic BP changes
Rationale: Hypovolemia may be manifested by hypotension and tachycardia. Estimates of severity of hypovolemia may be made when client’s systolic BP drops more than 10 mm Hg from a recumbent to a sitting or standing position. Note: Cardiac neuropathy may block reflexes that normally increase heart rate.

3. Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes.
Nursing intervention: Indicators of level of hydration and adequacy of circulating volume.

4. Monitor intake and output (I&O); note urine specific gravity.
Rationale: Provides ongoing estimate of volume replacement needs, kidney function, and effectiveness of therapy.

5. Weigh daily.
Rationale: Provides the best assessment of current fluid status and adequacy of fluid replacement.

6. Maintain fluid intake of at least 2,500 mL/day within cardiac tolerance when oral intake is resumed.
Rationale: Maintains hydration and circulating volume.

7. Promote comfortable environment. Cover client with light sheets.
Rationale: Avoids overheating, which could promote further fluid loss.

8. Investigate changes in mentation and sensorium.
Rationale: Changes in mentation can be due to abnormally high or low glucose, electrolyte abnormalities, acidosis, decreased cerebral perfusion, or developing hypoxia. Regardless of the cause, impaired consciousness can predispose client to aspiration.

9. Administer fluids, as indicated: Isotonic (0.9%) or lactated Ringer’s solution without additives
Rationale: Type and amount of fluid depends on degree of deficit and individual client response. Note: Client with DKA is often severely dehydrated and commonly needs 5 to 10 L of isotonic saline, 2 to 3 L within first 2 hours of treatment.

10. Administer potassium and other electrolytes intravenously (IV) or by oral route, as indicated.
Rationale: Potassium should be added to the IV as soon as urinary flow is adequate, to prevent hypokalemia. Note: Potassium phosphate may be drug of choice when IV fluids contain sodium chloride in order to prevent chloride overload. Phosphate concentrations tend to decrease with insulin therapy.

Risk for Deficient Fluid Volume | Nursing Care Plan for Bariatric Surgery

Risk factors may include
Excessive gastric losses—nasogastric suction, diarrhea
Reduced intake

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 with balanced intake and output (I&O) and be free of signs reflecting dehydration.

Nursing intervention with rationale:
1. Assess vital signs, noting changes in blood pressure (BP), such as orthostatic hypotension, tachycardia, and fever. Assess skin turgor, capillary refill, and moisture of mucous membranes.
Rationale: Indicators of dehydration and hypovolemia and adequacy of current fluid replacement. Note: Adequately-sized cuff must be used to ensure factual measurement of BP. If cuff is too small, reading will be falsely elevated.

2. Monitor I&O, measuring nasogastric (NG) suction losses.
Rationale: Changes in gastric capacity and intestinal motility and nausea greatly influence intake and fluid needs, increasing risk of dehydration.

3. Evaluate muscle strength and tone. Observe for muscle tremors.
Rationale: Large gastric losses may result in decreased magnesium and calcium, leading to neuromuscular weakness and tetany.

4. Establish individual needs and replacement schedule.
Rationale: Determined by amount of measured losses and estimated insensible losses and dependent on gastric capacity.

5. Encourage increased oral intake when able.
Rationale: Permits discontinuation of invasive fluid support measures and contributes to return of normal bowel functioning.

6. Administer IV fluids, as indicated.
Rationale: Replaces fluid losses and restores fluid balance in immediate postoperative phase until client is able to take sufficient oral fluids.

7. Monitor electrolyte levels and replace, as indicated.
Rationale: Use of NG tube, vomiting, or onset of diarrhea can deplete electrolytes, affecting organ function.

Risk for Deficient Fluid Volume | Nursing Care Plan for Anorexia/Bulimia

Nursing diagnosis: risk for deficient Fluid Volume related to Inadequate intake of food and liquids, Consistent self-induced vomiting, Chronic, excessive laxative or diuretic use

Possibly evidenced by (actual)
Dry skin and mucous membranes, decreased skin turgor
Increased pulse rate, body temperature, decreased BP
Output greater than input (diuretic use); concentrated urine and decreased urine output (dehydration)
Weakness
Change in mental state
Hemoconcentration, altered electrolyte balance

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

Risk Control
Verbalize understanding of causative factors and behaviors necessary to correct fluid deficit.

Nursing intervention with rationale:
1. Monitor vital signs, capillary refill, status of mucous membranes, and skin turgor.
Rationale: Indicators of adequacy of circulating volume. Orthostatic hypotension may occur with risk of falls and injury following sudden changes in position.

2. Monitor amount and types of fluid intake. Measure urine output accurately.
Rationale: Client may abstain from all intake, with resulting dehydration, or substitute fluids for caloric intake, disturbing electrolyte balance.

3. Discuss strategies to stop vomiting and laxative or diuretic use.
Rationale: Helping client deal with the feelings that lead to vomiting and laxative or diuretic use will prevent continued fluid loss. Note: Client with bulimia has learned that vomiting provides a release of anxiety.

4. Identify actions necessary to regain or maintain optimal fluid balance, such as specific fluid intake schedule.
Rationale: Involving client in plan to correct fluid imbalances improves chances for success.

5. Review electrolyte and renal function test results.
Rationale: Fluid and electrolyte shifts or depressed renal function can adversely affect client’s recovery and may require additional intervention.

6. Administer intravenous (IV) fluids and electrolytes, as indicated.
Rationale: Used to correct fluid and electrolyte imbalances and prevent cardiac dysrhythmias.

Risk for Deficient Fluid Volume | Nursing Care Plan for Cholecystectomy

Risk factors may include
Losses from nasogastric (NG) aspiration, vomiting
Medically restricted intake
Altered coagulation, such as reduced prothrombin, prolonged coagulation time

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

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

Nursing intervention with rationale:
1. Monitor intake and output (I&O), including drainage from NG tube, T-tube, and wound. Weigh client periodically.
Rationale: Provides information about replacement needs and organ function. Initially, 200 to 1,000 mL of bile drainage per 24 hours may be expected via the T-tube, decreasing as more bile enters the intestine. Continuing large amounts of bile drainage may be an indication of unresolved obstruction or, occasionally, a biliary fistula. Note: Sudden cessation of drainage may indicate blockage of tube.

2. Monitor vital signs. Assess mucous membranes, skin turgor, peripheral pulses, and capillary refill.
Rationale: Indicators of adequacy of circulating volume and perfusion.

3. Observe for signs of bleeding, such as hematemesis, melena, petechiae, ecchymosis, epistaxis, and oozing from incision and injection sites.
Rationale: Prothrombin is reduced and coagulation time prolonged when bile flow is obstructed, increasing risk of bleeding or hemorrhage.

4. Use small-gauge needles for injections, and apply firm pressure for longer than usual after venipuncture.
Rationale: Reduces trauma and risk of bleeding or hematoma formation.

5. Have client use soft toothbrush or cotton or sponge swabs and alcohol-free mouthwash instead of a toothbrush, if bleeding is a problem.
Rationale: Avoids trauma and bleeding of the gums. Alcohol can be drying and cause irritation to mucosa.

6. Monitor laboratory studies, such as complete blood count (CBC), electrolytes, prothrombin and clotting time, and amylase.
Rationale: Provides information about circulating volume, electrolyte balance, and adequacy of clotting factors. The hematocrit (Hct) rises when plasma volume is reduced, as in dehydration from vomiting. Falling hemoglobin (Hgb) and Hct may reflect bleeding as a complication of obstructed bile flow, surgical procedure, or preexisting bleeding disorder. Elevated white blood cells (WBCs) can indicate inflammation from surgery, peritonitis, or pancreatitis or other infection. Damage to the pancreas is indicated by elevated levels of amylase.

7. Administer the following, as indicated: Intravenous (IV) fluids, blood products, and vitamin K
Rationale: Maintains adequate circulating volume and aids in replacement of clotting factors.

8. Electrolytes (such as potassium, sodium, and chloride)
Rationale: Imbalances resulting from excessive gastric or surgical fluid losses may require replacement via oral and parenteral routes.

Risk for Deficient Fluid Volume | Nursing Care Plan for Cholecystitis

Desired Outcomes/Evaluation Criteria—Client Will
Hydration
Demonstrate adequate fluid balance evidenced by stable vital signs, moist mucous membranes, good skin turgor, capillary refill, individually appropriate urinary output, and absence of vomiting.

Nursing intervention with rationale:
1. Maintain accurate record of intake and output (I&O), noting output less than intake and increased urine specific gravity. Assess skin and mucous membranes, peripheral pulses, and capillary refill.
Rationale: Provides information about fluid status and circulating volume and replacement needs.

2. Monitor for signs and symptoms of increased or continued nausea or vomiting, abdominal cramps, weakness, twitching, seizures, irregular heart rate, paresthesia, hypoactive or absent bowel sounds, and depressed respirations.
Rationale: Prolonged vomiting, gastric aspiration, and restricted oral intake can lead to deficits in sodium, potassium, and chloride.

3. Eliminate noxious sights and smells from environment.
Rationale: Reduces stimulation of vomiting center.

4. Perform frequent oral hygiene with alcohol-free mouthwash; apply lubricants.
Rationale: Decreases dryness of oral mucous membranes and reduces risk of oral bleeding.

5. Assess for unusual bleeding: oozing from injection sites, epistaxis, bleeding gums, ecchymosis, petechiae, hematemesis, and melena.
Rationale: Prothrombin is reduced and coagulation time prolonged when bile flow is obstructed, increasing risk of bleeding or hemorrhage.

6. Use small-gauge needles for injections and apply firm pressure for longer than usual after venipuncture.
Rationale: Reduces trauma, risk of bleeding, and hematoma formation.

7. Keep client NPO as necessary.
Rationale: Decreases gastrointestinal (GI) secretions and hypermotility.

8. Insert NG tube, connect to suction, and maintain patency, as indicated.
Rationale: Provides rest for GI tract and relief of vomiting.

9. Administer antiemetics, such as promethazine (Phenergan), prochlorperazine (Compazine), or ondansetron (Zofran).
Rationale: Helpful in reducing nausea and vomiting often associated with cholecystitis and, particularly, common bile duct obstruction.

10. Review laboratory studies such as Hgb/Hct, electrolytes, arterial blood gases (ABGs) (pH), and clotting times.
Rationale: Aids in evaluating circulating volume, identifies deficits, and influences choice of intervention for replacement or correction.

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.

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.

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.

Nursing Diagnosis for Pneumonia | Risk for Deficient Fluid Volume

Nursing diagnosis: Risk for Deficient Fluid Volume

Risk factors may include

Excessive fluid loss—fever, profuse diaphoresis, mouth breathing and hyperventilation, vomiting

Decreased oral intake

Possibly evidenced by

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

Desired Outcomes/Evaluation Criteria—Client Will

Fluid Balance

Demonstrate fluid balance evidenced by individually appropriate parameters, such as moist mucous membranes, good skin

turgor, prompt capillary refill, and stable vital signs.

Nursing intervention with rationale:

1. Assess vital sign changes, such as increased temperature, prolonged fever, tachycardia, and orthostatic hypotension.

Rationale: Elevated temperature or prolonged fever increases metabolic rate and fluid loss through evaporation. Orthostatic BP changes and increasing tachycardia may indicate systemic

fluid deficit.

2. Assess skin turgor, moisture of mucous membranes—lips and tongue.

Rationale: Indirect indicators of adequacy of fluid volume, although oral mucous membranes may be dry because of mouth breathing and supplemental oxygen. Presence of these symptoms reduces oral

3. Note reports of nausea and vomiting.

Rationale: Presence of these symptoms reduces oral intake.

4. Monitor intake and output (I&O), noting color and character of urine. Calculate fluid balance. Be aware of insensible losses. Weigh as indicated.

Rationale: Provides information about adequacy of fluid volume and replacement needs.

5. Force fluids to at least 3,000 mL per day or as individually appropriate.

Rationale: Meets basic fluid needs, reducing risk of dehydration.

6. Administer medications, as indicated, such as antipyretics, antiemetics.

Rationale: Useful in reducing fluid losses.

7. Provide supplemental IV fluids as necessary.

Rationale: In the presence of reduced intake or excessive loss, use of parenteral route may correct or prevent deficiency.