Monday, February 27, 2012

Nursing Interventions Risk for Fluid Volume Deficit related to Appendicitis

Definition

Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Common sources for fluid loss are the gastrointestinal tract, polyuria, and increased perspiration. Fluid volume deficit may be an acute or chronic condition managed in the hospital out patient center, or home setting.

The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of restoring fluid volume and correcting any electrolyte imbalances. Early recognition and treatment paramount to prevent potentially life-threatening hypovolemic shock. Older clients are more like to develop fluid imbalances.

Nursing Interventions Risk for Fluid Volume Deficit related to Appendicitis

Nursing Diagnosis Fluid Volume Deficit related to nausea, vomiting, and fasting

characterized by:
  • Lips dry.
  • The mouth chapped.
  • Blood pressure decreased.
  • Rapid pulse.
  • Nausea and vomiting.
  • A cold sweat.
  • Thirst.
Objectives: The client will maintain body fluid balance by the following criteria:
  • Normal blood pressure.
  • Lips are not dry.
  • Normal pulse.
  • Clients do not complain of thirst.
  • Intake and output balance.

Risk for Fluid Volume Deficit related to Appendicitis


Nursing Interventions Risk for Fluid Volume Deficit for Appendicitis :

1.) Record intake and output.
rational:
To find out the balance of fluids in the body that are needed for daily metabolism.

2.) Monitor skin turgor.
rational:
To find out the less interstitial fluid / loss can lead to loss of skin elasticity.

3.) Observed temperature and mucous membranes.
rational:
Dry mucous membranes which is an indicator of dehydration.

4.) Monitoring of urine.
rational:
The reduced amount of urine as indicators of reduced fluid in the body.

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