Fluid Volume Deficit Concept Map

Holistic Nursing Process Map Fluid Volume Deficit Pathophysiology = RT Go beyond the medical diagnosis. Explain the process as if explaining it to your patient or a child, ok to cite a source if necessary. Order the process chronologically. Condition where fluid output exceeds intake. Negative fluid and electrolyte balance or extracellular fluid contraction from a loss of total body sodium. Water crosses plasma membranes in the body via passive osmosis. When sodium is lost as a cause of vomiting, diarrhea, excessive sweating, burns, diuretics or kidney failure, water follows it from ECF space leading to a decrease of circulating volume, ineffective tissue perfusion, lowered venous return, arterial hypotension, and electrolyte imbalance within the body. standing, Increased respirations >20 breaths/min Risks for Developing Things that put the client at risk for developing the disease and the risks the patient has now developed related to the disease. Risk for hypovolemic shock, electrolyte imbalance, altered mental status, cardiovascular collapse, death, seizures, cardia arrhythmias Assessment Signs & Symptoms = AEB Everything you get from your assessment Both Objective and Subjective assessments link them to the pathophysiological process above. Dark urine, weakness, decreased urine output <30ml/hr, anxiety, confusion Hypotension, sbp <90, dbp <60 Diagnostics Decreased Serum Sodium Norm:135-145mEq/L Increased BUN Norm:824mg/dl Increased hematocrit (HCT) Norm: Males=4054ml/dl, Females=3747ml/dl Increased urine specific gravity (1.005-1.030), Increased serum osmolarity Norm: 275 to 295 mmol/kg Decreased Central venous pressure Labs to check for electrolyte imbalance: Potassium, phosphorus, calcium, magnesium ABG for DKA Nursing Diagnosis Caused by vomiting, diarrhea, excessive sweating, burns, diuretics, kidney failure, diabetes insipidus, diabetic ketoacidosis, decrease of thirst mechanism with age, hemorrhage At least three diagnoses in NANDA format in descending order from highest priority to lowest priority (only 1 may be a risk for). The related to ALWAYS comes from the pathophysiology and the as evidenced by ALWAYS comes from the signs & symptoms. They should match each other. Fluid volume deficit r/t a loss of body water and electrolytes from Medi Dry mucous membranes, Poor skin turgor, Tachycardia, HR >100 Increased temperature, Postural hypotension: vertigo, fall in SBP with Diagnosing Disease Process vomiting and diarrhea AEB poor skin turgor, HR >100 and BP <90/60 Ineffective tissue perfusion r/t low Holistic Nursing Process Map – Student Name Fluid Volume Deficit extracellular fluid volume AEB blood pressure <90/60 Altered mental status related to ineffective tissue from a decrease of fluid circulating volume AEB confusion and anxiety. Planning Nursing Intervention Written as SMART goals - Should match with the nursing diagnosis and have at least three interventions per nursing diagnosis. Monitor v/s, pulse quality and amplitude Monitor skin turgor Monitor intake and output Obtain specimen for analysis of altered electrolyte levels. Monitor for neurologic or neuromuscular changes as results of electrolyte imbalances Administer replacement fluids as ordered Implement fall precautions Medications Oral hydration if only mild and able to tolerated. IV therapy for more severe cases or unable to tolerate oral intake: Isotonic solutions for treatment of fluid volume deficit 9% normal saline, ges to hypotonic) Hypertonic solution for fluid volume deficit with hyponatremia: 3% sodium chloride, 5% Dextrose and 0.45% Sodium Chloride, 5% Dextrose and Lactated Ringer’s Education/Spiritual Needs: Refers to the “Art” of Nursing Answer how you will address the spiritual needs of the client and complete how you will educate the client about their health. Be sure to remember to meet the client where they are at. Educate patient on the importance of adequate fluid intake. Educate and provide the rationale to the client and family on when to contact a health care professional, such as in the cases of a significant change in urine output Hypotonic solution for fluid volume deficit with hypernatremia: 0.45% Sodium Chloride, 5% Dextrose in Water Teach family members the rationale for the importance of offering fluids regularly to clients who are unable to meet their own needs because of age, impaired mobility or cognition Inform clients about any expected side effects of prescribed medications and how to handle them such as potassium depleting diuretics