Deficient Fluid Volume related to Diarrhea

Nursing Care Plan for Diarrhea

Nursing Diagnosis : Deficient Fluid Volume related to input decreases, loss of active fluid volume, failure in the regulatory mechanism

Defining Characteristics:

• Weakness
• Thirsty
• Decreased skin turgor
• Mucous membrane / dry skin
• Pulse increases, blood pressure decreases, pulse pressure decreases
• Decreased capillary filling
• Change in mental status
• Decreased urine output
• Increased urine concentration
• Increased body temperature
• Hematocrit increases
• Sudden weight loss.

Goal
After implementation, fluid and electrolyte requirements are adequate, with the following criteria:

Hydration

• Adequate skin hydration
• Blood pressure is within normal limits
• The pulse is palpable
• Moist mucous membrane
• Normal skin turgor
• Stable weight and within normal limits
• Eyelid - not concave
• Fontanela - not concave
• Normal urine output
• No fever
• There is no very thirst
• There is no short breaths

Fluid Balance

• Normal blood pressure
• Palpable peripheral pulse
• There is no orthostatic hypotension
• Balanced intakes and output in 24 hours
• Serum, electrolytes within normal limits.
• Hematocrit within normal limits
• No additional breath sounds
• Stable weight
• There is no ascites, peripheral edema
• There is no distention of the neck vein
• Eyes; not concave
• Not confused
• Thirst is not excessive
• Moist mucous membrane
• Adequate skin hydration

Nursing Interventions

Liquid Monitor

1. Determine history, type and amount of fluid intake and elimination habits.
2. Determine risk factors that cause fluid imbalances (hyperthermia, diuretics, kidney disorders, vomiting, polyuria, diarrhea, diaphoresis, exposure to heat,
3. Measure weight regularly.
4. Vital sign monitor.
5. Monitor intake and output.
6. Check serum, electrolytes and limit fluids if needed.
7. Maintain the accuracy of the intake and output records.
8. Monitor mucous membranes, skin turgor and thirst.
9. Monitor color and amount of urine.
10. Monitor distension of neck veins, crackles, peripheral odem and increase in body weight.
11. Monitor intravenous access.
12. Monitor signs and symptoms of ascites.
13. Note the presence of vertigo.
14. Maintain infusion according to doctor's advice.

Fluid Management

1. Measure weight and monitor trends.
2. Weigh diapers.
3. Maintain the accuracy of the intake and output records.
4. Use a catheter if necessary.
5. Monitor hydration status (humidity of mucous membranes, pulse, blood pressure).
6. Vital sign monitor.
7. Monitor signs of overhydration / excess fluid (ckrackles, peripheral edema, distension of the neck veins, ascites, pulmonary edema).
8. Give intravenous fluids.
9. Monitor nutritional status.
10. Give oral intake for 24 hours.
11. Monitor patient response to electrolyte therapy.
12. Collaborate with the doctor if there are signs and symptoms of excess fluid.

Management of Hypovolemia

1. Monitor the fluid intake and output status.
2. Maintain intravenous access patency.
3. Monitor Hemoglobin and Hematocrit.
4. Monitor fluid loss (vomiting and diarrhea).
5. Monitor vital signs.
6. Monitor patient response to fluid changes.
7. Monitor the site of intravenous puncture from signs of infiltration or infection.
8. IWL monitor (for example: diaphoresis).
9. Encourage the client to avoid changing positions quickly, from sleeping to sitting or standing.
10. Monitor weight regularly.
11. Monitor signs of dehydration (decreased skin turgor, slow capillary filling, dry mucous membrane, decreased urine output, hypotension, increased thirst, weak pulse.
12. Encourage oral intake (distribute fluids for 24 hours and give fluids between meals).
13. Maintain infusion flow.
14. Position the trendelenburg / foot elevation higher than the head when hypotensive if necessary.

Electrolyte Monitoring

1. Serum electrolyte monitor.
2. Collaboration with the doctor if there is electrolyte imbalance.
3. Monitor signs and symptoms of electrolyte imbalance (seizures, abdominal cramps, tremors, nausea and vomiting, lethargy, anxiety, confusion, disorientation, muscle cramps, bone pain, respiratory depression, cardiac arrhythmia, decreased consciousness: apathy, coma) .

Electrolyte Management

1. Maintain electrolyte-containing infusion fluid.
2. Monitor electrolyte loss through nasogastric succes, diarrhea, diaphoresis.
3. Give a diet rich in potassium.
4. Provide a safe environment for clients who experience neurological or neuromuscular disorders.
5. Teach clients and families about the types, causes, and treatment of electrolyte imbalances.
6. Collaboration with doctors if signs and symptoms of electrolyte imbalance persist.
7. Monitor client response to electrolyte therapy.
8. Monitor the side effects of electrolyte supplementation.

Source :

Johnson, M., et all. 2000. Nursing Outcomes Classification (NOC) Second Edition. New Jersey: Upper Saddle River

Mc Closkey, C.J., et all. 1996. Nursing Interventions Classification (NIC) Second Edition. New Jersey: Upper Saddle River