koz74686_ch52.qxd
11/8/06
2:08 PM
Page 1480
1480 UNIT X / Promoting Physiologic Health
Deficient Fluid Volume
CONCEPT MAP
MC
27 y.o. female
• Sales clerk, Reports weakness,
malaise, and flu-like symptoms for 3-4
days. Although thirsty, is unable to
tolerate fluids because of nausea and
vomiting, and she has liquid stools 2-4
times per day.
assess
• Height: 160 cm (5' 3")
• Weight: 66.2 kg (146 lbs)
• T: 38.6°C; P: 96 BPM;
• R: 24; BP: 102/84
• Dry mucous membranes
• Decreased skin turgor
•
•
•
•
Urine specific gravity: 1.035
Serum sodium: 155 mEq/L
Serum potassium 3.2 mEq/L
Chest x-ray negative
generate nursing diagnosis
Deficient Fluid Volume r/t nausea, vomiting, diarrhea aeb decreased urine output, increased urine
concentration, weakness, fever, decreased skin turgor, dry mucous membranes, increased pulse,
and decreased BP
outcome
outcome
Outcomes met:
• BP: 122/74
• P: 74
• Urine output
increased
• Specific gravity:
1.105
• Moist mucous
membranes
• Elastic skin turgor
evaluation
Fluid balance aeb not
compromised
• 24 hour intake and output
• Blood pressure, pulse,
and temperature
• Skin turgor
• Urine specific gravity
• Mucous membranes
nursing intervention
Electrolyte and Acid/
Base Balance aeb
not compromised
• Serum electrolytes
• Muscle strength
nursing intervention
nursing intervention
Electrolyte Management: Hypernatremia
Fluid Management
evaluation
Outcomes met:
• Serum potassium:
3.8 mEq/L
• Serum sodium:
140 mEq/L
Behavior Modification
activity
activity
activity
activity
Give
fluids as
appropriate
Weigh
daily and
monitor
trends
activity
Provide
frequent
oral
hygiene
activity
Administer IV
therapy as
prescribed
activity
activity
Monitor
vitals signs
as appropriate
Maintain
accurate
intake and
output
record
activity
Monitor for
neurologic and
neuromuscular
manifestations
of hypokalemia
(e.g., hypotension,
tachycardia,
weak pulse, rhythm
irregularities)
Obtain specimens
for analysis of
altered potassium
levels as indicated
activity
Monitor for
cardiac
manifestations of
hpyernatremia
(e.g., tachycardia,
orthostatic
hypotension)
Monitor for
neurologic and
neuromuscular
manifestations of
hypernatremia
(e.g., lethargy,
irritability,
seizures,
and
hyperreflexia)
activity
Obtain specimens for analysis of altered
sodium levels (e.g., serum and urine
sodium, urine osmolality, and urine specific
gravity) as indicated
activity
Administer prescribed
supplemental
potassium (PO, NG, or
IV) per policy