Lack of fluid volume

Nursing diagnosis: lack of fluid volume associated with fluid shifts from the extracellular, intravascular and interstitial spaces in the intestine and / or peritoneal cavity, vomiting, health restrictions on imports of a nasogastric (NG) or intestinal aspiration, fever, a hypermetabolic State

It is obvious from
Dehydrated mucous membranes, deprived skin turgor, late capillary restock, weak peripheral pulse
Decreased urine output, dark, concentrated urine
Hypotension, tachycardia

Desired outcomes / evaluation criteria, the client
Moisture Balance
Demonstrate improvement in the water, as evidenced by appropriate urine with normal density, stable vital signs, moist mucous membranes, good skin turgor, capillary high-speed loading and weight within acceptable limits.

Nursing interventions on the ground:
1. Monitor vital signs, noting the presence of hypotension (including orthostatic changes), tachycardia, tachypnea, and fever. Measurement of central venous pressure (CVP), if any.
Background: Aid for evaluation of moisture deficit, an effective fluid replacement therapy and drugs.

2. Keep an accurate dose and second output (I & O) and related to the daily weight. Includes measured and estimated losses of gastric suction drains, bandages, Hemovacs, excessive sweating, abdominal circumference and third space fluid.
Reason: it reflects the general state of hydration. Urine can be reduced due to hypovolemia and decreased renal perfusion, and weight can still increase due to tissue edema or ascites accumulation (third place). Gastric suction losses can be large and very liquid can be cold in the intestines and peritoneal cavity (ascites).

3. Measurement of urine density.
Reason: it reflects changes in hydration status and renal function, which warn of acute renal failure in response to hypovolemia, and the effects of toxins. Note: Many antibiotics and nephrotoxic effects on renal function and urinary affected.

4. Observe skin turgor and mucous membranes and dryness. Note peripheral edema and sacred.
Justification: hypovolemia, fluid shifts, and nutritional deficiencies contribute to weak skin turgor severely swollen tissue.

5. Link noxious odors or sights in the area. Limit consumption of ice chips.
Background: Reduces stomach and stimulate the vomiting response. Warning: Excessive use of ice chips in the stomach, the aspiration of gastric washings electrolytes.

6. Position changes, regular skin care and dry, wrinkle-free beds.
Justification: swollen tissues with impaired circulation tendency to break.

7. Monitor laboratory tests: HGB / HCT, electrolytes, protein, albumin, urea, creatinine (Cr).
Background: Provides information on hydration and body functions. Significant impact on system performance is possible thanks to the mast of fluid shifts, hypovolemia, hypoxia, circulating toxins and necrotic tissue products.

8. Use of plasma, blood, fluids, electrolytes and diuretics, аs indicated.
Reason: Restoration and circulating volume and electrolyte balance. Colloids such аs plasma or blood, helps return the water in the intravascular space by increasing the osmotic force grade. Diuretics be able to used to remove toxins and strengthen the kidney function.

9. Conservation status of NGOs in natural gas or intestinal aspiration.
Background: Reduce vomiting caused by hyperactivity of the intestine, stomach and intestinal management.

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