Nursing Care Plan for Deficient Fluid Volume (Hypovolemia)

Definition

Extracellular Fluid Volume Deficient or hypovolemia (FVD) is isotonic body fluid loss, which is accompanied by loss of sodium and water in the same relative amount. Volume deficits often termed isotonic dehydration that should be used for conditions of relatively pure water loss resulting in hypernatremia.



Etiology

Factors that affect the body's fluid and electrolyte balance, among others:

Age:

Fluid intake needs vary depending on age, because age affects the surface area of the body, metabolism, and weight. Infant and children are more susceptible to interference than the fluid balance adulthood. In old age often occurs due to fluid balance disorders with impaired renal function or heart.

Climate:

People who live in areas that are hot (high temperature) and low air humidity has an increased loss of body fluids and electrolytes through sweat. While someone who indulge in a hot environment can lose up to 5 L of fluid per day.

Stress:

Stress can increase cell metabolism, blood glucose, and the breakdown of muscle glykogen. This mechanism can increase sodium and water retention so that when prolonged can increase blood volume.

Diet:

Diet affects the intake of fluids and electrolytes. When inadequate nutritional intake, the body will burn protein and fat so it will spare protein and serum albumin will be decreased even though both are indispensable in the process fluid balance so that this will lead to edema.



Clinical manifestations

Clinical signs and symptoms which may be obtained on the client with hypovolemia include: dizziness, weakness, fatigue, syncope, anorexia, nausea, vomiting, thirst, mental confusion, constipation, oliguria. Depending on the type of fluid loss. Hypovolemia may be accompanied by acid-base imbalance, or osmolar electrolyte. Depletion (CES) severe, can lead to hypovolemic shock.

Compensatory mechanisms of the body on the condition of hypovolemia, is to be an increase in the sympathetic nervous system stimulation (increased frequency of heart, inotropic [contraction of the heart] and vascular resistance), thirst, release of antidiuretic hormone [ADH], and the release of aldosterone. The condition can lead to hypovolemia long acute renal failure.



Complication

• Loss of abnormal GI: vomiting, NG suction, diarrhea, intestinal drainage.
• Abnormal skin loss: excessive diaphoresis secondary to fever or exercise, burns, cystic fibrosis.
• Abnormal kidney loss: diuretic therapy, diabetes insipidus, osmotic diuresis (polyuria form), adrenal insufficiency, osmotic diuresis (uncontrolled diabetes, post-use of contrast agents.
• Spasium third or plasma to interstitial fluid displacement: peritonitis, intestinal obstruction, burns, acites.
• Hemorragia.
• Changes in input: coma, lack of fluids.

Nursing Care Plan for Deficient Fluid Volume (Hypovolemia)

Assessment

• Intake-output.
• Weight.
• Breath sounds.
• Edema.
• Check skin turgor.

Nursing Diagnosis

1. Deficient Fluid Volume: less than body requirements related to diarrhea, gastric fluid loss, diaphoresis, polyuria.
2. Impaired skin integrity related to dehydration and or edema.

Outcomes:

Individuals will:

1. Increasing fluid intake of at least 2000 ml / day (unless contraindicated).
2. Telling the need to increase fluid intake during stress or heat.
3. Maintain urine specific gravity within normal limits.
4. Showed no signs and symptoms of dehydration.

Interventions:

1. Assess the preferred and non-preferred; give a favorite drink in the diet limits.
2. Plan objectives fluid intake (eg, 1000 ml during the morning, afternoon 800 ml, and 200 ml of the evening).
3. Assess individual understanding of the reasons to maintain adequate hydration and methods to achieve goals fluid intake.

Care Plan Nursing Read more »

NCP Cholera - 6 Nursing Diagnosis and Interventions

Nursing Care Plan for Cholera

Cholera, a severe diarrheal disease caused by the bacterium Vibrio cholerae, has plagued human populations for centuries. This waterborne illness poses significant public health challenges, particularly in regions with inadequate sanitation and limited access to clean water. This article explores the causes, symptoms, transmission, and global efforts in the prevention and management of cholera.

Causes and Transmission:

1. Vibrio cholerae, the bacterium responsible for cholera, typically thrives in contaminated water and food sources. The primary mode of transmission is through the ingestion of contaminated water or food, often via the consumption of raw or undercooked seafood, or contaminated fruits and vegetables.
2. Once ingested, the bacterium releases a toxin that affects the small intestine, leading to rapid and profuse watery diarrhea—a hallmark symptom of cholera. The severity of the disease can range from mild to severe, with severe cases potentially progressing to life-threatening dehydration without prompt intervention.

Symptoms:

1. Watery Diarrhea: Cholera is characterized by the sudden onset of profuse, painless, and watery diarrhea, often described as "rice-water stool."
2. Vomiting: Individuals with cholera may experience vomiting, contributing to fluid loss and dehydration.
3. Dehydration: Rapid fluid loss can lead to severe dehydration, accompanied by symptoms such as sunken eyes, dry mucous membranes, lethargy, and a rapid heart rate.
4. Muscle Cramps: Dehydration can cause muscle cramps and weakness.

Nursing Assessment for Cholera

1. Assess the status of dehydration (skin color, temperature, acral, skin turgor, mucous membranes, eyes, crown, body temperature, pulse, respiration, behavior, weight loss).
2. Observe for manifestations of acute diarrhea
   • A sudden attack of diarrhea
   • Fever
   • Anorexia, nausea, vomiting
   • Weight loss
   • Pain and abdominal cramps, abdominal distension
   • Increased bowel sounds / hyper-peristaltic
   • Malaise
   • Bowel movements more than 3 times a day, liquid stool consistency, with / or without mucus and blood
3. Assess the psychosocial status of families
4. Assess the level of knowledge of family
   • Knowledge of diarrhea at home
   • Knowledge of dietary
   • Knowledge about the prevention of recurrent diarrhea

Nursing Diagnosis for Cholera

1. Deficient fluid volume related to excessive fluid loss through the stool or emesis
2. Imbalanced Nutrition: Less Than Body Requirements related to loss of fluids through diarrhea, inadequate intake
3. Risk for infection related to microorganisms that penetrate the gastrointestinal tract.
4. Impaired Skin Integrity: perianal, related to irritation from diarrhea
5. Anxiety related to separation from parents, unfamiliar environment, a stressful procedure.
6. Interrupted Family Processes related to crisis situations, lack of knowledge about diseases, treatment of clients.

Nursing Interventions for Cholera


Deficient fluid volume related to excessive fluid loss through the stool or emesis

Goal :

• Maintain adequate hydration

Expected outcomes:

No signs of dehydration: elastic skin turgor, sunken fontanel not, the patient is not agitated, mucous membranes moist, no weight loss.

Nursing Interventions and Rational:
1) Record Intake Output every 24 hours.
R / Knowing the status of dehydration and evaluate the effectiveness of interventions.

2) Measure the child's weight every day.
R / observe dehydration.

3) Measure vital signs and evaluation of skin turgor, mucous membranes, mental status.
R / observe dehydration.
4) Tell the family to give the child a drink gradually.
R / improve hydration.

collaboration:
5) Give oral rehydration solution (ORS).
R / rehydration and replacement of fluid loss through the stool.

6) Provide and monitor IV fluids as indicated (collaboration).
R / replacement fluid loss.

7) Observe the results of the electrolyte.
R / know the level of hydration and the effectiveness of interventions.


Imbalanced Nutrition: Less Than Body Requirements related to loss of fluids through diarrhea, inadequate intake

Goal :

• consume adequate nutrition intake.

Expected outcomes:

• No weight loss (weight stable)
• Eating out 1 serving.
• No nausea, vomiting.

Nursing Interventions and Rational:

1) Evaluation of nutritional status and weight loss
R / Identifying the need for further intervention.

2) Notify and motivation of mothers / families to continue breast-feeding.
R / breast milk reduces the severity and duration of disease and provide additional nutrients.

3) Tell the mother to give the child to eat small meals but often
R / increase food intake.

4) Observe and record the response to feeding.
R / know the tolerance of feeding.

 

 

Bibliography:

1. Ali, M., Nelson, A. R., Lopez, A. L., & Sack, D. A. (2015). Updated global burden of cholera in endemic countries. PLoS Neglected Tropical Diseases, 9(6), e0003832. doi: 10.1371/journal.pntd.0003832
2. Clemens, J. D., Nair, G. B., Ahmed, T., Qadri, F., Holmgren, J., & Cholera Symposium Participants. (2017). Cholera. The Lancet, 390(10101), 1539-1549. doi: 10.1016/S0140-6736(17)30559-7

Care Plan Nursing Read more »