Fluid Loss Essay

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Pages: 3

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Key problem #1
Diagnosis: Deficient fluid volume related to active fluid loss from frequent diarrhea.
Goals: Patient has normal fluid volume.
Desired outcome: Patient has normal skin turgor and moist mucous membranes. Patient has blood pressure and pulse within normal range for patient.
Interventions: Response:
1. Assess for and report signs and symptoms of fluid volume deficit (e.g. decreased skin turgor, dry mucous membranes, weak rapid pulse, and etc.).
2. Assess alterations in mentation/sensorium.
3. Maintain a fluid intake of at least 2500mL/day.
4. Note presence of nausea, vomiting, and fever.
5. Identify the possible cause of the fluid disturbance or imbalance. 1. Patient has dry and cracked lips. Patient has normal skin turgor. Patient has a strong pulse.
2. Patient is confused orientated mostly …show more content…
Goal: Patient had no injuries.
Desired outcome: Patient will not experience a fall. Patient will not pull out her IV.
Interventions: Response:
1. Assess general status of the patient.
2. Ask significant other to be with patient to prevent her from accidentally falling or pulling out tubes.
3. Keep bed in the low position with side rails up when client is in bed.
4. Have a bed alarm if so staff knows when patient is getting up on her own.
5. Cover IV with Coban self-adherent wrap if patient is at risk for tearing out her IV. 1. Patient is confused. She is a high fall risk due to her being wobbly and weak when ambulating.
2. Husband wants to remain with wife as long at he can; he is willing to watch over her since he is already doing so.
3. Patient’s bed is low with side rails up.
4. Patient on bed alarm to prevent herself from falling.
5. Patient has Coban covering the IV after she almost tore it out.
Evaluation:

Patient is a high fall risk and has a bed alarm to prevent her from injuring herself. Patient’s IV covered in Coban to keep her from pulling it

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