Situation:
Rosalka Kuba, a 30 years old mother of 2 was admitted last August 9, 2010 with a chief complaint of Epigastric pain. She was diagnosed to have Acute Gastroenteritis ( AGE ). Today, August 12, 2010, you have assessed the patient with the following data: Sunken eyeballs, poor skin turgor, BP: 170/100, PR: 82 bpm, RR: 40 bpm, and T: 36.7°C. The patient verbalizes pain the scale of 8/10.
CUES
S: “ Kanina pa ako dumudumi ng malambot na malambot.”
O: ( + ) sunken eyeballs. ( + ) poor skin turgor. Pain scale of 8/10 V/S as follows: BP: 170/100mmHg PR: 82 bpm RR: 40 bpm, and T: 36.7°C
NURSING
SCIENTIFIC
DIAGNOSIS
EXPLANATION
Deficient Fluid Volume related to active fluid volume loss.
Volume depletion, or extracellular fluid (ECF) volume contraction, occurs as a result of loss of total body sodium. Causes include vomiting, excessive sweating, diarrhea, burns, diuretic use, and kidney failure. Clinical features include diminished skin turgor, dry mucous membranes, tachycardia, and orthostatic
PLANNING
NUSING
RAT IO IO NA NALE
INTERVENTIONS
After 8° of Nursing Interventions, the patient fluid and blood volume will return to normal.
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Monitor and record vital signs q 2° or as often as necessary until stable. Then monitor and record vital signs q 4°. Measure intake and output q 4°. Record and report significant changes. Include urine, and stools. Administer fluids, blood, or blood
EX PE PE CT CT ED ED OUTCOMES°
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Tachycardia, dypnea, or hypotension may indicate fluid volume deficit or electrolyte imbalance.
Low urine output and high specific gravity indicates hyovolemia.
To replace fluids and whole blood
After 8° of Nursing Interventions, the patient’s fluid and blood volume return to normal as evidenced by stable vital signs.
hypotension.
products, or plasma expanders.
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Assess skin turgor and oral mucous membranes q 4°. Give oral/mouth care q 4
loss and facilitate fluid movement into intravascular space. •
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Don’t allow patient to sit or stand up quickly as long as circulation is compromise. Administer and monitor medications.
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To check for dehydration.
To avoid dehydrating mucous membranes
To avoid orthostatic hypotension and possible syncope.
To prevent further fluid loss.
