fluid volume deficit - actual or potential?

MendedHeart · Mar 26, 2013

Definitely looks like hypovolemia. .fluids stat..signs---vitals signs and history and age this is an actual problem..also look at temp..is there also an infection somewhere? Are there labs or xrays?

marsy82 · Mar 26, 2013

No other tests, only obs have been taken. I was also thinking hypovolemia but what would the nursing diagnosis be? Decreased cardiac output r/t hypovolemia secondary to vomiting?

MendedHeart · Mar 26, 2013

Yes..but you have to break down hypovolemia into the pathophysiology. .

MendedHeart · Mar 26, 2013

And its also secondary to decreased PO intake and age

Esme12, ASN, BSN, RN · Mar 26, 2013

OP have you bought a care plan book yet? I can't emphasize how much this will help you make these decisions about care plans. Care plans in school are to help you learn how to use/develop those critical thinking skills. It is very important that you tell us what you think first so we can best help you.

client is 85, has vomited 4 times in the last 12 hours and has had very little to eat and drink - his BP is 90/50, RR 28, HR 110, T 102.7

Great! You have recognized that this patient has a volume issue and yes the patient needs fluids. So what is the priority?

NANDA I defines Decreased cardiac output as......

Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body

Related Factors (r/t)

Altered heart rate; altered heart rhythm; altered stroke volume: altered preload, altered afterload, altered contractility

Defining Characteristics (AEB)

Altered Heart Rate/Rhythm: Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia

Altered Preload: Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain

Altered Afterload: Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings

Altered Contractility: Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds

Behavioral/Emotional: Anxiety; restlessness

Ackley: Nursing Diagnosis Handbook, 9th Edition

Does your patient have this evidence based on the evidence provided to you?

Your patient also has......

Deficient Fluid volume which is defined as......Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium level

Related Factors (r/t)

Active fluid volume loss; failure of regulatory mechanisms

Defining Characteristics (AEB)

Change in mental state; decreased blood pressure, pulse pressure and pulse volume; decreased skin and tongue turgor; decreased urine output; decreased venous filling; dry mucous membranes; dry skin; elevated hematocrit; increased body temperature; increased pulse rate; increased urine concentration; sudden weight loss (except in third spacing); thirst; weakness.

Which of these does your patient fit better into with the evidence supplied to you?

vomited 4 times in the last 12 hours and has had very little to eat and drink - his BP is 90/50, RR 28, HR 110, T 102.7 - this is all I know concerning this issue.

guest042302019, BSN, RN · Mar 26, 2013

This is an actual problem. I'll say the same thing in a different way than other contributors. Also, I can see why students have difficulty determining actual vs potential problems. I guess the a good way to determine the difference is to look at the problem and determine if you have evidence (assessments) in the present moment or do you foresee a problem occurring?

With that being said, we have evidence in the present moment. Therefore, this would be an actual problem. Here is your evidence:

1. Vomit 4x in 12 hours (Unknown cause/reason)

2. No food or liquids (No appetite or ability to take in fluid, hence the necessity for IV fluid)

3. BP 90/50 (Loss of intravascular fluid leading to decreased BP)

4. RR 28 (Could be compensatory to related to the fluid loss to deliver oxygen to tissues)

5. HR 110 (Compensatory, when BP goes down, HR usually goes up)

6. T 102.7 (Sign of shock coming, the elevation maybe related to warmth loss from fluid loss)

7. Age (At risk for fluid loss related to being 85, normal loss of thirst mechanism, thinner skin, and the possibility of heart of renal problems)

As far as problem priorities go, here's how I arrange them. First of all, in this scenario, there is one main problem. Fluid loss for some unknown reason. Vomit is potentially the cause but nonetheless we don't know the cause. But, I prioritize problems by what is going to kill the patient first. Morbid, I know. But, it does work. Fluid loss here would kill the patient first. Fluid loss would lead to decreased cardiac output leading to organ failure (heart, kidneys, etc.) and hypovolemic shock then likely death or permanent organ damage.

Needless to say, in this case, hypothetically, if there wasn't the evidence above, you realize that there is a potential fluid loss problem. What is the difference? Either way, actual or potential, you are addressing the problem.

I hope I haven't confused you more. :) Hope this helps!

-Andrew

nurseprnRN, BSN, RN · Mar 26, 2013

This is an actual problem. I'll say the same thing in a different way than other contributors. Also, I can see why students have difficulty determining actual vs potential problems. I guess the a good way to determine the difference is to look at the problem and determine if you have evidence (assessments) in the present moment or do you foresee a problem occurring?
With that being said, we have evidence in the present moment. Therefore, this would be an actual problem. Here is your evidence:
1. Vomit 4x in 12 hours (Unknown cause/reason)
2. No food or liquids (No appetite or ability to take in fluid, hence the necessity for IV fluid)
3. BP 90/50 (Loss of intravascular fluid leading to decreased BP)
4. RR 28 (Could be compensatory to related to the fluid loss to deliver oxygen to tissues)
5. HR 110 (Compensatory, when BP goes down, HR usually goes up)
6. T 102.7 (Sign of shock coming, the elevation maybe related to warmth loss from fluid loss)
7. Age (At risk for fluid loss related to being 85, normal loss of thirst mechanism, thinner skin, and the possibility of heart or renal problems)

I'd like to add that acidosis could also contribute to the increased RR-- you lose acid with vomiting, true, but dehydration (this is loss of saline, intravascular fluid) and sepsis can upset a/b balance; if there is barely compensated septic shock present (with decompensation yet to come) you can be sure that tissue hypoxia will make fr lactic acidosis sure as god made little green apples, and that's the prime driver of the resp rate. He could also be in DKA, diabetic ketoACIDOSIS, which would have many of these symptoms (it doesn't cause vomiting, but someone with DM who gets sick can get DKA in a heartbeat).

If you have the opportunity to check urine pH, chemistries, and ABGs, that will give you more info.

(You don't get a higher temperature from "warmth loss from fluid loss"- it's the other way around. Lack of fluid makes it less possible for your body to lose body heat by radiation after vasodilation, because lower BP triggers vasoconstriction and sweating is decreased, making for less heat loss from evaporation.)