Need Assistance w/Care Plan - Dehydration

[RNpandoraRN]

I've been given a case study (not a real patient) in which to write a care plan. Patient is over 60, admitted with dehydration. Pt has severe vomiting, dry mucous membranes, and decreased urine output. The physician has ordered an IV and NPO.

Now I've determined the dx (assuming I'm correct) to be "Deficient fluid volume R/T to severe vomiting AEB decreased urine output and dry mucous membranes."

However, I am hung up on the expected outcome because my book shows to increase fluid intake according to age and metabolic rate, but no further information. And because he is NPO, how do I do this?

Also, for Interventions, I know I should be monitoring vital signs, urine output, weight, etc, but how do I know how often to do these assessments according to the diagnosis?

Thanks in advance!

[augigi, CNS]

You're going to increase the fluid intake via the IV fluid, and determine the rate according to the medical order. No point giving po since he's vomiting.

No point measuring weight more often than daily.

[mysterious_one, ASN, RN]

you also monitor labs, maybe give ice chips and provide frequent oral care.

[Daytonite, BSN, RN]

your outcome(s) are going to be based on what the patient's problem is with the decreased fluid volume. look first to your cause of the fluid deficit. outcomes will either result in the improvement, stabilization or support the deterioration of the fluid loss that is the focus of this nursing diagnosis.

i do, however, have a problem with the construction of your nursing diagnosis. your fluid volume deficit is not from vomiting, but from the loss of fluids. based on what you have written, the scenario does not ascribe vomiting as the cause of the dehydration. that would be a medical decision. the official nanda definition of the diagnosis of deficient fluid volume is "decreased intravascular, interstitial, and/or intracellular fluid. this refers to dehydration, water loss alone without change in sodium." (nursing diagnoses: definitions & classification 2005-2006 published by nanda international, page 79.) i would re-word your nursing diagnosis as: deficient fluid volume r/t loss of fluids aeb decreased urine output and dry mucous membranes.

i would place vomiting in it's own nursing diagnosis of nausea if it's that serious and handle it that way. the problem you would have with that, however, is that you don't know a related factor, or cause, for the vomiting. you could address the problem of the vomiting when you list interventions for the deficient fluid volume, i suppose. if you look at the official nic (nursing interventions classification) interventions that are paired by nanda with the diagnosis of deficient fluid volume you will not find any interventions for vomiting listed. in fact, many of the interventions focus on fluid replacement. however, you will find nic interventions for vomiting for the nursing diagnosis of nausea.

to get back to your outcomes for deficient fluid volume, you need to focus on hydration, fluid intake or restoring electrolyte/acid-base balance. and, remember, that outcomes are based on the independent nursing actions that you take. so, getting a patient rehydrated by giving iv fluids as ordered is a goal because it is a collaborative action (depends on a doctor's order) and not an outcome. however, through your independent monitoring efforts of checking skin turgor and the dryness or moisture of mucus membranes you can list an outcome of maintaining elastic skin turgor and moist mucous membranes with this diagnosis. another outcome is to have a urine output of more than 1300ml per 24 hours. this is a noc outcome linked specifically with this nursing diagnosis. you achieve it through your independent nursing interventions of monitoring the patient's intake and output every 8 hours. you must understand that monitoring is a valid and legitimate type of independent nursing intervention.

here are online links to nursing diagnosis information from the gulanick and ackley/ladwig care plan constructor sites that are similar to what is in their care plan books. they have information about the definition of each diagnosis, the related factors (causes), defining characteristics (symptoms), noc outcomes, nic interventions and teaching.

deficient fluid volume

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=21

http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_030.php

nausea

http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_048.php

[RNpandoraRN]

your outcome(s) are going to be based on what the patient's problem is with the decreased fluid volume. look first to your cause of the fluid deficit. outcomes will either result in the improvement, stabilization or support the deterioration of the fluid loss that is the focus of this nursing diagnosis.

i do, however, have a problem with the construction of your nursing diagnosis. your fluid volume deficit is not from vomiting, but from the loss of fluids. based on what you have written, the scenario does not ascribe vomiting as the cause of the dehydration. that would be a medical decision. the official nanda definition of the diagnosis of deficient fluid volume is "decreased intravascular, interstitial, and/or intracellular fluid. this refers to dehydration, water loss alone without change in sodium." (nursing diagnoses: definitions & classification 2005-2006 published by nanda international, page 79.) i would re-word your nursing diagnosis as: deficient fluid volume r/t loss of fluids aeb decreased urine output and dry mucous membranes.]

wow, this makes me feel so much better!! as i was finishing up my assignment last night, i did realize that "loss of fluids" was more accurate than "vomiting" and i made the change, though i was still uncertain. i got your post this morning and i am so relieved that i changed it and made the correct diagnosis after all.

also, i had previously listed as some of my actions/interventions to check skin turgor and mucous membranes and monitor urine output. again, i am so relieved to see that i appear to be thinking along the right track!

thanks so much for the guidance!

[Daytonite, BSN, RN]

That is awesome! Never underestimate the power of a good night's sleep and the ability of the brain's cognitive ability! Somewhere in those gray cells you put 2 and 2 together. But, it's important to know "why" it goes together the way it does. This is all part of the process of critical thinking. By definition, critical thinking is NOT making judgments by random guesses, it is reasoned, logical thinking where each step has rationale supporting it. The hard part when first learning this is how to consciously get to the right answer in the first place. The nursing process, and therfore the written nursing care plan, is no different. Hope your care plan knocks your instructor's socks off!