Nursing care plan- risk for fluid volume deficit

Nursing Students Student Assist


I have a nursing care plan to be done and I need Help. I had a patient whose diagnosis was small bowel obstruction. She did surgery. She did a exploratory laparotomy/small bowell resection x 2. resected jejunum, resected ileum. The Patient complain of Abd pain. The patient is NPO. She had in a NGT for suctioning but it was removed. Activity as tolerated. Patient abd is distended but soft. Have bowel sound and her lung are clear bilaterally. Patient is getting D5W 1/2NS/KCL @125ml/hr. Her 24hr intake was 1000 and her output was 300. NGT 150 anf foley 150. The foley was removed. She is anemic and have a phych history. He last bp110/70 p 80 R 18 T98.6 and 02sat 98 with deep breathing and using the incentive spirometer. Her last urine was dark yellow and she complain of dry mouth and thirst. Her labs are as follows-: RBC 2.6*, K 3.7, Na 140, Hgb. 8.2*, Hct. 23.5*, WBC 4.2, Glucose 130, Cl 101*, Platelets 393*. I donot know if I can use risk for fluid volume deficit. Need your help.:crying2:

What are your other nanda's? I personally wouldn't use fluid volume deficit.

Whats wrong with fluid volume defict?? The pt fit most of the criteria....The big things I see are NPO, NG (fluid loss), input 1000 VS out 300 (when we want pt's to have 30 per hours, the pt is at like 13 per hours, which it is going to be low when the pt is NPO but pt is getting 3000 through the IV in 24 hours) and dark urine...the electrolytes look good...Did you have another idea for a Diagnosis?

What were the pre-op vital signs vs post op vital signs? What was the pre-op HGB/HCT, intraop EBL, and intra-op fluid admin totals? As a rule of thumb blood loss should be treated with 3ml of crystallloid for 1ml blood loss or 1ml colloid for 1ml blood loss. A small quantity of concentrated urine is highly specific for decreased intravascular volume.

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