Care plan help-Def. Fluid Volume?

  1. I have a patient that has terminal ileitis with free air, but it is not Crohn's disease. They think it might be from a foreign body but are still unsure. He is post up 4 days from a lapileocecal resection. He is still NPO with ice chips and has a NG tube. His labs are slightly low Hct and Hgb levels, and high EBS levels, his electroyltes are normal. I was thinking my top 5 nursing diagnosis would be
    1) Deficient fluid volume
    2) Imbalanced nutrition: less than body requirements
    3) Acute pain
    4) Anxiety
    5) Disturbed sleep pattern (pt has sleep apnea)

    I have to conduct a care plan on deficient fluid volume. I was thinking about Deficient fluid volume r/t NG tube and inadequate fluid intake from being NPO AEB dry mucous membranes, thirst, and poor skin turgor. Is this a good diagnosis...and I was wondering if anyone could help on some goals and interventions. Thanks for all your help!!!!!!!
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    About nrsingrulz

    Joined: Feb '07; Posts: 2


  3. by   Daytonite
    the nursing diagnostic statement helps to express how all the elements, related factors (cause) and defining characteristics (patient symptoms), all fit together and are inter-related. let's look at what you have presented and ask a couple of questions.

    you are saying that patient's defining characteristics, or symptoms, of the dehydration (which is what this particular nursing diagnosis is referring to) are:
    • dry mucous membranes
    • thirst
    • poor skin turgor
    are these symptoms of dehydration? yes, they are! very good!

    you have listed these as evidence of the related factor(s), or cause, of the fluid volume deficit of:
    • ng tube
    • inadequate fluid intake from being npo
    ask yourself, is the ng tube the underlying cause of the patient's dehydration here? is the inadequate fluid intake (from being npo) the underlying cause of the patient's dehydration? i want you to forget about the patient being npo for a moment and go back to what happened to this patient before he went to surgery as well as when he was in surgery because i think you've missed a couple of important things. what was going in with the bowel just before surgery. was the patient already dehydrated at that point? if so, what was contributing to it? was there a bowel obstruction? you mention that they thought there was a foreign body. was this causing a bowel obstruction? with bowel obstructions there are huge amounts of fluid and electrolyte losses due to fluid third spacing (collecting) in the non-functioning bowel. this fluid can be a couple of liters or more and cannot be retrieved. it is lost. it may have been suctioned out when the surgeon had the patient open on the operating table. the operative report would say that. also, when patients are in surgery and opened up, as in a surgical incision, they lose fluid through evaporation into the atmosphere. that is another big fluid loss for surgical patients and why they are often given so much fluid replacement in the immediate post-op period.

    so, what is the cause of the fluid deficit? it is the loss of fluid volume and you could be right that it might be inadequate fluid intake. however, being npo isn't going to make a difference because, certainly, he has iv's, doesn't he? he will be getting fluid replacement by iv. and, if that is not enough, then the doctor needs to be queried.

    i would re-word your first nursing diagnosis:
    deficient fluid volume r/t fluid volume loss aeb dry mucous membranes, thirst, poor skin turgor, 24 hour fluid outputs that exceed intakes.
    what kind of goals, then, will you want to have? look at your "problems" and cause. your interventions, and therefore, your goals focus around them. (remember i said above that everything fits together and is inter-related.) once you've got your rational thinking on the causation and symptoms straightened out, goals and interventions just fall into place nicely.

    • moist mucous membranes
    • elastic skin turgor
    • urine outputs of more than 1300 ml/day
    with sleep apnea, is this patient in danger of his heart stopping due to his apnea during sleep? if there is a cardiac component to this, then the sleep apnea will need a nursing diagnosis addressing the cardiac problem which will place it in a different priority than at the bottom of your list of nursing diagnoses. if his disturbed sleep is due to the positioning and noise from the breathing apparatus he must keep on at night, then your nursing diagnosis is right on.

    otherwise, your sequencing of nursing diagnoses by priority is right on target! what a great progress you've made since your first post! good for you!
  4. by   juan de la cruz
    Nicely done Daytonite! Kinda brings me back to my undergrad days of never ending care plans which I did enjoy (I know, I was a dork in nursing school!)

    Nursingrulz, I do have an observation about your patient case. I am not here to question your clinical assessment but you mentioned that this patient has poor skin turgor. Decreased skin turgor is a late sign in dehydration. It is associated with moderate to severe dehydration. Fluid loss of 5% of the body weight is considered mild dehydration, 10% is moderate and 15% or more is severe dehydration (medline link:

    I would also like you to think in terms of patho-physiology. What would happen to someone's labs if they are dehydrated? Usually, there would be a rise in BUN and creatinine. You mentioned the lytes being normal. Maybe take a second look and see if the labs are really OK. You should also see some changes with the sodium level.

    So I'm wondering if this was truly the case, this patient required immediate attention from the surgical team. I would check his fluid balance from over a period of days. Check how total outputs from NG drain, foley, and insensible losses compare to total intake from IV fluids and IV meds for each 24-hour period and inform the primary team if he is has been at a negative fluid balance for a few days. I am wondering if this patient was receiving adequate IV fluids and maybe needed some parenteral nutrition since he has been NPO for 4 days.

    I don't know what level you are in your nursing program but I thought I'd take this opportunity to give my 2 cents.
    Last edit by juan de la cruz on Feb 9, '07