Fluid Volume Deficit related to Dehydration

Dehydration occurs when water or fluids out of the body more than the incoming fluid, so that the body is not able to function as it should. If the fluid needs are not immediately met, then the body will become dehydrated.

The initial signs of dehydration include:

• Feeling thirsty.
• Dizziness.
• Dark yellow urine color.
• Frequency of urination less than usual.

The most obvious indicator to determine the body dehydration / less fluid is to look at the color of urine: if bright and clear, the body hydrated, and if the yellow - dark red then it is almost certainly a sign of dehydration.

Dehydration mild - moderate effect and can cause the following symptoms:

• Dry mouth and sticky.
• Tired and sleepy.
• Thirst.
• The quantity of urine is reduced.
• Dry skin.
• Constipation.
• Headache.

In children, they usually become less active than usual when dehydrated.

Severe dehydration

If left unchecked, the body that dehydration can cause dehydration worse. Severe dehydration is an emergency medical condition, and must be given treatment.

Symptoms of severe dehydration can include:

• Very thirsty.
• Mouth, skin, and mucous membranes are very dry.
• Confusion and irritability.
• Not urinating more than 8 hours.
• Urine is very dark, and few in number.
• Eyes look sunken, heavy, dry and sore.
• Rapid heartbeat.
• Low blood pressure.
• Low level of awareness to a fever.

Fluid Volume Deficit related to excessive output, less input. (Doenges, 1999)

Goal: Adequate fluid volume, so the lack of fluid volume can be resolved.

Expected outcomes:

• Maintaining fluid balance.
• Vital signs (pulse = 80-100 x / min, temperature = 36-37 ° C)
• Capillary refill less than 3 seconds.
• Acral warm.
• Urine output is 1-2 cc / kg body weight / hour.

Action Plan

1) Monitor vital signs, capillary refill, status mucous membranes, turgor.
Rationale: circulation volume adequacy indicator, the data hypotension occurs with risk of injury after the change of position.

2) Monitor the amount and type of fluid intake, urine output measure accurately.
Rational: Patients should not consume fluids at all lead to dehydration, or changing caloric intake of fluids to affect electrolyte balance.

3) Discuss strategies to stop vomiting and use of laxatives / diuretics.
Rationale: Helping patients received the feeling that as a result of vomiting and / or use of laxatives / diuretics prevent further loss.

4) Identification of a plan to improve / maintain optimal fluid balance. For example: fluid intake schedule.
Rationale: Involving the patient in a plan to correct the imbalance.

5) Assess function test results electrolyte / kidney.
Rationale: The transfer fluids / electrolytes, renal function decline may extend affect healing.

6) Provide / supervise administration of IV fluids.
Rationale: Emergency measures to correct the imbalance of fluid.

7) Additional potassium, oral or N as indicated.
Rationale: It can prevent cardiac dysrhythmias.

Fluid Volume Deficit related to Diabetic Ketoacidosis Care Plan

Diabetic ketoacidosis is a complication of diabetes. It is a result of relative insulin deficiency and is a rare feature of acromegaly, in which the chemical balance of the body becomes far too acidic, and starts a dangerous condition in which the body starts to break down fats for fuel because it has no insulin to allow it to use glucose.

Diabetic Ketoacidosis is unclear or arbitrary, when the case is severe, you may have difficulty breathing, your brain may swell (cerebral edema), and there is a risk of coma, the loss of life due to diabetic ketoacidosis is distinctly linked to the delay in the institution of the appropriate therapy in a hospital setting.

Outward signs and symptoms of DKA include the following; eyeballs are soft and appear sunken, skin turgor is poor, the person is very pale, cold, clammy, and exhibits deep rapid respirations, an effort the body makes to eliminate excess carbon dioxide.


Nursing Care Plan for Diabetic Ketoacidosis

Nursing Diagnosis : Fluid volume deficit related to excessive secretion of fluid ( osmotic diuresis ) due to hyperglycemia.

Outcomes:

• Vital signs within normal limits
• Peripheral pulse can be palpated
• Skin turgor and capillary refill good
• Balance urine output
• Normal electrolyte levels
• Blood sugar while : normal

Iintervention:
1. Observation intake and output of fluids every hour.
2. Observation smooth infusion.
3. Monitor vital signs and level of consciousness every 15 minutes, if stable continue for every hour.
4. Observation of skin turgor, mucous membranes, acral, capillary refill.
5. Monitor results of laboratory tests:

• Hematocrit
• BUN / Creatinine
• Blood osmolarity
• Sodium
• Potassium

6. EKG Monitor
7. CVP monitoring (when used)
8. Collaboration with other health team:

• Provision of parenteral fluids
• Provision of insulin therapy
• Installation of a urine catheter
• Installation of CVP if possible