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NCP DHF - Fluid Volume Deficit related to Active Fluid Loss


Nursing Care Plan for Dengue Hemorrhagic Fever

Nursing Diagnosis : Fluid Volume Deficit related to Active Fluid Loss

Defining characteristics:
  • Changes in mental status.
  • Decreased blood pressure.
  • Decreased pulse pressure.
  • Decreased pulse volume.
  • Decreased skin turgor.
  • Decreased turgor tongue.
  • Spending urine output.
  • Decrease venous filling.
  • Dry mucous membranes.
  • Dry skin.
  • Increased hematocrit.
  • Increased body temperature.
  • Increased pulse frequency.
  • Increasing the concentration of urine.
  • Weight loss suddenly.
  • Thirsty.
  • Weakness.

Goal: Do not occur voume fluid deficit.

Outcomes:
  • Input and output balance.
  • Vital signs within normal limits.
  • There is no sign of pre-shock.
  • Akral warm.
  • Capilarry refill less than 3 seconds.

Intervention:

1. Monitor vital signs every 3 hours / more often.
Rationale: Vital sign help identify fluctuations in intravascular fluid

2. Observation of capillary refill.
Rationale: Indications adequacy of peripheral circulation.

3. Observations intake and output. Note the color of urine / concentration, specific gravity.
Rationale: Decreased urine output with increased density concentrated suspected dehydration.

4. Suggest to drink 1500-2000 ml / day (as tolerated)
Rationale: To consume body fluids orally.

5. Collaboration: intravenous fluid administration.
Rational: It can increase the amount of body fluid, to prevent hypovolemic shock.

Pediatric Nurses