Fluid Volume Deficit related to restrictions on inputs, nausea, anorexia, lethargy
Goal: Not to dehydration
Outcomes:
- Maintain dehydration
- Mucous membranes moist
- Good skin turgor, vital signs stable
Intervention:
1. Note the increase in temperature and duration of fever. Give warm compresses as indicated. Keep clothing dry. Keep the temperature in the environment.
Rationale: Increasing metabolic needs and excessive diaphoresis associated with fever in increasing fluid loss invisible.
2. Skin turgor, mucous membranes and thirst
Rationale: Indirect indicators and fluid status.
3. Measure body weight as indicated.
Rationale: Although weight loss can indicate the use of muscle, sudden fluctuations indicate hydration status. Fluid loss with regard to diarrhea can quickly lead to crises and life threatening.
4. Monitor input and oral fluid at least 2500 ml / day.
Rationale: Maintaining fluid balance, relieve thirst and moisten the mucous membrane.
5. Give fluid / electrolyte through the tube food giver
Rationale: It may be necessary to support / increase circulation volume, especially if inadequate oral intake, nausea / vomiting continuously.
6. Monitor the results of laboratory examinations as indicated, eg, hemoglobin / hematocrit.
Rational: Electrolytes serum / urine useful in estimating fluid needs.
7. Alert the possibility of electrolyte disturbances and to determine the needs of the electrolyte.
8. Give medications as indicated.