Nursing Diagnosis related to Fluid and Electrolyte

Fluid and Electrolyte

1. Deficient Fluid volume: less than body requirements related to excessive fluid output.

  • Observation of vital signs.
  • Observed signs of dehydration.
  • Measure the input and output of fluid (fluid balance).
  • Provide and encourage families to give drink plenty of approximately 2000 - 2500 cc per day.
  • Collaboration with physicians in the delivery of fluid therapy, electrolyte laboratory examination.
  • Collaboration with a team of nutrition in low-sodium fluid administration.

2. Risk for Deficient fluid volume related to insufficient fluid intake, excessive discharge (vomiting / nausea).

  • Record the number of vomiting and bleeding characteristics.
  • Assess vital signs (BP, pulse, temperature).
  • Monitor fluid intake and output.
  • Elevate the head for taking medication.
  • Give saturated liquid / soft if the input starts again, avoid caffeinated and carbonated beverages.
  • Maintain bed rest.
  • Collaboration with fluid administration as indicated.

3. Risk for ineffective airway clearance related to the operative incision site.

  • Give analgesics as prescribed.
  • Fixation incision with both hands or a pillow to help patients when they cough.
  • Encourage the use of Incentive spirometer if there is an indication.
  • Help and encourage early ambulation.
  • Help the patient to change positions frequently.

4. Disturbed Body Image related to changes in appearance secondary to loss of body parts.

  • Encourage the patient to express feelings, especially about the thoughts, feelings, views of self. Rational: Helping patients to be aware of unusual feelings.
  • Note withdrawing behavior. Increased dependency, manipulation or not involved in treatment. Rational: Alleged problems in assessment can require follow-up evaluation and more rigorous therapy.
  • Maintain a positive approach during maintenance activities. Rational: Help the patient / person closest to accept changes in their own bodies and feel good about themselves.

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