ASSESSMENT Subjective Cues: >Patient states, I am very thirsty.

Objective Cues: > excessive thirst > dry oral mucous membranes > increased heart rate (HR= 140) > decreased BP (BP= 80/57) > increased body temperature (T= 38) > severe polyuria (>7L/day) > urine specific gravity= 1.001 > decreased skin turgor > weakness > irritability

DIAGNOSIS Deficient Fluid Volume related to nausea, vomiting, and diarrhea as evidenced by decreased urine output, increased urine concentration, weakness, fever, decreased skin/tongue turgor, dry mucous membranes, increased pulse rate, and decreased blood pressure

INFERENCE Fluid imbalance can arise due to hypovolemia, normovolemia with maldistribution of fluid, and hypervolemia. Trauma is among the most frequent causes of hypovolemia, with its often profuse attendant blood loss. Another common cause is dehydration, which primarily entails loss of plasma rather than whole blood. The consequences of hypovolemia include reduction in circulating

PLANNING Within 8 hours, patient will maintain adequate fluid volume as evidenced by: > vital signs within N range for age > urine output of 5080ml/hr > urine specific gravity between 1.004 and 1.030 > moist mucous membranes > good skin turgor > patient verbalizing that thirst is no longer excessive

INTERVENTION y Monitor for the existence of factors causing deficient fluid volume (e.g., gastrointestinal losses, difficulty maintaining oral intake, fever, uncontrolled type IIdiabetes mellitus, diuretic therapy).

RATIONALE y Early identification of risk factors and early intervention can decrease the occurrence and severity of complications from deficient fluid volume.

Watch for early signs of hypovolemia, including weakness, muscle cramps, and postural hypotension.

Late signs include oliguria; abdominal or chest pain; cyanosis; cold, clammy skin; and confusion.

EVALUATION Goal met. Patient maintained adequate fluid volume as evidenced by N vital signs, adequate urinary output with normal specific gravity, moist mucous membranes, good skin turgor, and patient s verbalization that thirst is not excessive.

Watch trends in output for 3 days; include all routes of intake and output and

Monitoring for trends for 2 to 3 days gives a more valid picture of the

blood volume, lower venous return and, in profound cases, arterial hypotension. Myocardial failure may result from increased myocardial oxygen demand in conjunction with reduced tissue perfusion.

note color and specific gravity of urine.

client's hydration status than monitoring for a shorter period. Darkcolored urine with increasing specific gravity reflects increased urine concentration.

Monitor daily weight for sudden decreases, especially in the presence of decreasing urine output or active fluid loss. Weigh client on same scale with same type of clothing at same time of day, preferably before breakfast.

Body weight changes reflect changes in body fluid volume. A 1pound weight loss reflects a fluid loss of about 500 cc.