http://nurseslabs.

com

Deficient Fluid Volume

Glucose appears in the urine (glycosuria) because the kidney excretes the excess glucose to make the blood glucose level normal. Glucose excreted in the urine acts as osmotic diuretic and causes excretion of increased amount of water, resulting in fluid volume deficit or polyuria.

Assessment

Nursing Planning Nursing Rationale Evaluation Diagnosis Interventions Subjective:(none) Deficient Short Establish Friendly Short Fluid Term:After 3 of rapport relationship Term:After 3 Objective: Volume r/t NI, patient shall with patient of NI, patient Take and record intracellular have verbalized and to be able will have vital signs elevated DHN 2 the understanding of to each others verbalized temperature DM II causative factors concern understanding of Monitor the and purpose of of causative To obtain 38.4C/axilla temperature individual factors and baseline data increased therapeutic purpose of urine output. interventions and Assess skin individual sweating of To monitor turgor and medications. therapeutic the skin changes in mucous interventions Long Term: thirst membranes for temperature and exhaustion signs of medications. weight loss After 2 days of dehydration Dry skin and Long Term: dry skin or NI, the patient mucous mucous shall have membranes Encourage the membrane maintained fluid patient to After 2 days of are signs of volume at a dehydration NI, the patient increase fluid functional level as intake will have evidenced by maintained To replace individual good Administer IVF fluid loss and fluid volume at skin turgor, moist as ordered by prevent a functional mucous dehydration level as the Doctor membrane and evidenced by stable vital signs. Administer anti- To replace individual good skin electrolytes pyretic as prescribed by and fluid loss turgor, moist mucous the Doctor. To decrease membrane and stable vital body temperature signs and will have less

occurrence of dehydration. Assessment Nursing Planning Nursing Rationale Evaluation Diagnosis Interventions Subjective:(none) Fatigue Short Term:After -Assess response -Response to The patient related to 2-3 of nursing to activity an activity can shall have been Objective: decreased interventions, the be evaluated to able to identify -Asses muscle muscular patient will be achieve measures to strength of generalized strength able to identify desired level of conserve and patient and weakness measures to tolerance. increase body functional level increased conserve and energy of activity. -To determine respiratory increase body the level of The patient rate of energy. activity shall have been 25cpm -Discuss with free from signs Long Term: presence of patient the need of fatigue non-healing for activity -Education wound on After 3-5 days of may provide both feet nursing motivation to -Alternate body interventions, the activity with increase weakness patient will be free periods of rest/ activity level wt. loss from signs of even though uninterrupted fatigue fatigue patient may sleep. limited ROM feel too weak inability to -Monitor pulse, initially perform respiration rate ADL -Prevents and blood altered VS excessive pressure altered fatigue before/after sensorium activity -Indicates -Perform activity physiological levels of slowly with tolerance frequent rest periods -Tolerance -Promote energy develops by adjusting conservation techniques by frequency, discussing ways duration and intensity until of conserving desired activity energy while level is bathing, transferring and achieved. so on. -Interventions

-Provide adequate ventilation

should be directed at delaying the onset of -Provide comfort fatigue and optimizing and safety muscle -Instruct patient efficiency. to perform deep Symptoms of fatigue are breathing alleviated with exercises rest. Also, -Instruct client to patient will be able to increase Vitamins A, C accomplish more with a and D and decreased protein in her expenditure of diet. energy. -Instruct also -For proper patient to increase iron in oxygenation diet -To be free from injury -Administer oxygen as -Promotes ordered. relaxation -For muscle strength and tissue repair -To prevent weakness and paleness -To provide proper ventilation

~~~~~~~~~~~~