NURSING CARE PLAN

HYPOVOLEMIA
NAME : IHSANAT REFI SUHARTI
NIM : 2014901062
ASSESSMENT DATA

Nursing Assessment

Merlyn Chapman, a 27-year-old sales clerk,

reports weakness, malaise, and flu-like symptoms
for 3–4 days. Although thirsty, she is unable to
tolerate fluids because of nausea and vomiting,
and she has liquid stools 2–4 times per day.
PHYSICAL EXAMINATION
Height:
Height: 160
160 cm
cm

Weight:
Weight: 66.2
66.2 kg
kg

Temperature:
Temperature: 38.6°C
38.6°C

Pulse:
Pulse: 86
86 BPM
BPM

Respirations:
Respirations: 24/minute
24/minute

Scant
Scant urine
urine output
output

BP:
BP: 102/84
102/84 mm
mm Hg
Hg

Dry
Dry oral
oral mucosa,
mucosa, furrowed
furrowed tongue,
tongue, cracked
cracked lips.
lips.
DIAGNOSTIC DATA

Serum sodium 155

Urine specific mEq/L
(Milliequivalents per
gravity: 1.035 litre)

Serum
potassium 3.2
Chest x-ray
mEq/L negative
NURSING DIAGNOSIS
 Hypovolemia 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
 DESIRED OUTCOMES

 Electrolyte & Acid/Base Balance as evidenced by not compromised:

 Serum electrolytes
 Muscle strength

 Fluid Balance] as evidenced by not compromised:

 24-hour intake and output balance
 Urine specific gravity
 Blood pressure, pulse, and body temperature
 Skin turgor
 Moist mucous membranes
 NURSING INTERVENTIONS
NURSING INTERVENTIONS*
/SELECTED ACTIVITIES
Electrolyte Management: Hypokalemia
1) Obtain specimens for analysis of altered
potassium levels (e.g., serum and urine
potassium) as indicated.
2) Administer prescribed supplemental
potassium (PO, NG, or IV) per policy.
3) Monitor for neurologic and neuromuscular
manifestations of hypokalemia (e.g., muscle
weakness, lethargy, altered level of
consciousness). Limit ingestion of bladder
irritants (e.g., colas, coffee, tea, and
chocolate).
4) Monitor for cardiac manifestations of
hypokalemia (e.g., hypotension, tachycardia,
weak pulse, rhythm irregularities).
RATIONALE
1) Urine and serum analysis provides
information about extracellular levels of
potassium. There is no practical way to
measure intracellular .
2) Low potassium levels are dangerous and
Mrs. Chapman may require supplements.
3) Potassium is a vital electrolyte for skeletal
and smooth muscle activity Increased fluids
during the day will increase urinary output
and discourage bacterial growth. Alcohol,
coffee, and tea have a natural diuretic effect
and are bladder irritants.
4) Many cardiac rhythm disorders can result
from hypokalemia. It is critical to monitor
cardiac function with hypokalemia.
 NURSING INTERVENTIONS* RATIONALE
/SELECTED ACTIVITIES
Electrolyte Management: Hypernatremia
[  
1) Obtain specimens for analysis of altered 1) Urine analysis provides information about
sodium levels (e.g., serum and urine retention or loss of sodium and the ability
sodium, urine osmolality, and urine of the kidneys to concentrate or dilute
specific gravity) as indicated. urine in response to fluid changes.
2) Provide frequent oral hygiene. 2) Oral mucous membranes become dry and
3) Monitor for neurologic and neuromuscular sticky due to loss of fluid in the interstitial
manifestations of hypernatremia (e.g., spaces.
lethargy, irritability, seizures, and 3) Hypernatremia, as a result of low fluid
hyperreflexia). volume, creates a hypertonic vascular
4) Monitor for cardiac manifestations of space, which causes water to move out of
hypernatremia (e.g., tachycardia, the cells, including brain cells. This
orthostatic hypotension). accounts for neurologic symptoms.
4) The heart responds to a loss of fluid by
increasing the heart rate to compensate
with an increase in cardiac output. Low
fluid volume leads to a fall in blood
pressure.
 NURSING INTERVENTIONS*
/SELECTED ACTIVITIES
Fluid Management
1) Weigh daily and monitor trends.
2) Maintain accurate I & O record.
3) Monitor vital signs as appropriate.
4) Give fluids as appropriate.
5) Administer IV therapy as prescribed
RATIONALE
 
1) Weight helps to assess fluid balance.
2) Accurate records are critical in
assessing the patient’s fluid balance.
3) Vital sign changes such as increased
heart rate decreased blood pressure, and
increased temperature indicate
hypovolemia.
4) As her nausea decreases encourage her
oral intake of fluids as tolerated, again
to replace lost volume.
5) Mrs. Chapman has signs of severe fluid
volume deficit. She will probably
require intravenous replacement of
fluid. This is especially true because her
oral intake is limited because of nausea
and vomiting..