Nursing diagnosis: risk for deficient Fluid Volume related to Inadequate intake of food and liquids, Consistent self-induced vomiting, Chronic, excessive laxative or diuretic use
Possibly evidenced by (actual)
Dry skin and mucous membranes, decreased skin turgor
Increased pulse rate, body temperature, decreased BP
Output greater than input (diuretic use); concentrated urine and decreased urine output (dehydration)
Change in mental state
Hemoconcentration, altered electrolyte balance
Desired Outcomes/Evaluation Criteria—Client Will
Maintain and demonstrate improved fluid balance, as evidenced by adequate urine output, stable vital signs, moist mucous membranes, and good skin turgor.
Verbalize understanding of causative factors and behaviors necessary to correct fluid deficit.
Nursing intervention with rationale:
1. Monitor vital signs, capillary refill, status of mucous membranes, and skin turgor.
Rationale: Indicators of adequacy of circulating volume. Orthostatic hypotension may occur with risk of falls and injury following sudden changes in position.
2. Monitor amount and types of fluid intake. Measure urine output accurately.
Rationale: Client may abstain from all intake, with resulting dehydration, or substitute fluids for caloric intake, disturbing electrolyte balance.
3. Discuss strategies to stop vomiting and laxative or diuretic use.
Rationale: Helping client deal with the feelings that lead to vomiting and laxative or diuretic use will prevent continued fluid loss. Note: Client with bulimia has learned that vomiting provides a release of anxiety.
4. Identify actions necessary to regain or maintain optimal fluid balance, such as specific fluid intake schedule.
Rationale: Involving client in plan to correct fluid imbalances improves chances for success.
5. Review electrolyte and renal function test results.
Rationale: Fluid and electrolyte shifts or depressed renal function can adversely affect client’s recovery and may require additional intervention.
6. Administer intravenous (IV) fluids and electrolytes, as indicated.
Rationale: Used to correct fluid and electrolyte imbalances and prevent cardiac dysrhythmias.