Risk factors may include
Excessive gastric losses—nasogastric suction, diarrhea
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Maintain adequate fluid volume with balanced intake and output (I&O) and be free of signs reflecting dehydration.
Nursing intervention with rationale:
1. Assess vital signs, noting changes in blood pressure (BP), such as orthostatic hypotension, tachycardia, and fever. Assess skin turgor, capillary refill, and moisture of mucous membranes.
Rationale: Indicators of dehydration and hypovolemia and adequacy of current fluid replacement. Note: Adequately-sized cuff must be used to ensure factual measurement of BP. If cuff is too small, reading will be falsely elevated.
2. Monitor I&O, measuring nasogastric (NG) suction losses.
Rationale: Changes in gastric capacity and intestinal motility and nausea greatly influence intake and fluid needs, increasing risk of dehydration.
3. Evaluate muscle strength and tone. Observe for muscle tremors.
Rationale: Large gastric losses may result in decreased magnesium and calcium, leading to neuromuscular weakness and tetany.
4. Establish individual needs and replacement schedule.
Rationale: Determined by amount of measured losses and estimated insensible losses and dependent on gastric capacity.
5. Encourage increased oral intake when able.
Rationale: Permits discontinuation of invasive fluid support measures and contributes to return of normal bowel functioning.
6. Administer IV fluids, as indicated.
Rationale: Replaces fluid losses and restores fluid balance in immediate postoperative phase until client is able to take sufficient oral fluids.
7. Monitor electrolyte levels and replace, as indicated.
Rationale: Use of NG tube, vomiting, or onset of diarrhea can deplete electrolytes, affecting organ function.