Nursing Diagnosis

Objective

Fluid Volume Deficient

(Regulatory
Failure)Possible Etiologies:
(Related to)
Uncontrolled diabetes
mellitus
Osmotic dieresis from
hyperglycemia

Short term goal:

Client will maintain
hydration at a
functional level as
evidenced by
adequate urine output,
stable vital signs,
palpable peripheral
pulses, good skin
turgor and capillary
refill, and electrolyte
levels within normal
range.

Excessive gastric loss

(diarrhea and
vomiting)
Restricted or low
fluid intake due to
nausea or confusion

Defining characteristics:
(Evidenced by)

Statements of fatigue
and nervousness
Increased urinary
output
Concentrated urine
Weakness
Thirst
Sudden weight loss
Poor skin turgor/ dry
skin and mucous
membranes
Hypotension
Increased pulse rate

Long term goal:

Client will
demonstrate
behaviours to monitor
and correct deficit as
indicated.

Nursing Interventions

1. Obtain history for intensity

and duration of symptoms such
as vomiting and excessive
urination.2. Monitor the vital
signs like:
a. Orthostatic BP changes
b. Respiratory changes i.e.
Kussmauls respiration,
acetone breath
c. Respiratory rate and
quality; use of accessory
muscles, periods of
apnea, and cyanosis

Rationale

- Helps in making approximation of

total volume loss. Symptoms may be
present for hours or days and presence
of other diseases usually result, too, to
increase in sensible fluid losses.Hypovolemia can be manifested by
hypotension and tachycardia; Carbonic
acid is removed in the lungs through
respiration and producing respiratory
alkalosis for ketoacidosis; Acetone
breath is due to acetoacetic acid and
should disappear when condition is
corrected; Cyanosis, apnea and increase
in respiratory effort may be due to
compensation from acidosis; Fever with
flushed skin reflects dehydration.

d. Temperature, skin turgor

3. Check peripheral pulses,
capillary refill, and for skin
turgor.

- These are indicators for the hydration

status of a client and so as the
circulating volume in the body.

- Gives baseline data of clients

4. Strictly monitor the intake and hydration status and to know the
the output.
approximation of fluid replacement; the
function of kidney and the effectiveness
5. Encourage client to take at
of the fluid replacement therapy.
least 2500ml/ day.
- It maintains hydration level in the
6. Weigh client daily or as
functional state.
indicated.
- It provides the current fluid status and
7. Investigate changes in
adequacy of fluid replacement.
mentation.

Evaluation

Clients
hydration
status will
resume to a
functional
level through
demonstrating
a clearcolored urine
approximately
100 cc in
amount and
reflecting the
same
approximate
amount of
intake; less
occurrence of
postural
hypotension
with BP
ranging from
120/80mmHg
to
110/70mmHg;
palpable
peripheral
pulses in
synchronous
with cardiac

Decreased pulse
volume and pressure/
delayed capillary
refill
Change in mental
state

8. Administer fluid replacement

measures are prescribed by the
physician.
9. Insert and maintain a catheter
as indicated.
10. Monitor laboratory results
i.e. hematocrit, BUN/ creatinine,
sodium, and potassium.
11. Administer medications like
potassium intravenously or
orally as indicated by the
physician.(As soon as urinary
flow is present)

- Changes in mentation reflect

abnormally high or low glucose level,
acidosis, electrolyte imbalances and
decreased cerebral perfusion.
- The type and amount of fluid depend
on the degree of dehydration.
- It gives accurate assessment of urinary
output.
- These parameters reflect fluid shifts
and degree of dehydration of client. It
may also pertain to how the body reacts
to metabolic acidosis.
- To prevent hypokalemia.

12. Insert NGT as indicated.

- To decompress the stomach and to
stop vomiting.

rate of 80 95
beats per
minute; good
skin turgor
and capillary
refill of less
than 2
seconds; and
sodium and
potassium
levels within
normal range
after one
week of
nursing care.
Client will be
able to know
and perform
activities
helpful in
controlling
diabetes
mellitus and
maintaining
adequate fluid
volume like
monitoring
blood glucose
periodically,
administering

own
medications
like insulin
injection,
increasing
fluid intake
and
monitoring
urine for
presence of
ketones, and
other
activities like
proper diet,
exercise and
lifestyle.