Fluid Volume Deficit

Fluid
Volume Deficit

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_)
Excessive urinary output.
(_) Inadequate fluid intake.
(_) Abnormal drainage.

(_) Excessive emesis.
(_) Difficulty in swallowing.
(_) Medication:________________________
(_) Diarrhea (_) Shock (_) Hemorrhage (_) Fever (_) Burns
(_) Other:_____________________________
____________________________________

____________________________________

 

As
evidenced by:
[Check
those that apply]
Major:

(
Must be
present
)
(_)
Output greater than intake.
(_) Dry skin/mucous membranes.
Minor:

(
May be
present
)
(_)
Increased serum sodium. (_) Increased pulse from
baseline.
(_) Decreased or excessive urine output. (_) Concentrated
urine.

(_) Urinary frequency. (_) Decreased fluid intake. (_)
Poor skin tugor.
(_) Thirst/nausea/anorexia.

 

Date &

Sign.

Plan and Outcome
[Check
those that apply]
Target
Date:
Nursing Interventions
[Check
those that apply]
Date
Achieved:
  The
patient will:

(_)
Demonstrate adequate fluid balance A.E.B.:

  • Moist mucous
    membranes.
  • Balanced intake
    and output.
  • Normal lab
    values.
  • Improved skin
    turgor.

(_) Other:

  (_)
Asses:
  • Moistness of
    mucous membrane and skin turgor and chart
    findings.
  • Intake and output
    q___ hours.
  • Orthostatic
    hypotension QD.
  • Daily weights
    each _____ am/pm using same scale.
  • Labs: HCT, BUN,
    Specific gravity, Sodium, Other:______

(_) Encourage fluid
intake of ____ cc/day; ____.

(_) Assist patient
with drinking if necessary.

(_) Explore patient’s
understanding of etiological factors and provide
necessary teaching.

(_)
Other:________________

________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature