NURSING INTERVENTION
Nursing Out Come
No Nursing diagnosis
1 Lack of fluid volume
Characteristic Limitation:
□ Thirst
□ Weaknesses
□ Dry skin
□ Dry mucosal membranes
□ Pulse rate increase
□ Increased hematocrit
□ Increase in urine concentration
□ Increased body temperature
□ Sudden weight loss
□ Decreased urine output
□ Decreased venous filling
□ Blood pressure reduction
□ Pulse pressure drop
□ Decreased skin turgor
□ Decreased tongue turgor
Nursing In Come
(NOC) (NIC)
After being given nursing care for
... ..x ... hours are expected the Fluid Management
□ Monitor laboratory results that correspond to fluid
problem of lack of fluid volume
retention (increased BUN, decreased hematocrit,
can be overcome by the results
increased urine osmolarity)
criteria:
□ Monitor vital signs (blood pressure and pulse)
NOC: □ Hemodynamic status (MAP) monitor
□ Collaboration of fluid therapy via infusion
Fluid Monitoring
Fluid Balance □ Monitor fluid input and outpu
□ Blood pressure is within normal
limits
□ MAP is within normal limits
□ Pulse rate is normal
□ There is no decline in
consciousness
□ Hematocrit levels are within
normal limits
□ Serum electrolyte levels (BUN
and urine osmolarity) are within
normal limits)
□ Pulse volume decrease □ Elastic skin turgor
□ Changes in mental status □ 24 hour balanced intake and
fluid output
Related factors:
□ Failure of regulatory mechanisms
□ Active fluid loss