CONCEPT MAP

Deficient Fluid Volume

Sales clerk, Reports weakness, malaise, and flu-like symptoms for 3-4 days. Although thirsty, is unable to tolerate fluids because of nausea and vomiting, and she has liquid stools 2-4 times per day. Height: 160 cm (5' 3") Weight: 66.2 kg (146 lbs) T: 38.6C; P: 96 BPM; R: 24; BP: 102/84 Dry mucous membranes Decreased skin turgor Urine specific gravity: 1.035 Serum sodium: 155 mEq/L Serum potassium 3.2 mEq/L Chest x-ray negative

MC 27 y.o. female

assess

generate nursing diagnosis

Deficient Fluid Volume r/t nausea, vomiting, diarrhea aeb decreased urine output, increased urine concentration, weakness, fever, decreased skin turgor, dry mucous membranes, increased pulse, and decreased BP outcome outcome Outcomes met: BP: 122/74 P: 74 Urine output increased Specific gravity: 1.105 Moist mucous membranes Elastic skin turgor Fluid balance aeb not compromised 24 hour intake and output Blood pressure, pulse, and temperature Skin turgor Urine specific gravity Mucous membranes

evaluation

Electrolyte and Acid/ Base Balance aeb not compromised Serum electrolytes Muscle strength

evaluation

Outcomes met: Serum potassium: 3.8 mEq/L Serum sodium: 140 mEq/L

nursing intervention Fluid Management activity activity Give fluids as appropriate activity

nursing intervention Electrolyte Management: Hypernatremia

nursing intervention Behavior Modification activity activity Monitor for neurologic and neuromuscular manifestations of hypokalemia (e.g., hypotension, tachycardia, weak pulse, rhythm irregularities) activity

Weigh daily and monitor trends

Provide frequent oral hygiene activity activity

activity

Obtain specimens for analysis of altered potassium levels as indicated

Administer IV therapy as prescribed activity activity

Monitor vitals signs as appropriate

Maintain accurate intake and output record

Monitor for neurologic and neuromuscular manifestations of hypernatremia (e.g., lethargy, irritability, seizures, and hyperreflexia) activity

Monitor for cardiac manifestations of hpyernatremia (e.g., tachycardia, orthostatic hypotension)

Administer prescribed supplemental potassium (PO, NG, or IV) per policy

Obtain specimens for analysis of altered sodium levels (e.g., serum and urine sodium, urine osmolality, and urine specific gravity) as indicated