NOC Fluid Balance

INTERVENTIONS

Assess food frequency and 24 hour recall, oral fluids, medications, food likes and dislikes, financial and cultural influences, food allergies, food preparation methods.

Assess onset of nausea and vomiting, quality, quantity and presence of blood, bile, food, and odor.

Assess relationship of nausea and vomiting to meals, time of day or activities, and associated triggers.

Assess for presence of associated symptoms: diarrhea, fever, ear pain, UGI symptoms, vision changes, headache, seizures, high pitched cry, polydipsia, polyuria, polyphagia, anorexia, and so forth; record intake and output, including all body fluid losses, IVs and oral fluids (specify frequency).

Assess skin turgor, mucous membranes, weight, fontanelles of an infant, last void, and behavior changes.

Maintain NPO status, if prescribed (specify).

Initiate and monitor IV

administration of nutrients as prescribed (specify).

RATIONALES

Provides information to evaluate nutritional status, patterns, habits, and environmental influences on diet.

Provides information about emesis and defining characteristics.

Provides information to identify factors related to time of fluid deficit.

Provides information to identify associated medical conditions; indicates fluid status; increased output and decreased intake indicate a fluid deficit and need for replacement.

Provides information about hydration status; including extracellular fluid losses, decreased activity levels, malaise, weight loss, poor skin turgor, concentrated urine.

Provides rest for the gastrointestinal tract because of nausea and vomiting and associated medical conditions.

Provides fluid and nutritional support to replace active fluid loss and prevention of fluid

Assess vital signs, including apical pulse (specify when).

Initiate small amounts of clear liquids, as tolerated when nausea and vomiting subside; offer oral hydration fluids; breast-fed babies need frequent short feedings at the breast:Infant: 70 to 100 ml/kg in 24 hours, toddler: 50 to 70 ml/kg in 24 hours, school-age: 20 to 50 ml/kg in 24 hours.

Gradually reintroduce other fluids and regular diet.

Monitor urine specific gravity, color, and amount every voiding or as ordered.

Monitor laboratory data results, as ordered (electrolytes, BUN, CBC, pH, etc.).

Administer medications (specify drug, dose, route, and times) as ordered and evaluate effects/side effects.

Position child on side or sitting up when vomiting; keep suction available.

Provide comfort measures (e.g., cool cloth, clean linens, etc.).

Administer or assist with good oral hygiene (brushing teeth, mouthwash or oral swabs).

Explain all interventions to child and parents and provide psychological support.

Assist child with activity and position changes.

Instruct parents regarding causes of nausea and vomiting, signs of dehydration, and when to report them to the physician (specify).

Teach parents to position child safely during vomiting episodes and to provide oral hygiene.

NIC: Fluid Management overload.

Provides monitoring of cardiovascular response to dehydration (weak, thready pulse, drop in blood pressure). Increased respiratory rate may contribute to fluid loss.

Provides fluids in minimal amounts until nausea and vomiting resolved.

Allows for the gradual return to the expected dietary intake.

Concentrated urine with an increased specific gravity indicates lack of fluids to dilute urine.

Allows identification of fluid losses and electrolyte imbalances.

Specify action.

Avoids aspiration of emesis.

Promotes comfort level and distraction.

Provides moisture and comfort for drying oral mucosa.

Provides comfort, information, relieves anxiety, and decreases feeling of powerlessness.

Prevents injury and provides safety because of possible postural hypertension.

Provides information for immediate treatment of excessive loss of fluids and electrolytes caused by nausea and vomiting.

Provides information to promote safety, oral hydration and hygiene.

Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

Get My Free Ebook


Post a comment