Primary Nursing Diagnosis

Fluid volume deficit related to water loss

OUTCOMES. Fluid balance; Circulation status; Cardiac pump effectiveness; Hydration; Nutrition management; Nutrition therapy

INTERVENTIONS. Fluid/electrolyte management; Fluid monitoring; Shock management: Volume; Medication administration; Circulatory care


Upon assessment of a pattern of heavy drinking, the patient is often placed on prophylactic benzodiazepines. These medications are particularly important if the patient develops early signs of withdrawal, such as irritability, anxiety, tremors, restlessness, confusion, mild hypertension (blood pressure >140/90), tachycardia (heart rate >100), and a low-grade fever (temperature > 100°F). Keeping the patient safe during the withdrawal process depends on managing the physiological changes, the signs and symptoms, and the appropriate drug protocols. The goal is to keep the patient mildly sedated or in a calm and tranquil state but still allow for easy arousal.

Although sedation should prevent withdrawal, if withdrawal occurs patients will often require intravenous hydration, with fluid requirements ranging from 4 to 10 L in the first 24 hours. Hypoglycemia is common, and often a 5% dextrose solution in 0.90% or 0.45% saline will be used. Monitor and replace electrolytes as necessary because people with alcohol dependence often have low calcium, magnesium, phosphorous, and potassium.

Once the patient's nausea and vomiting have been controlled, encourage a well-balanced diet. Monitor the patient continually for signs of dehydration, such as poor skin turgor, dry mucous membranes, weight loss, concentrated urine, and hypotension. Record intake and output. If the patient's blood pressure drops below 90 mm Hg, a significant fluid volume loss has occurred; notify the physician immediately.



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