ConceptMap_DefficientFluidVolume - koz74686_ch52.qxd 2:08...

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nursing intervention nursing intervention nursing intervention 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 MC 27 y.o. female assess generate nursing diagnosis • 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: 38.6 ° C; 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 Outcomes met: • Serum potassium: 3.8 mEq/L • Serum sodium: 140 mEq/L outcome outcome evaluation evaluation Electrolyte and Acid/ Base Balance aeb not compromised • Serum electrolytes • Muscle strength
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