Fluid Volume Deficit - Nursing Care Plan for Antepartum Haemorrhage

Antepartum haemorrhage (APH) defined as bleeding from the genital tract in the second half of pregnancy, remains a major cause of perinatal mortality and maternal morbidity in the developed world.

Fluid Volume Deficit Definition

Decreased intravascular, interstitial, and/or intracellular fluid (refers to dehydration, water loss alone without change in sodium level)

Defining Characteristics:

• Decreased urine output;
• increased urine concentration;
• weakness;
• sudden weight loss (except in third-spacing);
• decreased venous filling;
• increased body temperature;
• decreased pulse volume/pressure;
• change in mental state;
• elevated hematocrit;
• decreased skin/tongue turgor;
• dry skin/mucous membranes;
• thirst;
• increased pulse rate;
• decreased blood pressure

Nursing Diagnosis for Antepartum Haemorrhage : Fluid Volume Deficit related to excessive vomiting
and inadequate inputs (ireneM. Bobak, 1995: 637)

Intervention :
1. Rest your clients in a comfortable place.
Rationale : Rest will reduce energy needs. Increased metabolism does not work so it does not stimulate to not occurrence of nausea and vomiting.

2. Monitor vital signs and signs of dehydration.
Rationale: By observing the signs of dehydration can know the general state of the client and the extent to which the lack of fluid on the client. Decreased blood pressure, increased temperature and increased pulse are signs of dehydration and hypovolemia.

3. Collaboration with physicians in the delivery of infusion.
Rasoinal : Giving intravenous fluids to replace the amount of fluid lost electrolytes quickly.

4. Monitor infusion liquid droplets.
Rationale: The number and improper infusion droplets can cause excess or lack of fluids in the circulatory system.

5. Record intake and output
Rationale: By knowing intek and unknown liquids output fluid balance in the body.

6. After the first 24 hours suggest drinking every hour.
Rational : Drinking can often increase revenue through oral fluids.