Nursig Diagnosis for Diabetes Mellitus : Fluid Volume Deficits
Fluid Volume Deficits Definition : Decreased intravascular fluid, interstitial or intracellular.
Defining characteristics :
- Thirsty.
- Decreased skin turgor and tongue.
- Decreased venous filling.
- Skin and mucous membranes dry.
- Increased heart rate, decreased blood pressure, decreased volume and pulse pressure.
- Weight loss is sudden (except the 3rd room).
- Weakness.
- Loss of fluid volume.
- Failure mechanisms of regulation (diabetes insipidus, hyperaldosteronisme).
Goal :
After nursing actions 2x24 hours, expected the patient does not experience pain with indicator :
- Maintain urine output in accordance with the age and weight, normal urine specific gravity.
- Blood pressure, pulse, body temperature within normal limits.
- No signs of dehydration, elasticity good skin turgor, mucous membranes moist, no excessive thirst.
- Orientation to time and place well.
- The number and the respiratory rhythm within normal limits.
- Electrolytes, hemoglobin, Hmt within normal limits.
- urine pH within normal limits.
- Intake of oral and intravenous adequate.
NOC :
- The patient will have a normal urine concentration.
- The patient had a hemoglobin and hematocrit within normal limits for the patient.
- The patient did not experience abnormal thirst.
- The patient has a balance of intake and output balance within 24 hours.
- The patient show good hydration.
- The patient had oral fluid / intravenous adequate.
NIC :
- Maintain records accurate intake and output.
- Monitor the status of hydration (moisture mucous membranes, adequate pulse, orthostatic blood pressure), if necessary.
- Monitor vital signs every 15 minutes - 1 hour.
- Collaboration of IV fluids.
- Monitor nutritional status.
- Give oral fluids.
- Encourage families to help patients eat.
- Collaboration with doctor if signs of excess fluid appears to worsen.
- Attach the catheter if necessary.
- Monitor intake and urine output every 8 hours.