Question

Extracellular fluid volume deficit

Harriet 30 years old, has been admitted to the burn treatment center with a full thickness burns over 30% of her upper body.Her diagnosis is consistent with extracellular fluid volume deficit(FVD).

1.What symptom would indicate to the nurse that the patient may be experiencing an FVD ?

2.what should the nursing plan of care for harried include that would indicate to the nurse that there may be an FVD .

3.what intervention provided by the nurse would be appropriate for this patient ?

Answer 1

ANSWER 1:- Symptoms that would indicate nurse that patient is suffering from Fluid volume deficit are:-

1. Hypotension due to hypovolemia.

2. Cold, clammy extremities.

3. Oliguria ( decrease urination)

4. Confusion and anxiety.

5. Rapid weak pulse.

6. Fast and deep shallow breathing.

7. Thirst.

8. Muscle weakness.

9. Loss of consciousness.

ANSWER 2:- The Nursing care plan that would indicate there is Fluid Volume Deficit in Harried are:-

1. Diagnosis- Vital signs measurement including blood pressure, heart rate and Respiratory rate measurement, measurement of urine output.

2. Goals for patient recovery-

•To give enough fluid to patient to compensate the loss and the necessary electrolytes.

•To keep track record of hourly vital monitoring like blood pressure, heart rate and respiratory rate.

• To Keep separate track record of hourly Input (fluid given via IV) and Output (urine output) monitoring.

3. Nursing order or intervention - depends upon severity of patient ( intravenous fluids, blood transfusion given accordingly).

4. Evaluation - by the end of implementing goals and interventions all positive outcomes should be evaluated and patient should be assessed by checking the response towards goals and interventions implemented and then accordingly decided whether to continue the goals and intervention or stop.

ANSWER 3:- The interventions provided by the nurse that would be appropriate for this patient are:-

1. Administering intravenous fluid therapy and monitoring fluid replacement levels so that patient should not experience fluid overload.

2. Administering electrolyte rich fluids.

3. Administering Blood transfusion.

4. Assess mental state of patient by checking consciousness, confusion and agitation.

5. Monitoring of vital signs like blood pressure, heart rate.

6. Monitoring input and output of fluids.

7. Check for skin turgor and moisture of mucous membranes.