Nursing Care Plan : Nursing Diagnosis Nanda

Nursing Diagnosis for Diabetes Mellitus : Fluid Volume Deficits

Diabetes mellitus (or diabetes) is a chronic, lifelong condition that affects your body's ability to use the energy found in food. There are three major types of diabetes: type 1 diabetes, type 2 diabetes, and gestational diabetes.



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.

Related factors:
  • 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.

Source :
http://nurse-books.blogspot.com/2015/01/fluid-volume-deficits-related-to.html
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