Nursing Diagnosis: Fluid Volume, risk for deficient
Risk factors may include
- Preoperative vomiting, postoperative restrictions (e.g., NPO)
- Hypermetabolic state (e.g., fever, healing process)
- Inflammation of peritoneum with sequestration of fluid
Desired Outcomes
- Hydration (NOC)
- Maintain adequate fluid balance as evidenced by moist mucous membranes, good skin turgor, stable vital signs, and individually adequate urinary output.
| Nursing Interventions | Rationale |
| Monitor BP and pulse. | Variations help identify fluctuating intravascular volumes |
| Inspect mucous membranes; assess skin turgor and capillary refill. | Indicators of adequacy of peripheral circulation and cellular hydration. |
| Monitor I&O; note urine color/concentration, specific gravity. | Decreasing output of concentrated urine with increasing specific gravity suggests dehydration/need for increased fluids. |
| Auscultate bowel sounds. Note passing of flatus, bowel movement. | Indicators of return of peristalsis, readiness to begin oral intake. Note: This may not occur in the hospital if patient has had a laparoscopic procedure and been discharged in less than 24 hr. |
| Provide clear liquids in small amounts when oral intake is resumed, and progress diet as tolerated. | Reduces risk of gastric irritation/vomiting to minimize fluid loss. |
| Give frequent mouth care with special attention to protection of the lips. | Dehydration results in drying and painful cracking of the lips and mouth. |
| Maintain gastric/intestinal suction, as indicated. | An NG tube may be inserted preoperatively and maintained in immediate postoperative phase to decompress the bowel, promote intestinal rest, prevent vomiting. |
| Administer IV fluids and electrolytes. | The peritoneum reacts to irritation/infection by producing large amounts of intestinal fluid, possibly reducing the circulating blood volume, resulting in dehydration and relative electrolyte imbalances. |
