Derick Mussen Preventive Healthcare

Risk For Deficient Fluid Volume

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Related to: Inadequate oral intake, excessive losses through abnormal route.

Defining Characteristics: (Specify, e.g., child states it hurts to drink, decreased intake [specify amount]; post-tonsillectomy risk for hemorrhage.) Goal: Child will not experience deficient fluid volume by (date/time to evaluate). Outcome Criteria

V Intake equals output.

V No signs of bleeding from operative site. NOC: Fluid Balance

INTERVENTIONS

Assess hourly intake and output.

Monitor skin turgor and moisture of mucous membranes.

Observe post-tonsillectomy client for signs of bleeding: assess operative site using a flashlight (specify frequency), monitor child for excessive swallowing, even during sleep.

Monitor vital signs per protocol (specify which parameters and frequency).

Monitor and maintain IV fluids via pump as ordered (specify fluid and rate). Evaluate IV site hourly.

Encourage child to drink small amounts of favorite clear liquids (specify, e.g., 30 cc per hour of apple juice). Avoid red or brown-colored liquids or citrus. Do not allow use of a straw.

Use creative, developmentally appropriate techniques to make a game of drinking (specify, e.g., placing stars or coloring in blocks on a chart or earning stickers.

Teach child to avoid excessive coughing or clearing of throat. Administer antiemetics as ordered (specify) to prevent vomiting.

Provide parents with discharge teaching regarding fluid intake,

RATIONALES

Provides information about physiologic fluid balance and signs of dehydration.

Provides information about the integrity of the surgical site. Bleeding from the operative site may cause the child to swallow frequently.

Tachycardia and hypotension are physiologic responses to deficient fluid volume.

Replaces losses from surgery and maintains hydration if child is unable to drink.

Small amounts may be more easily tolerated. Red or brown may be confused with bleeding if child vomits. Suction created by sucking could disrupt operative site, avoids risk for injury.

Child's desire to play or to gain approval can help promote increased intake.

Excessive coughing, clearing the throat, or vomiting may disrupt the operative site.

Teaching ensures that parents will continue to monitor fluid balance.

activity, and when to seek medical care (specify caregiver's orders).

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