Nursing Diagnosis for Leukemia
Risk for Fluid Volume Deficit
related to
Purpose : the volume of fluid being met
Expected outcomes:
Risk for Fluid Volume Deficit
related to
- fluid intake and output,
- excessive loss: vomiting, bleeding, diarrhea
- decrease in fluid intake: nausea, anorexia
- increased need for fluids: fever, hypermetabolic.
Purpose : the volume of fluid being met
Expected outcomes:
- Adequate fluid volume
- The mucosa moist
- Vital signs are stable: BP 90/60 mm Hg, pulse 100x/menit, RR 20x/menit
- Pulse palpated
- Urine output 30 ml / hour
- Capillaries and refill less than 2 seconds
- Monitor fluid intake and output
- Monitor body weight
- Monitor BP and heart frequency
- Evaluation of skin turgor, capillary refill and mucous membrane conditions
- Give fluid intake 3-4 L / day
- Inspection of skin / mucous membranes for petechiae, ecchymoses area; noticed bleeding gums, blood color of rust or vague in feces and urine, bleeding from the puncture further invasive.
- Implement measures to prevent tissue injury / bleeding
- Limit oral care to wash mouth when indicated
- Give diet a smooth
- Collaboration:
- Give IV fluids as indicated
- Supervise laboratory tests: platelet count, Hb / Ht, freezing
- Provide HR, platelets, clotting factors
- Maintain a central vascular access device external (sub-clavicle artery catheter, tunneld, implantable ports)