Monitor and record vital signs every 2 hours or as often as necessary until stable. Then monitor and record vital signs every 4 hours. Tachycardia, dyspnea, or hypotension may indicate fluid volume deficit or electrolyte imbalance. 
Cover patient lightly. Avoid overheating to prevent vasodilation, blood pooling in extremities, and reduced circulating blood volume.- Measure intake and output every 1 to 4 hours. Record and report significant changes. Include urine, stools, vomitus, wound drainage, nasogastric drainage, chest tube drainage, and any other output. Low urine output and high specific gravity indicate hypovolemia.
- Administer fluids, blood or blood products, or plasma expanders as ordered to replace fluids and whole blood loss and facilitate fluid movement into intravascular space. Monitor and record effectiveness and any adverse effects.
- Weigh patient daily at same time for more accurate and consistent data. Weight is a good indicator of fluid status.
- Assess skin turgor and oral mucous membranes every 8 hours to check for dehydration. Give meticulous mouth care every 4 hours to avoid dehydrating mucous membranes.
- Test urine specific gravity every 8 hours. Elevated specific gravity may indicate dehydration.
- Don't allow patient to sit or stand up quickly as long as circulation is compromised to avoid orthostatic hypotension and possible syncope.
- Measure abdominal girth every 12 hours to monitor for ascites and third-space shift. Report changes.
- Administer and monitor medications to prevent further fluid loss.
- Explain reasons for fluid loss and teach patient how to monitor fluid volume, for example, by recording daily weight and measuring intake and output. This encourages patient involvement in personal care.
Suggested NIC Interventions
Acid-Base Management; Electrolyte Monitoring; Fluid Management; Hypovolemia Management; Nutrition Management; Swallowing Therapy; Vital Signs Monitoring |