Dehydration

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Dehydration

  1. 1. Dehydration Krizza Anne C. Bucok, RN
  2. 2. CLINICAL PICTURE
  3. 3. The patient may have• Increased thirst, dry mouth, swollen tongue• Weakness, dizziness, palpitations• Tachycardia, hypotension• Confusion, sluggishness, fainting, seizu re• Decreased urine output
  4. 4. IMMEDIATE INTERVENTIONS
  5. 5. • Assess VS – Check BP lying, sitting, standing – Note changes• Assess current urine output and recent I&O• Make sure patient is comfortable and safe• Notify physician
  6. 6. • Document the following: – Patient’s status – Phone call to physician or NP – Physician or NP response
  7. 7. FOCUSED ASSESSMENT
  8. 8. Assess:• VS including temperature• Skin for color, moistness, temperature, integrity• Mucous membranes• LOC and orientation• For patent IV access
  9. 9. STABILIZING ANDMONITORING
  10. 10. • Administer or oral IVF• Closely monitor I&O• Monitor urine output for adequate hourly rate• Assess electrolytes, BUN, creatinine• Maintain safe environment• Provide oral care• Chart patient status and convey to physician or NP
  11. 11. BE PREPARED TO
  12. 12. • Obtain IV access• Obtain a nutritional/dietary assessment• Insert a urinary catheter with a urometer to monitor hourly output
  13. 13. POSSIBLE ETIOLOGIES
  14. 14. • Gastroenteritis • Gastrointestinal• Stomatitis obstruction• Diabetic • Heat stroke ketoacidosis • Diabetes insipidus• Febrile illness • thyrotoxicosis• Pharyngitis• Burns
  15. 15. Signs and Symptoms of Progressive Dehydration Moderate Symptom/sign Mild Dehydration Severe Dehydration DehydrationLOC Alert Lethargic ObtundedCapillary refill 2 sec 2-4 sec >4 sec, cool limbsMucous membranes Normal Dry Parched, crackedHR Slight increase Increased Very increased Increased andRR Normal Increased hyperpneaBP Normal Normal but orthostasis DecreasedPulse Normal Thready Faint or impalpableSkin turgor Normal Slow TentingUrine output Decreased Oliguria Oliguria/anuria

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