A patient has the nursing diagnosis of Deficient Fluid Volume related to anorexia, nausea, vomiting, and excessive T-tube drainage related to cholecystitis. Which interventions should the nurse recommend be included in the plan of care?
(Select all that apply.)
a. Monitor skin turgor.
b. Administer antiemetics as ordered.
c. Clamp T-tube for 2 hours each shift.
d. Monitor daily weight and intake and output.
e. Encourage use of incentive spirometer every hour while awake.
f. Contact the physician if T-tube drainage is greater than 150 mL within 24 hours of surgery.
ANS: A, B, D
Daily weights, intake and output, and skin turgor are good measures of fluid balance. Antiemetics will help reduce vomiting and contribute to fluid balance. F. About 500 to 1000 mL of yellowish-green bile is common within the first 24 hours after surgery. C. Clamping the T-tube is inappropriate and may put pressure on the surgical site. E. Use of incentive spirometer contributes to oxygenation status and not deficient fluid volume.
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