Nursing diagnosis – DEFICIENT FLUID VOLUME

DEFICIENT  FLUID  VOLUME

DEFINITION

Decreased intravascular, interstitial, or intracellular fluid; water loss

alone without change in sodium

DEFINING CHARACTERISTICS

• Changes in mental status

• Decreased pulse volume and pressure, urine output, and venous

filling

• Dry skin and mucous membranes

• Increased body temperature, HCT, pulse rate, and urine concen-

tration

• Low blood pressure

• Poor turgor of skin or tongue

• Sudden weight loss

• Thirst

• Weakness

RELATED FACTORS

• Active fluid volume loss

• Failure of regulatory mechanisms

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Maintain stable vital signs.

• Have normal skin color.

• Have electrolyte levels within normal range.

• Maintain an adequate fluid volume.

• Maintain an adequate urine volume.

• Have normal skin turgor and moist mucous membranes.

• Have a urine specific gravity between 1.005 and 1.010.

• Have normal fluid and blood volume.

• Express understanding of factors that caused fluid volume deficit.

SUGGESTED NOC OUTCOMES

Electrolyte & Acid–Base Balance; Fluid Balance; Hydration; Nutri-

tional Status: Food & Fluid Intake

INTERVENTIONS AND RATIONALES

Determine: Monitor and record vital signs every 2 hr or as often as

necessary until stable. Then monitor and record vital signs every

4 hr. Tachycardia, dyspnea, or hypotension may indicate fluid

volume deficit or electrolyte imbalance.

Measure intake and output every 1–4 hr. Record and report sig-

nificant changes. Include urine, stools, vomitus, wound drainage,

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nasogastric drainage, chest tube drainage, and any other output.

Low urine output and high specific gravity indicate hypovolemia.

Weigh patient daily at same time to give more accurate and con-

sistent data. Weight is a good indicator of fluid status.

Assess skin turgor and oral mucous membranes every 8 hr to

check for dehydration. Give meticulous mouth care every 4 hr to

avoid dehydrating mucous membranes.

Test urine specific gravity every 8 hr. Elevated specific gravity may

indicate dehydration.

Measure abdominal girth every shift to monitor for ascites and

third-space shift. Report changes.

Perform: Cover patient lightly. Avoid overheating to prevent vasodi-

lation, blood pooling in extremities, and reduced circulating blood

volume.

Administer fluids, blood or blood products, or plasma expanders

to replace fluids and whole blood loss and facilitate fluid movement

into intravascular space. Monitor and record effectiveness and any

adverse effects.

Don’t allow patient to sit or stand up quickly as long as circula-

tion is compromised to avoid orthostatic hypotension and possible

syncope.

Administer and monitor medications to prevent further fluid loss.

Inform: 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

Reference

Kelley, D. M. (2005, January–March). Hypovolemic shock: An overview. Crit-

ical Care Nursing Quarterly, 28(1), 2–19.

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