Nursing diagnosis – READINESS FOR ENHANCED FLUID BALANCE

READINESS  FOR  ENHANCED

FLUID  BALANCE

DEFINITION

A pattern of equilibrium between fluid volume and chemical compo-

sition of body fluids that is sufficient for meeting physical needs and

can be strengthened

DEFINING CHARACTERISTICS

• Verbalization of willingness to enhance fluid balance

• Stable weight

• Moist mucous membranes

• Food and fluid intake adequate for daily needs

• Straw-colored urine with specific gravity within normal limits

• Good tissue turgor

• No excessive thirst

• Urine output appropriate for intake

• No evidence of edema or dehydration

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Cardiac function

• Neurocognition

• Elimination

• Respiratory function

EXPECTED OUTCOMES

The patient will

• Have stable vital signs within normal ranges; electrocardiograph

shows no abnormality in rhythm.

• Have normal skin temperature, moistness, turgor, and color.

• Have moist and noncracked mucous membranes.

• Have stable weight.

• Have adequate fluid volume intake and thirst satiety.

• Produce adequate urine volume (approximately equal to fluid

intake) of light to straw-colored urine.

• Maintain a urine specific gravity between 1.015 and 1.025.

• Have normal values for plasma and serum for electrolytes, osmo-

larity, glucose, blood urea nitrogen, hematocrit (HCT), and hemo-
globin (Hb).

• Be alert and respond to demands of living; react appropriately to

reflex needs (i.e., thirst); have normal muscle reflexes, strength,
and tone.

• Express understanding of factors that contribute to normal fluid

and electrolyte balance.

• Adhere to prescribed therapies to manage such coexisting disease

processes.

SUGGESTED NOC OUTCOMES

Fluid Balance; Hydration; Nutritional Status: Food & Fluid Intake;

Tissue Integrity: Skin & Mucous Membranes; Vital Signs

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INTERVENTIONS AND RATIONALES

Determine: Assess usual fluid intake and desire to improve fluid sta-

tus to establish a baseline.

Inform: Teach patient to read and interpret labels on beverage and

food containers. For example, humans require 0.5 g (500 mg) of

sodium per day; typical intake is 5–6 g daily. Reducing the amount

of sodium reduces the amount of fluid volume in the vascular

system.

Encourage adequate water intake (1,200–2,000 ml) during

exercise or high environmental temperatures; unmeasured fluid losses

through diaphoresis and lung evaporation can be significant.

Teach signs and symptoms of dehydration (dry mouth and

mucous membranes), light-headedness (blood pressure and vital sign

changes), scant urine output (glycosuria and polyuria), and over-

hydration (cough, increased weight gain, dependent edema, and

jugular vein distention). Teaching prevents severe complications.

Attend: Encourage patient to select healthy beverages such as water

and limit beverages such as soda or sports drinks that have high

sugar content (which increase the osmolar content of the body, caus-

ing greater thirst and increased load on the renal system and diuresis)

and caffeine (which causes diuresis and may cause an increased fluid

loss), alcoholic beverages during hot weather because these can

cause fluid and electrolyte disturbances through excess diuresis.

SUGGESTED NIC INTERVENTIONS

Electrolyte Management; Fluid/Electrolyte Management; Fluid Man-

agement; Fluid Monitoring

Reference

Mentes, J. (2006, June). Oral hydration in older adults: Greater awareness is

needed in preventing, recognizing, and treating dehydration. American Journal
of Nursing, 106(6), 40–49.

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