RISK FOR DEFICIENT FLUID VOLUME
At risk for experiencing vascular, cellular, or intracellular
• Conditions that inﬂuence ﬂuid
• Knowledge deﬁcit related to
needs (e.g., hypermetabolic state)
• Excessive loss of ﬂuid from
• Loss of ﬂuid through abnor-
normal routes (e.g., diarrhea)
mal routes (e.g., drainage
• Extremes of age or weight
• Factors that affect intake or
• Medications that cause ﬂuid
absorption of, or access to,
ﬂuids (e.g., immobility)
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Fluid and electrolytes
• Physical regulation
The patient will
• Maintain stable vital signs.
• Have normal skin color.
• Maintain urine output of at least ___ ml/hr.
• Maintain electrolyte values within normal range.
• Maintain intake at _____ ml/24 hr.
• Have an intake equal to or exceeding output.
• Express understanding of need to maintain adequate ﬂuid intake.
• Demonstrate skill in weighing himself or herself accurately and
• Measure and record own intake and output.
• Return to normal, appropriate diet.
SUGGESTED NOC OUTCOMES
Electrolyte & Acid–Base Balance; Fluid Balance; Hydration;
Nutritional Status: Food & Fluid Intake; Risk Detection; Urinary
INTERVENTIONS AND RATIONALES
Determine: Monitor and record vital signs every 4 hr. Fever, tachy-
cardia, dyspnea, or hypotension may indicate hypovolemia.
Determine patient’s ﬂuid preferences to enhance intake.
Maintain accurate record of intake and output to aid estimation
of patient’s ﬂuid balance. Measure urine output every hour. Record
and report output of less than ____ ml/hr. Decreased urine output
may indicate reduced ﬂuid volume. Measure and record drainage
from all tubes and catheters to take such losses into account when
When copious drainage appears on dressings, weigh dressings
every 8 hr and record with other output sources. Excessive wound
drainage causes signiﬁcant ﬂuid imbalances (1 kg dressing equals
about 1 qt [1 L] of ﬂuid).
Test urine speciﬁc gravity each shift. Monitor laboratory values
and report abnormal ﬁndings to physician. Increased urine speciﬁc
gravity may indicate dehydration. Elevated HCT and Hb levels also
Monitor serum electrolyte levels and report abnormalities. Fluid
loss may cause signiﬁcant electrolyte imbalance.
Obtain and record patient’s weight at same time every day to help
ensure accurate data. Daily weighing helps estimate body ﬂuid status.
Monitor skin turgor each shift to check for dehydration; report
any decrease in turgor. Poor skin turgor is a sign of dehydration.
Examine oral mucous membranes each shift. Dry mucous
membranes are a sign of dehydration.
Perform: Cover wounds to minimize ﬂuid loss and prevent skin
Keep oral ﬂuids at bedside within patient’s reach and encourage
patient to drink. This gives patient some control over ﬂuid intake
and supplements parenteral ﬂuid intake.
Force oral ﬂuids when possible and indicated to enhance replace-
ment of lost ﬂuids. (Bowel sounds should be present and patient
awake before giving oral ﬂuids.)
Administer parenteral ﬂuids, as prescribed, to replace ﬂuid losses.
Maintain parenteral ﬂuids or blood transfusions at prescribed rate to
prevent further ﬂuid loss or overload.
Progress patient to appropriate diet, as prescribed, to help achieve
ﬂuid and electrolyte balance.
Inform: Instruct patient in maintaining appropriate ﬂuid intake,
including recording daily weight, measuring intake and output, and
recognizing signs of dehydration. This encourages patient and care-
giver participation and enhances patient’s sense of control.
SUGGESTED NIC INTERVENTIONS
Acid–Base Management; Fluid Management; Fluid Monitoring;
Hypovolemia Management; Hypovolemia Intravenous Therapy;
Hypovolemia Monitoring; Surveillance
Mentes, J. (2006, June). Oral hydration in older adults: Greater awareness is
needed in preventing, recognizing, and treating dehydration. American Jour-
nal of Nursing, 106(6), 40–49.