Nursing diagnosis – RISK FOR DEFICIENT FLUID VOLUME

RISK  FOR  DEFICIENT  FLUID  VOLUME

DEFINITION

At risk for experiencing vascular, cellular, or intracellular

dehydration

RISK FACTORS

• Conditions  that  influence  fluid

• Knowledge deficit related to

needs (e.g., hypermetabolic state)

fluid volume

• 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

tube)

• Factors that affect intake or

• Medications that cause fluid

absorption of, or access to,
fluids (e.g., immobility)

loss

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.

• 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

recording weight.

• 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

Elimination

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

replacing fluid.

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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

indicate dehydration.

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

excoriation.

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

Reference

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.

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