Nursing diagnosis – RISK FOR IMBALANCED FLUID VOLUME

RISK  FOR  IMBALANCED  FLUID  VOLUME

DEFINITION

At risk for a decrease, increase, or rapid shift from one to the other

of intravascular, interstitial, and/or intracellular fluid. This refers to

body fluid loss, gain, or both

RISK FACTORS

• Receiving apheresis

• Intestinal obstruction

• Abdominal surgery

• Sepsis

• Traumatic injury

• Pancreatitis

• Burns

• Ascites

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac function

• Fluid and electrolytes

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Remain hemodynamically stable.

• Not experience electrolyte imbalance.

• Maintain adequate urine output.

• Identify risk factors contributing to possible imbalanced fluid volume.

SUGGESTED NOC OUTCOMES

Fluid Balance; Hydration; Vital Signs

INTERVENTIONS AND RATIONALES

Determine: Assess for conditions that may contribute to imbalanced

fluid volume. Prompt treatment of the underlying cause may prevent

serious complications of fluid imbalance.

Monitor vital signs and other assessment parameters frequently.

Changes in heart rate and rhythm, blood pressure, and breath

sounds may indicate altered fluid status.

Monitor intake and output to evaluate need for fluid replacement.

Perform: Collect and evaluate urine output frequently. Measure urine

specific gravity as indicated. Decreased urine volume and elevated

specific gravity indicate hypovolemia.

Collect and evaluate serum electrolyte levels. Fluid alterations may

affect electrolyte levels.

Administer intravenous fluids as indicated. Proactive fluid manage-

ment may prevent serious imbalances.

Inform: Educate patient and family regarding fluid restrictions or

need for increased fluids, depending on underlying condition. Knowl-

edge will enhance feeling of participation and sense of control.

Attend: Provide encouragement and support for cooperation with

prescribed treatment regimen. Positive reinforcement will promote

compliance.

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Manage: Coordinate care with other members of healthcare team to

effectively manage underlying medical condition and prevent any

alteration in fluid balance.

SUGGESTED NIC INTERVENTIONS

Fluid Management; Fluid Monitoring; Intravenous Therapy

Reference

Noble, K. A. (2008). Fluid and electrolyte imbalance: A bridge over troubled

water. Journal of Perianesthesia Nursing, 23, 267–272.

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