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.

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.

Nursing diagnosis – EXCESS FLUID VOLUME

EXCESS  FLUID  VOLUME

DEFINITION

Increased isotonic fluid retention

DEFINING CHARACTERISTICS

• Altered mental status or respiratory pattern

• Anasarca

• Azotemia

• Changes in blood pressure, pulmonary artery pressure, urine

specific gravity, and electrolyte levels

• Crackles

• Decreased Hb and HCT levels

• Dyspnea

• Edema

• Increased central venous pressure (CVP)

• Intake greater than output

• Jugular vein distention

• Oliguria

• Orthopnea

• Pleural effusion

• Positive hepatojugular reflex

• Pulmonary congestion

• Rapid weight gain

• Restlessness and anxiety

• S3 heart sound

RELATED FACTORS

• Compromised regulatory mechanism

• Excess fluid intake

• Excess sodium intake

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac function

• Neurocognition

• Elimination

• Nutrition

• Fluid and electrolytes

• Respiratory function

EXPECTED OUTCOMES

The patient will

• State ability to breathe comfortably.

• Maintain fluid intake at ___ ml/day.

• Return to baseline weight.

• Maintain vital signs within normal limits (specify).

• Exhibit urine specific gravity of 1.005–1.010.

• Have normal skin turgor.

• Show electrolyte level within normal range (specify).

• Avoid complications of excess fluid.

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SUGGESTED NOC OUTCOMES

Electrolyte Balance; Fluid Balance; Fluid Overload Severity; Kidney

Function; Nutritional Status: Food & Fluid Intake

INTERVENTIONS AND RATIONALES

Determine: Monitor and record vital signs at least every 4 hr.

Changes may indicate fluid or electrolyte imbalances. Measure and

record intake and output. Intake greater than output may indicate

fluid retention and possible overload.

Weigh patient at same time each day to obtain consistent

readings. Test urine specific gravity every 8 hr and record results.

Monitor laboratory values and report significant changes to

physician. High specific gravity indicates fluid retention. Fluid over-

load may alter electrolyte levels.

Assess patient daily for edema, including ascites and dependent or

sacral edema. Fluid overload or decreased osmotic pressure may

result in edema, especially in dependent areas.

Perform: Help patient into a position that aids breathing, such as

Fowler’s or semi-Fowler’s, to increase chest expansion and improve

ventilation.

Administer oxygen, as ordered, to enhance arterial blood oxygena-

tion. Restrict fluids to ____ ml per shift. Excessive fluids will worsen

patient’s condition.

Administer diuretics to promote fluid excretion. Record effects.

Maintain patient on sodium-restricted diet, as ordered, to reduce

excess fluid and prevent reaccumulation.

Reposition patient every 2 hr, inspect skin for redness with each

turn, and institute measures as needed to prevent skin breakdown.

Apply antiembolism stockings or intermittent pneumatic compres-

sion stockings to increase venous return. Remove for 1 hr every

8 hr or according to facility policy.

Inform: Educate patient regarding maintenance of daily weight

record, daily measuring and recording of intake and output, diuretic

therapy, and dietary restrictions, especially sodium. These measures

encourage patient and caregivers to participate more fully.

Attend: Encourage patient to cough and deep breathe every 2–4 hr

to prevent pulmonary complications.

SUGGESTED NIC INTERVENTIONS

Electrolyte Management; Fluid Management; Fluid Monitoring;

Nutrition Management

Reference

Bennett, S. J., et al. (2005, December). Medication and dietary compliance

beliefs in heart failure. Western Journal of Nursing Research, 27(8),
977–993.

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.

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.