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 imbalanced body temperature

Risk for Imbalanced body temperature
Definition
At risk for failure to maintain body temperature within normal
range
RISK FACTORS
• RISK FOR IMBALANCED BODY TEMPERATURE
• Altered metabolic rate
• Dehydration
• Exposure to extreme hot/cold
environments
• Advanced age
• Extremes of weight
• Illness/trauma affecting
temperature regulation
• Medications causing vasoconstriction
• Inactivity/vigorous activity
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Fluid and electrolytes
• Neurocognition
EXPECTED OUTCOMES
The patient will
• Maintain body temperature of 98.6 F–99.5 F (37 C–37.5 C).
• Maintain weight within 5% of baseline.
• Maintain balanced intake and output within normal limits for age.
• Have a urine-specific gravity between 1.010 and 1.015.
SUGGESTED NOC OUTCOMES
Hydration; Medication Response; Thermoregulation
INTERVENTIONS AND RATIONALES
Determine: Assess temperature every 4 hr. Use a temperature-taking
method appropriate for age and size (rectal or axillary for an infant
or toddler, axillary or oral for a preschooler, and oral for a schoolaged
child or adult). Prolonged elevation of temperature above 104 F
(40 C) may produce dehydration and harmful central nervous system
effects.
Weigh patient every morning and record results. A decrease in
weight may indicate dehydration.
Assess the patient’s knowledge and lifestyle before teaching about
hypothermia and hyperthermia to gear the teaching plan to the
patient’s needs.
Perform: Maintain adequate fluid intake by offering small amounts
of flavored fluids at frequent intervals; record intake and output
every shift. Fever increases fluid requirements by increasing the
metabolic rate. Provide high-calorie liquids, such as colas, fruit
juices, and flavored water sweetened with corn syrup, to help
prevent dehydration.
Administer antipyretics, as ordered, and monitor effectiveness.
Antipyretics act on the hypothalamus to regulate body temperature.
• Nutrition
• Respiratory function
Check and record urine-specific gravity with each voiding. Urinespecific
gravity increases with dehydration. Adequate urine output
and urine-specific gravity between 1.010 and 1.015 indicate
sufficient hydration.
Give a tepid sponge bath for increased temperature to increase
vaporization from skin and decrease body temperature.
Inform: Teach patient to dress in lightweight clothing when experiencing
elevated body temperature to allow perspiration to evaporate,
thereby releasing body heat.
Instruct the patient on the signs and symptoms of imbalanced
body temperature:
– Hypothermia: shallow respirations; slow, weak pulse; decreased
body temperature; low blood pressure; and pallor
– Hyperthermia: shivering, shaking chill; feeling hot; extreme
thirst; elevated body temperature; and high blood pressure.
Listing the signs and symptoms helps the patient learn and identify
warning signals of imbalanced body temperature. Large black
type is easier for the older patient to read.
Explain to the patient or family member why the patient needs
warm clothing in cool climates, even indoors. Suggest socks, nonslip
house shoes, and leg warmers to provide warmth to vulnerable
lower extremities, where vascular changes may cause decreased temperature
sensation.
Instruct the patient or family member to label home thermostats
with large numbers and to use black or bright contrasting colors to
indicate appropriate temperature settings. Easy-to-read labels will
help the patient maintain room temperature.
Teach the patient or his or her family members about the dangers
of too much direct sunlight on warm days to prevent overheating in
an older patient with faulty thermoreceptors.
Attend: Encourage the patient to remain active when in a cool environment
to keep warm and maintain normal metabolism.
Manage: Suggest that a friend, family member, or volunteer from a
local community organization visit the patient daily to help ensure
the patient’s safety.
SUGGESTED NIC INTERVENTIONS
Fever Treatment; Medication Management; Temperature Regulation;
Vital Signs Monitoring
Reference
Braun, C. A. (2006, September–October). Accuracy of pacifier thermometers
in young children. Pediatric Nursing, 32(5), 413–418.