NCP for AGE

Deficient Fluid volume r/t

-Active fluid volume loss

-failure of regulatory mechanisms

Nursing Outcomes Classification)

Fluid Balance

Hydration

Nutritional Status: Food and Fluid Intake

Client Outcomes

Maintain urine output more than 1300 ml/day (or at least 30 ml/hr)

Maintain normal blood pressure, pulse, and body temperature

Maintain elastic skin turgor; moist tongue and mucous membranes; and orientation to person,
place, and time

Explain measures that can be taken to treat or prevent fluid volume loss

Describe symptoms that indicate the need to consult with health care provider

Nursing Interventions and Rationales

1. Monitor for the existence of factors causing deficient fluid volume Early identification of risk
factors and early intervention can decrease the occurrence and severity of complications from
deficient fluid volume
2. Watch for early signs of hypovolemia, including restlessness, weakness, muscle cramps, and
postural hypotension. Late signs include oliguria, abdominal or chest pain, cyanosis, cold
clammy skin, and confusion
3. Monitor total fluid intake and output every 8 hours (or every hour for the unstable client).
Recognize that urine output is not always an accurate indicator of fluid balance. A urine output
of less than 30 ml/hr is insufficient for normal renal function and indicates hypovolemia or onset
of renal damage
4. Monitor daily weight for sudden decreases, especially in the presence of decreasing urine
output or active fluid loss. Weigh the client on the same scale with the same type of clothing at
same time of day, preferably before breakfast. Body weight changes reflect changes in body fluid
volume
5. provide oral replacement therapy as ordered and tolerated with a hypotonic glucoseelectrolyte
solution when the client has acute diarrhea or nausea/vomiting. Provide small, frequent quanes of
slightly chilled solutions. Maintenance of oral intake stabilizes the ability of the intestines to
digest and absorb nutrients; glucose-electrolyte solutions increase net fluid absorption while
correcting deficient fluid volume
6. Assist with ambulation if the client has postural hypotension. Postural hypotension can cause
dizziness, which places the client at higher risk for injury.