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Nursing Diagnosis: Deficient Fluid Volume

Hypovolemia; Dehydration

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels   Fluid Balance Hydration

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels    Fluid Monitoring Fluid Management Fluid Resuscitation

NANDA Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Common sources for fluid loss are the gastrointestinal (GI) tract, polyuria, and increased perspiration. Fluid volume deficit may be an acute or chronic condition managed in the hospital, outpatient center, or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of restoring fluid volume and correcting any electrolyte imbalances. Early recognition and treatment are paramount to prevent potentially life-threatening hypovolemic shock. Elderly patients are more likely to develop fluid imbalances. Defining Characteristics:                Decreased urine output Concentrated urine Output greater than intake Sudden weight loss Decreased venous filling Hemoconcentration Increased serum sodium Hypotension Thirst Increased pulse rate Decreased skin turgor Dry mucous membranes Weakness Possible weight gain Changes in mental status

with same scale. Febrile states decrease body fluids through perspiration and increased respiration. Causes may include acute trauma and bleeding. Concentrated urine denotes fluid deficit. Evaluate fluid status in relation to dietary intake. diarrhea) Failure of regulatory mechanisms Electrolyte and acid-base imbalances Increased metabolic rate (fever. and water formed by oxidation of foods. Monitor temperature. therefore skin turgor should be assessed over the sternum or on the inner thighs. Assess or instruct patient to monitor weight daily and consistently. The skin in elderly patients loses its elasticity. Assess skin turgor and mucous membranes for signs of dehydration. Ongoing Assessment  Obtain patient history to ascertain the probable cause of the fluid disturbance. infection) Fluid shifts (edema or effusions) Expected Outcomes  Patient experiences adequate fluid volume and electrolyte balance as evidenced by urine output greater than 30 ml/hr. Most fluid enters the body through drinking.Related Factors:       Inadequate fluid intake Active fluid loss (diuresis. normotensive blood pressure (BP).        . This can help to guide interventions. This facilitates accurate measurement and follows trends. heart rate (HR) 100 beats/min. Longitudinal furrows may be noted along the tongue. Note the following orthostatic hypotension significance:  Greater than 10 mm Hg drop: circulating blood volume is decreased by 20%. Assess color and amount of urine. Monitor and document vital signs. reduced fluid intake from changes in cognition. Monitor blood pressure for orthostatic changes (from patient lying supine to high-Fowler’s). Hypotension is evident in hypovolemia. Determine if patient has been on a fluid restriction. Usually the pulse is weak. water in foods.  Greater than 20 to 30 mm Hg drop: circulating blood volume is decreased by 40%. and preferably at the same time of day. consistency of weight. large amount of drainage post-surgery. and may be irregular if electrolyte imbalance also occurs. Report urine output less than 30 ml/hr for 2 consecutive hours. Sinus tachycardia may occur with hypovolemia to maintain an effective cardiac output. and normal skin turgor. abnormal drainage or bleeding. or persistent diarrhea.

Place at bedside within easy reach. flushed skin. Elevated hemoglobin and elevated blood urea nitrogen (BUN) suggest fluid deficit. venous distention. Determine patient’s fluid preferences: type. Document baseline mental status and record during each nursing shift. This prevents complications associated with therapy. sports drink).  If oral fluids are tolerated. Plan daily activities. tachypnea. Evaluate whether patient has any related heart problem before initiating parenteral therapy. tachycardia. pulmonary artery pressure (PAP).  Monitor active fluid loss from wound drainage. Oral fluid replacement is indicated for mild fluid deficit. shortness of breath. If hospitalized. elevated central venous pressure [CVP]. temperature (hot or cold). Provide oral hygiene. bleeding. cough). This direct measurement serves as optimal guide for therapy. tubes. Parenteral fluid replacement is indicated to prevent shock.    Assist patient if unable to feed self and encourage caregiver to assist with feedings as appropriate. and pulmonary capillary wedge pressure (PCWP) if available. maintain accurate input and output. flavored gelatin. Dehydration can alter mental status. . Administer blood products as prescribed. Monitor serum electrolytes and urine osmolality and report abnormal values. This promotes interest in drinking. Urine-specific gravity is likewise increased. Administer parenteral fluids as ordered. Anticipate the need for an IV fluid challenge with immediate infusion of fluids for patients with abnormal vital signs. During treatment.      Therapeutic Interventions  Encourage patient to drink prescribed fluid amounts. frozen juice bars. diarrhea. Elderly patients have a decreased sense of thirst and may need ongoing reminders to drink. Planning prevents patient from being too tired at mealtimes.g. These may be required for active GI bleeding. provide oral fluids patient prefers. Provide fresh water and a straw. increased BP. monitor closely for signs of circulatory overload (headache. and vomiting. Be creative in selecting fluid sources (e.. monitor hemodynamic status including CVP. For more severe hypovolemia:    Obtain and maintain a large-bore intravenous (IV) catheter. Cardiac and elderly patients often have precarious fluid balances and are prone to develop pulmonary edema.

administering antipyretics as ordered). fever. Inform patient or caregiver of importance of maintaining prescribed fluid intake and special diet considerations involved. elderly caregivers may not have the cognitive ability and manual dexterity required for this therapy. Maintain IV flow rate. This allows more effective fluid administration and monitoring.  Assist the physician with insertion of a central venous line and arterial line as indicated. If patients are to receive IV fluids at home. Once ongoing fluid losses have stopped. Refer to home health nurse as appropriate.    . In addition. Explain importance of maintaining proper nutrition and hydration. and other conditions causing fluid deficits. begin to advance the diet in volume and composition.    Institute measures to control excessive electrolyte loss (e..  Should signs of fluid overload occur. These decrease venous return and optimize breathing. Allow sufficient time for return demonstration. For hypovolemia due to severe diarrhea or vomiting. Education/Continuity of Care     Describe or teach causes of fluid losses or decreased fluid intake. stop infusion and sit patient up or dangle.g. Elderly patients are especially susceptible to fluid overload. in addition to IV fluids. Patients need to understand the importance of drinking extra fluid during bouts of diarrhea. Explain or reinforce rationale and intended effect of treatment program. instruct caregiver in managing IV equipment. resting the GI tract. administer antidiarrheal or antiemetic medications as prescribed. Responsibility for maintaining venous access sites and IV supplies may be overwhelming for caregiver. Teach interventions to prevent future episodes of inadequate intake.

Fluid Overload NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels  Fluid Balance NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels   Fluid Monitoring Fluid Management NANDA Definition: Increased isotonic fluid retention Fluid volume excess. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. intravenous (IV) solutions. medications. Hypervolemia may be an acute or chronic condition managed in the hospital. orthopnea Pulmonary congestion on x-ray Abnormal breath sounds: crackles (rales) Change in respiratory pattern Third heart sound (S3) Intake greater than output Decreased hemoglobin or hematocrit Increased blood pressure Increased central venous pressure (CVP) Increased pulmonary artery pressure (PAP) Jugular vein distension Change in mental status (lethargy or confusion) Oliguria Specific gravity changes Azotemia Change in electrolytes Restlessness and anxiety . or hypervolemia. and liver failure. Defining Characteristics:                     Weight gain Edema Bounding pulses Shortness of breath.Nursing Diagnosis: Excess Fluid Volume Hypervolemia. outpatient center. Treatment consists of fluid and sodium restriction. For acute cases dialysis may be required. occurs from an increase in total body sodium content and an increase in total body water. or home setting. kidney failure. or diagnostic contrast dyes. and the use of diuretics. This fluid excess usually results from compromised regulatory mechanisms for sodium and water as seen in congestive heart failure (CHF). It may also be caused by excessive intake of sodium from foods.

These are signs of fluid overload. Poor nutrition and decreased appetite over time result in a decrease in weight. and resolution of edema. Monitor for a significant weight change (2 pounds) in 1 day. with same scale and preferably at the same time of day. Assess or instruct patient to monitor weight daily and consistently. thus their response to fluid overload may be blunted. Auscultate for a third sound. sherbet. Sinus tachycardia and increased blood pressure are seen in early stages. If patient is on fluid restriction. This can help to guide interventions. review daily log or chart for recorded intake. Monitor abdominal girth to follow any ascites accurately. Ongoing Assessment  Obtain patient history to ascertain the probable cause of the fluid disturbance. Monitor and document vital signs. and assess for bounding peripheral pulses. In some heart failure patients. Patients should be reminded to include items that are liquid at room temperature such as Jell-O. which may be accompanied by fluid retention even though the net weight remains unchanged.        . Evaluate weight in relation to nutritional status. pulmonary congestion absent on x-ray. and Popsicles. chronic or acute heart disease Head injury Liver disease Severe stress Hormonal disturbances Expected Outcomes  Patient maintains adequate fluid volume and electrolyte balance as evidenced by vital signs within normal limits. May include increased fluids or sodium intake. weight may be a poor indicator of fluid volume status. Instruction facilitates accurate measurement and helps to follow trends. clear lung sounds.Related Factors:           Excessive fluid intake Excessive sodium intake Renal insufficiency or failure Steroid therapy Low protein intake or malnutrition Decreased cardiac output. Elderly patients have reduced response to catecholamines. or compromised regulatory mechanisms. Monitor for distended neck veins and ascites. with less rise in heart rate.

Monitor chest x-ray reports. suggest that patients measure out and pour into a large pitcher the prescribed daily fluid allowance (e. urine osmolality. changes in respiratory pattern. he or she is to remove that amount from the pitcher. the x-rays show cloudy white lung fields. Restrict sodium intake as prescribed. The risk of this occurring increases when diuretics are given. ankles. feet.. it is unrealistic to expect patients to measure each void. Monitor input and output closely. rather than the actual amount voided. and PCWP. During therapy. For example.g.   . Pitting edema is manifested by a depression that remains after one’s finger is pressed over an edematous area and then removed. shortness of breath.         Therapeutic Interventions  Institute/instruct patient regarding fluid restrictions as appropriate. Grade edema from trace (indicating barely perceptible) to 4 (severe edema). This direct measurement serves as optimal guide for therapy. weakness. 1000 ml). Provide innovative techniques for monitoring fluid allotment at home. hypotension.  Assess for crackles in lungs. If hospitalized. fluids may need to be restricted to 1000 ml/day. Monitor serum electrolytes. For some patients. Monitor for excessive response to diuretics: 2-pound loss in 1 day. Patients may use diaries for home assessment. blood urea nitrogen (BUN) elevated out of proportion to serum creatinine level. Focus is on monitoring the response to the diuretics. This helps reduce extracellular volume. and orthopnea. monitor for signs of hypovolemia. and sacrum. Although overall fluid intake may be adequate. Measurement of an extremity with a measuring tape is another method of following edema. At home. These are early signs of pulmonary congestion. monitor hemodynamic status including CVP. NOTE: Fluid volume excess in the abdomen may interfere with absorption of oral diuretic medications. As interstitial edema accumulates. Monitoring prevents complications associated with therapy. shifting of fluid out of the intravascular to the extravascular spaces may result in dehydration. Assess for presence of edema by palpating over tibia. if available. and urine-specific gravity. Treatment focuses on diuresis of excess fluid. then every time patient drinks some fluid. This provides a visual guide for how much fluid is still allowed throughout the day. Medications may need to be given intravenously by a nurse in the home or outpatient setting. Sodium diets of 2 to 3 g are usually prescribed. Therefore recording two voids versus six voids after a diuretic medication may provide more useful information. Assess the need for an indwelling urinary catheter. PAP. Evaluate urine output in response to diuretic therapy.

Provide interventions related to specific etiological factors (e. Identify signs and symptoms of fluid volume excess. inotropic medications for heart failure. certain vasodilators. Reduce constriction of vessels (e. Elevate edematous extremities. paracentesis for liver disease). avoid crossing of legs or ankles). Instruct in need for antiembolic stockings or bandages as ordered. use appropriate garments. Explain or reinforce rationale and intended effect of treatment program. This is a very effective method to draw off excess fluid. Apply saline lock on IV line. congestive heart failure [CHF]. This increases venous return and. Instruct patient to avoid medications that may cause fluid retention. This prevents venous pooling. .g. This prevents fluid accumulation in dependent areas. Provide information as needed regarding the individual’s medical diagnosis (e. Education/Continuity of Care       Teach causes of fluid volume excess and/or excess intake to patient or caregiver. Collaborate with the pharmacist to maximally concentrate IVs and medications. This ensures accurate delivery of IV fluids.g. This maintains patency but decreases fluid delivered to patient in a 24-hour period. if possible. Assist with repositioning every 2 hours if patient is not mobile.g. and diet modifications. renal failure). depending on the acuteness or chronicity of the problem. and steroids. Diuretic therapy may include several different types of agents for optimal therapy. in turn. These help promote venous return and minimize fluid accumulation in the extremities. Administer IV fluids through infusion pump. Explain importance of maintaining proper nutrition and hydration. For chronic patients. Identify symptoms to be reported. compliance is often difficult for patients trying to maintain a normal lifestyle.. Administer or instruct patient to take diuretics as prescribed.. For acute patients:           Consider admission to acute care setting for hemofiltration or ultrafiltration. decreases edema. such as over-the-counter nonsteroidal antiinflammatory agents.. This decreases unnecessary fluids.

. Think "cardiac" with both. and coma Both HYPO and HYPER kalemia can cause cardiac dysrhythmias progressing to ventricular fibrillation and asystole. and seizures: Hypocalcemia Hypomagnesemia Hyperphosphatemia Electrolyte imbalances which can potentiate dig toxicity: Hypokalemia Hypomagnesemia Hypercalcemia Electrolyte imbalances which can cause dysrhythmias: Hypo/ hypokalemia Hypomagnesemia Hypocalcemia Both HYPO and HYPER natremia can cause mental confusion.MNEMONIC Hypernatremia: Think of “SALT” -Skin flushed -Agitation -Low-grade fever -Thirst Reciprocal relationship between calcium and phosphorus: INCREASED Ca2+ = DECREASED PO43-Increasing serum calcium levels decreases phosphate levels -Decreasing serum calcium increases phosphate Chvostek’s and Trousseau’s signs. irritability. seizures. Tetany. Hyperkalemia is the most deadly of all electrolyte imbalances.