Nursing Diagnosis: Deficient Fluid volume Application of NANDA, NOC, NIC

Nursing Diagnosis: Deficient Fluid volume
Betty J. Ackley

NANDA Definition: Decreased intravascular, interstitial, and/or intracellular fluid (refers to dehydration, water loss alone without change in sodium level)

Defining Characteristics: Decreased urine output; increased urine concentration; weakness; sudden weight loss (except in third-spacing); decreased venous filling; increased body temperature; decreased pulse volume/pressure; change in mental state; elevated hematocrit; decreased skin/tongue turgor; dry skin/mucous membranes; thirst; increased pulse rate; decreased blood pressure

Related Factors: Active fluid volume loss; failure of regulatory mechanisms

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Fluid Balance

·         Hydration

·         Nutritional Status: Food and Fluid Intake

Client Outcomes

·         Maintains urine output >1300 ml/day (or at least 30 ml/hr)

·         Maintains normal blood pressure, pulse, and body temperature

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

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

·         Describes symptoms that indicate the need to consult with health care provider

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Fluid Management

·         Hypovolemia Management

·         Shock Management: Volume

Nursing Interventions and Rationales

·         Monitor for the existence of factors causing deficient fluid volume (e.g., gastrointestinal losses, difficulty maintaining oral intake, fever, uncontrolled type II diabetes, diuretic therapy). Early identification of risk factors and early intervention can decrease the occurrence and severity of complications from deficient fluid volume. The gastrointestinal system is a common site of abnormal fluid loss (Metheny, 2000).

·         Watch for early signs of hypovolemia, including weakness, muscle cramps, and postural hypotension. Late signs include oliguria; abdominal or chest pain; cyanosis; cold, clammy skin; and confusion (Fauci et al, 1998).

·         Monitor total fluid intake and output every 8 hours (or every hour for the unstable client). A urine output of <30 ml/hr is insufficient for normal renal function and indicates hypovolemia or onset of renal damage (Metheny, 2000).

·         Watch trends in output for 3 days; include all routes of intake and output and note color and specific gravity of urine. Monitoring for trends for 2 to 3 days gives a more valid picture of the client's hydration status than monitoring for a shorter period (Metheny, 2000). Dark-colored urine with increasing specific gravity reflects increased urine concentration.

·         Monitor daily weight for sudden decreases, especially in the presence of decreasing urine output or active fluid loss. Weigh client on same scale with same type of clothing at same time of day, preferably before breakfast. Body weight changes reflect changes in body fluid volume. A 1-pound weight loss reflects a fluid loss of about 500 cc (Metheny, 2000).

·         Monitor vital signs of clients with deficient fluid volume every 15 minutes to 1 hour for the unstable client (every 4 hours for the stable client). Observe for decreased pulse pressure first, then hypotension, tachycardia, decreased pulse volume, and increased or decreased body temperature. A decreasd pulse pressure is an earlier indicator of shock than is the systolic blood pressure (Mikhail, 1999). Decreased intravascular volume results in hypotension and decreased tissue oxygenation. The temperature will be decreased as a result of decreased metabolism, or it may be increased if there is infection or hypernatremia present (Metheny, 2000).

·         Check orthostatic blood pressures with client lying, sitting, and standing. A 15 mm Hg drop when upright or an increase of 15 beats/minute in the pulse rate are seen with deficient fluid volume (Metheny, 2000).

·         Monitor for inelastic skin turgor, thirst, dry tongue and mucous membranes, longitudinal tongue furrows, speech difficulty, dry skin, sunken eyeballs, weakness (especially of upper body), and confusion. Tongue dryness, longitudinal tongue furrows, dryness of the mucous membranes of the mouth, upper body muscle weakness, thirst, confusion, speech difficulty, and sunkenness of eyes are symptoms of deficient fluid volume (Metheny 2000).

·         Provide frequent oral hygiene, at least twice a day (if mouth is dry and painful, provide hourly while awake). Oral hygiene decreases unpleasant tastes in the mouth and allows the client to respond to the sensation of thirst.

·         Provide fresh water and oral fluids preferred by client (distribute over 24 hours [e.g., 1200ml on days, 800ml on evenings, and 200ml on nights]); provide prescribed diet; offer snacks (e.g., frequent drinks, fresh fruits, fruit juice); instruct significant other to assist client with feedings as appropriate. The oral route is preferred for maintaining fluid balance (Metheny, 2000). Distributing the intake over the entire 24 hour period and providing snacks and preferred beverages increases the likelihood that the client will maintain the prescribed oral intake.

·         Provide free water with tube feedings as appropriate (50 to 100 ml every 4 hours). This provides water for replacement of intravascular or intracellular volume as necessary. Tube feeding has been found to increase the risk for dehydration (Lavizzo-Mourey, Johnson, Stolley, 1988; Sheehy, Perry, Cromwell, 2000).

·         Institute measures to rest the bowel when client is vomiting or has diarrhea (e.g., restrict food or fluid intake when appropriate, decrease intake of milk products). Hydrate client with ordered IV solutions if prescribed. The most common cause of deficient fluid volume is gastrointestinal loss of fluid. At times it is preferable to allow the gastrointestinal system to rest before resuming oral intake. Hydration should be maintained. (See care plan for Diarrhea or Nausea.)

·         Provide oral replacement therapy as ordered with a glucose-electrolyte solution when client has acute diarrhea or nausea/vomiting. Provide small, frequent quantities 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 (Cohen et al, 1995).

·         Administer antidiarrheals and antiemetics as appropriate. The gastrointestinal tract is a common site for fluid loss. The goal is to stop the loss that results from vomiting or diarrhea.

·         If client requires IV fluid replacement, maintain patent IV access, set an appropriate IV infusion flow rate, and administer at a constant flow rate as ordered. Isotonic IV fluids such as 0.9% N/S or lactated ringers allow replacement of intravascular volume (Metheny, 2000).

·         Assist with ambulation if client has postural hypotension. Postural hypotension can cause dizziness, which places the client at higher risk for injury.

·         Promote skin integrity (e.g., monitor areas for breakdown, ensure frequent weight shifts, prevent shearing, promote adequate nutrition). Deficient fluid volume decreases tissue oxygenation, which makes the skin more vulnerable to breakdown.

Critically ill

·         Monitor central venous pressure, right atrial pressure, and pulmonary wedge pressure for decreases. Hemodynamic parameters are sensitive indicators of intravascular fluid volume, and hemodynamic measurements are especially needed in the client with cardiac or renal problems (Metheny, 2000).

·         Monitor serum and urine osmolality, serum sodium, blood urea nitrogen (BUN)/creatinine ratio, and hematocrit for elevations. These are all measures of concentration and will be elevated with decreased intravascular volume (Fauci et al, 1998).

·         When ordered, initiate a fluid challenge of crystalloids for replacement of intravascular volume; monitor client's response to prescribed fluid therapy and fluid challenge, especially noting vital signs, urine output, and lung sounds. A fluid challenge can help the client with deficient fluid volume regain intravascular volume quickly, but the client must be carefully observed to ensure that he or she does not go into fluid volume overload. In trauma clients, if there is no clinical improvement after 2 L of crystalloids, then generally a blood transfusion should be iniated (Jordan, 2000).

·         Position client flat with legs elevated when hypotensive, if not contraindicated. This position enhances venous return, thus contributing to the maintenance of cardiac output.

·         If trauma client, monitor lactic acid levels as ordered, along with watching for signs of fluid deficit and shock. Increased lactic acid levels can help identify occult hypoperfusion, which results in decreased survival and increased incidence of respiratory complications and multiple organ failure in trauma clients (Blouchard, 1999; Mikhail, 1999; Blow et al, 1999.).

·         Consult physician if signs and symptoms of deficient fluid volume persist or worsen. Prolonged deficient fluid volume increases the risk for development of complications, including shock, multiple organ failure, and death.

Geriatric

·         Monitor elderly clients for deficient fluid volume carefully, noting new onset of weakness, dizziness, or dry mouth with longitudinal furrows. The elderly are predisposed to deficient fluid volume because of decreased fluid in body, decreased thirst sensation, and decreased ability to concentrate urine (Bennett, 2000; Sheehy, Perry, Cromwell, 2000).

·         Check skin turgor of elderly client on the forehead or sternum; also look for the presence of longitudinal furrows on the tongue and dry mucous membranes. Elderly people commonly have decreased skin turgor from normal age-related loss of elasticity; therefore checking skin turgor on the arm is not reflective of fluid volume (Bennett, 2000). The presence of longitudinal furrows or dry mucous membranes is a good indication of dehydration in the elderly (Bennett, 2000; Sheehy, Perry, Cromwell, 2000).

·         Encourage fluid intake by offering fluids regularly to cognitively impaired clients. The elderly have a decreased thirst sensation (Metheny, 2000), and short-term memory loss may impede the client's memory of fluid intake.

·         Incorporate regular hydration into daily routines (e.g., extra glass of fluid with medication or social activities). Integration of hydration into regular routines increases the chance that the client will meet the daily fluid requirements.

·         Monitor elderly clients for excess fluid volume during the treatment of deficient fluid volume: listen to lung sounds, watch for edema, and note vital signs. The elderly client has a decreased ability to adapt to rapid increases in intravascular volume and can quickly develop heart failure.

Home Care Interventions

·         Determine if it is appropriate to intervene for defecient fluid volume or allow the client to die comfortably without fluids as desired. Deficient fluid volume may be a symptom of impending death in terminally ill clients. The deficit may result in a mild euphoria, and a more comfortable death (Bennett, 2000).

·         Teach family members how to monitor output in the home (e.g., use of commode "hat" in the toilet, urinal, or bedpan, or use of catheter and closed drainage). Instruct them to monitor both intake and output. An accurate measure of fluid intake and output is an important indicator of client fluid status (Metheny, 2000).

·         When weighing client, use same scale each day. Be sure scale is on a flat (not cushioned) surface. Do not weigh client with scale placed on any kind of rug. Use bed or chair scales for clients who are unable to stand. An accurate daily weight is an excellent reflection of fluid balance (Metheny, 2000).

·         Teach family about complications of deficient fluid volume and when to call physician.

·         If the client is receiving IV fluids, there must be a responsible caregiver in the home. Teach caregiver about administration of fluids, complications of IV administration (e.g., fluid volume overload, speed of medication reactions), and when to call for assistance. Assist caregiver with administration for as long as necessary to maintain client safety. Administration of IV fluids in the home is a high-technology procedure and requires sufficient professional support to ensure safety of the client.

·         Identify an emergency plan, including when to call 911. Some complications of deficient fluid volume cannot be reversed in the home and are life-threatening. Clients progressing toward hypovolemic shock will need emergency care.

Client/Family Teaching

·         Instruct client to avoid rapid position changes, especially from supine to sitting or standing.

·         Teach client and family about appropriate diet and fluid intake.

·         Teach client and family how to measure and record intake and output accurately.

·         Teach client and family about measures instituted to treat hypovolemia and to prevent or treat fluid volume loss.

·         Instruct client and family about signs of deficient fluid volume that indicate they should contact health care provider.