Monday, November 7, 2011

Deficient Fluid Volume Nanda Nursing Diagnosis and Interventions

Nursing Diagnosis for Deficient Fluid Volume

Hypovolemia; Dehydration

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.

Deficient Fluid Volume related to
  • Loss of active fluid volume
  • Failure of regulatory mechanisms
Data:
  • Decrease in mental status
  • Decrease in vital signs
  • Decrease in skin turgor
  • Decrease in urine output
  • Dry mucous membranes
  • Ht increased
  • Increased concentration of urine
  • Thirst
  • Weight loss suddenly
Nursing Interventions for Deficient Fluid Volume

a. monitoring of fluid
  • Assess the history of the number and type of fluid intake and elimination patterns
  • Assess the cause of lack of fluid volume: vomiting, diarrhea, hyperthermia, diaphoresis.
  • Monitor weight, intake and output
  • Monitor vital signs
  • Monitor the mucous membrane, turgor, and thirst
  • Monitor urine color and quality
  • Monitor JVP, peripheral edema, ascites and weight gain

b. Management of fluid
  • Monitor weight
  • Maintain adequate intake
  • Install catheter
  • Monitor hydration status and hemodynamic
  • Monitor laboratory results related to fluid retention: Increased BUN, Ht decrease
  • Monitor the nutritional status
  • Encourage clients oral intake
  • Provision of IV therapy and NGT
  • Collaboration transfusion

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