NURSING DIAGNOSIS: Fluid Volume deficit
May be related to
Active fluid loss, e.g., hemorrhage, vomiting/gastric intubation, diarrhea, burns, wounds, fistulas
Regulatory failure, e.g., adrenal disease, recovery phase of ARF; diabetic ketoacidosis (DKA), HHNC; diabetes insipidus, systemic infections
Possibly evidenced by
Signs/symptoms noted in patient database
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Fluid Balance (NOC)
Maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor, and prompt capillary refill.
Knowledge: Treatment Regimen (NOC)
Verbalize understanding of causative factors and purpose of therapeutic interventions.
Demonstrate behaviors to monitor and correct deficit as appropriate.
Hypovolemia Management (NIC)
1. Monitor vital signs and CVP. Note presence/degree of postural BP changes. Observe for temperature elevations/fever
Tachycardia is present along with a varying degree of hypotension, depending on degree of fluid deficit. CVP measurements are useful in determining degree of fluid deficit and response to replacement therapy. Fever increases metabolism and exacerbates fluid loss.
2. Palpate peripheral pulses; note capillary refill, skin color/temperature. Assess mentation.
Conditions that contribute to extracellular fluid deficit can result in inadequate organ perfusion to all areas and may cause circulatory collapse/shock.
3. Monitor urinary output. Measure/estimate fluid losses from all sources, e.g., gastric losses, wound drainage, diaphoresis.
Fluid replacement needs are based on correction of current deficits and ongoing losses. Note: A diaphoretic episode requiring a full linen change may represent a fluid loss of as much as 1 L. A decreased urinary output may indicate insufficient renal perfusion/hypovolemia, or polyuria can be present, requiring more aggressive fluid replacement.
4. Weigh daily and compare with 24-hr fluid balance. Mark/measure edematous areas, e.g., abdomen, limbs.
Although weight gain and fluid intake greater than output may not accurately reflect intravascular volume, e.g., third-space fluid accumulation cannot be used by the body for tissue perfusion, these measurements provide useful data for comparison.
5. Monitor laboratory studies as indicated, e.g., electrolytes, glucose, pH/Pco2, coagulation studies.
Depending on the avenue of fluid loss, differing electrolyte/metabolic imbalances may be present/
require correction; e.g., use of glucose solutions in patients with underlying glucose intolerance may result in serum glucose elevation and increased urinary water losses.
6. Administer IV solutions as indicated:
Isotonic solutions, e.g., 0.9% NaCl (normal saline), 5% dextrose/water;
Crystalloids provide prompt circulatory improvement, although the benefit may be transient (increased renal clearance).