Deficient Fluid Volume – Nursing Diagnosis & Care Plan

0
109

Deficient Fluid Volume

The body is in need of nutrients for a constant functioning o the different body systems. These act as fuels which will feed the body in order to do its functions normally. There are a lot of foods which are good sources of all the nutrients needed by the body. In addition to, the body needs also water or fluids which play a vital role. It maintains the body’s homeostasis through the presence of fluid and electrolyte balance.

Fluid and electrolytes need to be in normal amounts in the body. This is very important to maintain and let it in balance always. Any fluids or electrolytes below or above the normal range yields to unexpected disorders or imbalances. This may lead to occurrence of such illness or disorders.

Read also : Example of a Nursing Care plan for deficient fluid volume.
Read also : Excess fluid volume Nursing Diagnosis & Nursing Care plan.

One of the problems in the fluid and electrolyte balance is the presence of a deficient fluid volume. Deficient fluid volume is the state of the body wherein it does not meet the minimum normal level of fluids needed. The fluids are below the normal range which can have negative or bad effects to the body if left untreated. There is decreased fluids either in the intravascular, interstitial or extracellular areas. Any decrease in the fluids can cause a deficient fluid volume.

There are a lot of causes that may yield to a deficient fluid volume. These are excessive vomiting, diarrhea, persistent and excessive sweating, frequent urination, excessive blood losses, burns, edema, and decreased fluid intake.

NANDA-I Definition for Deficient Fluid Volume

Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.

Related Factors (Deficient Fluid Volume related to…)

  • Diarrhea
  • frequent urination
  • excessive bleeding
  • burns
  • diaphoresis
  • edema (fluid shifting)
  • decreased fluid intake
  • presence of underlying infection
  • fever
  • vomiting

Defining Characteristics

  • poor skin turgor
  • concentrated and decreased urine output
  • dry mucous membrane
  • hypotension
  • weight loss
  • increased heart rate
  • excessive thirst
  • weakness

Desired Outcomes

  • patient maintains the normal fluid and electrolyte balance
  • no signs and symptoms reported such as excessive thirst, low blood pressure, weakness, weight loss, poor skin turgor, dehydration and hypovolemic shock
  • increase knowledge on the measures to treat and prevent the occurrence of fluid volume loss.

Nursing Assessment

Assessment Rationale
1. Assess and check the vital signs of the patient (BP, HR, RR, Temperature) ·       it will let the nurse determine for any signs of hypovolemia or decrease blood volume which may indicate excessive fluid losses.
2. Assess and check for signs of dehydration (poor skin turgor, dry mucus membrane, and reported excessive thirst). ·       Dehydration is a proof that the patient has fluid volume losses. It is a state wherein the patient needs to be treated to prevent worsening of the health condition.
3. Assess any signs of changes or alteration in level of thinking and consciousness ·       Any disturbance or alteration in the mentation of the patient can indicate excessive fluid and losses which affects the normal blood circulation going to the brain.
4. Assess the patient’s  color and amount of urine. ·       Decrease in the urine output for several hours can indicate excessive fluid losses and may lead to dehydration.
5. check presence of elevated temperature ·       Fever can diminished the fluid volume of the body
6. ask the patient’s oral fluid intake. ·       Decrease oral fluid intake can be an indicator of dehydration
7. Check and monitor serum electrolytes  report abnormal values. ·       Any abnormalities in the electrolyte levels can lead or indicate presence of dehydration. It needs immediate treatment to prevent worsening of the case.
8. assess possible causes of fluid imbalances ·       It provides an appropriate nursing intervention and treatment

Nursing Interventions/Rationale

Nursing Interventions Rationales
1. Educate the patient on the importance of maintaining fluid and electrolyte balance and the prevention of such imbalances ·       It will let the patient know the importance of maintain fluids always in normal range and to avoid recurrence of such imbalance
2. Rehydrate the patient by offering him or her the prescribed fluids. ·       Immediate rehydration for the patient suspected of dehydration is the first thing to do in order to manage the mild fluid losses.
3. Provide and maintain patient’s oral hygiene. ·       It will freshen up the patient and  promotes rehydration on the oral area.
4. Let the patient make his/her plan of daily activities. ·       It will let the nurse do only what is planned in order not to consume extra energy for unnecessary movements or activities
Collaborative
1. Monitor patient for signs of hypovolemia (hypotension, tachycardia, tachypnea), and refer to attending physician as needed ·       Hypovolemia needs an immediate nursing interventions because it indicates severe fluid losses which can be life-threatening
2. Insert an intravenous access in order to have site of emergency drug administration as prescribed ·       IV medications are the fastest to be absorbed in the body for immediate drug action.
3. Administer the prescribed IV fluids to the patient ·       IV fluids will replace the fluid losses
4. Administer blood products as prescribed if there is excessive bleeding or blood losses. ·       It is necessary to replace the blood losses if there is severe bleeding experienced by the patient.
5. Maintain IV flow rate and regulate as prescribed. ·       This is needed in order to prevent too much fluid that is given to the patient and to monitor closely for any signs of complications.
6. Refer patient to the attending physician if there is worsening of the fluid losses ·       To administer immediate nursing action and treatment

Leave a Reply