NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
* Fluid Balance
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
* Increased serum sodium
* Increased pulse rate
* Decreased skin turgor
* Dry mucous membranes
* Possible weight gain
* Changes in mental status
* Related Factors: Inadequate fluid intake
* Active fluid loss (diuresis, abnormal drainage or bleeding, diarrhea)
* Failure of regulatory mechanisms
* Electrolyte and acid-base imbalances
* Increased metabolic rate (fever, 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, normotensive blood pressure (BP), heart rate (HR) 100 beats/min, consistency of weight, and normal skin turgor.
* Obtain patient history to ascertain the probable cause of the fluid disturbance. This can help to guide interventions. Causes may include acute trauma and bleeding, reduced fluid intake from changes in cognition, large amount of drainage post-surgery, or persistent diarrhea.
* Assess or instruct patient to monitor weight daily and consistently, with same scale, and preferably at the same time of day. This facilitates accurate measurement and follows trends.
* Evaluate fluid status in relation to dietary intake. Determine if patient has been on a fluid restriction. Most fluid enters the body through drinking, water in foods, and water formed by oxidation of foods.
* Monitor and document vital signs. Sinus tachycardia may occur with hypovolemia to maintain an effective cardiac output. Usually the pulse is weak, and may be irregular if electrolyte imbalance also occurs. Hypotension is evident in hypovolemia.
* Monitor blood pressure for orthostatic changes (from patient lying supine to high-Fowler’s). Note the following orthostatic hypotension significance:
o Greater than 10 mm Hg drop: circulating blood volume is decreased by 20%.
o Greater than 20 to 30 mm Hg drop: circulating blood volume is decreased by 40%.
* Assess skin turgor and mucous membranes for signs of dehydration. The skin in elderly patients loses its elasticity; therefore skin turgor should be assessed over the sternum or on the inner thighs. Longitudinal furrows may be noted along the tongue.
* Assess color and amount of urine. Report urine output less than 30 ml/hr for 2 consecutive hours. Concentrated urine denotes fluid deficit.
* Monitor temperature. Febrile states decrease body fluids through perspiration and increased respiration.
* Monitor active fluid loss from wound drainage, tubes, diarrhea, bleeding, and vomiting; maintain accurate input and output.
* Monitor serum electrolytes and urine osmolality and report abnormal values. Elevated hemoglobin and elevated blood urea nitrogen (BUN) suggest fluid deficit. Urine-specific gravity is likewise increased.
* Document baseline mental status and record during each nursing shift. Dehydration can alter mental status.
* Evaluate whether patient has any related heart problem before initiating parenteral therapy. Cardiac and elderly patients often have precarious fluid balances and are prone to develop pulmonary edema.
* Determine patient’s fluid preferences: type, temperature (hot or cold).
* During treatment, monitor closely for signs of circulatory overload (headache, flushed skin, tachycardia, venous distention, elevated central venous pressure [CVP], shortness of breath, increased BP, tachypnea, cough). This prevents complications associated with therapy.
* If hospitalized, monitor hemodynamic status including CVP, pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP) if available. This direct measurement serves as optimal guide for therapy.
* Encourage patient to drink prescribed fluid amounts.
o If oral fluids are tolerated, provide oral fluids patient prefers. Place at bedside within easy reach. Provide fresh water and a straw. Be creative in selecting fluid sources (e.g., flavored gelatin, frozen juice bars, sports drink).
Oral fluid replacement is indicated for mild fluid deficit. Elderly patients have a decreased sense of thirst and may need ongoing reminders to drink.
* Assist patient if unable to feed self and encourage caregiver to assist with feedings as appropriate.
* Plan daily activities. Planning prevents patient from being too tired at mealtimes.
* Provide oral hygiene. This promotes interest in drinking.
* For more severe hypovolemia: Obtain and maintain a large-bore intravenous (IV) catheter. Parenteral fluid replacement is indicated to prevent shock.
* Administer parenteral fluids as ordered. Anticipate the need for an IV fluid challenge with immediate infusion of fluids for patients with abnormal vital signs.
* Administer blood products as prescribed. These may be required for active GI bleeding.
* Assist the physician with insertion of a central venous line and arterial line as indicated. This allows more effective fluid administration and monitoring.
* Maintain IV flow rate.
o Should signs of fluid overload occur, stop infusion and sit patient up or dangle. These decrease venous return and optimize breathing.
Elderly patients are especially susceptible to fluid overload.
* Institute measures to control excessive electrolyte loss (e.g., resting the GI tract, administering antipyretics as ordered).
* Once ongoing fluid losses have stopped, begin to advance the diet in volume and composition.
* For hypovolemia due to severe diarrhea or vomiting, administer antidiarrheal or antiemetic medications as prescribed, in addition to IV fluids.
Education/Continuity of Care
* Describe or teach causes of fluid losses or decreased fluid intake.
* Explain or reinforce rationale and intended effect of treatment program.
* Explain importance of maintaining proper nutrition and hydration.
* Teach interventions to prevent future episodes of inadequate intake. Patients need to understand the importance of drinking extra fluid during bouts of diarrhea, fever, and other conditions causing fluid deficits.
* Inform patient or caregiver of importance of maintaining prescribed fluid intake and special diet considerations involved.
* If patients are to receive IV fluids at home, instruct caregiver in managing IV equipment. Allow sufficient time for return demonstration. Responsibility for maintaining venous access sites and IV supplies may be overwhelming for caregiver. In addition, elderly caregivers may not have the cognitive ability and manual dexterity required for this therapy.
* Refer to home health nurse as appropriate.