00027 Deficient fluid volume

Domain 2: nutrition
Class 5: Hydration
Diagnostic Code: <00027
Nanda label: liquid volume deficit
Diagnostic focus: liquid volume
Approved 1978 • Revised 1996, 2017, 2020 • Level of evidence 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « liquid volume deficit »  is defined as: decrease in intravascular, interstitial and/or intracellular fluid. It refers to dehydration, loss only of water, without changes in sodium.

Definite characteristics

  • Alteration of mental state
  • Alteration of skin turgidity
  • Decrease in blood pressure
  • Decrease in pulse pressure
  • Pulse volume decrease
  • Decreased turtle of the language
  • Decrease in diuresis
  • Decrease in venous filling
  • Dry mucous membranes
  • Dry skin
  • Increase in body temperature
  • Increase in heart rate
  • Increase in serum hematocrit levels
  • Increased urine concentration
  • Sudden weight loss
  • Sunk eyes
  • thirst
  • Weakness

Related factors

  • Difficulty to satisfy an increase in the liquid requirement
  • Inappropriate access to liquids
  • Inappropriate knowledge about liquid needs
  • INEFICA MANAGEMENT OF MEDICATION
  • Insufficient fluid intake
  • Insufficient muscle mass
  • Malnutrition

Risk population

  • People in weight
  • People with external conditions that affect the needs of liquids
  • People with internal conditions that affect liquid needs
  • Women

Associated problems

  • Active loss of liquid volume
  • Deviations that affect the absorption of liquids
  • Deviations that affect the elimination of liquids
  • Deviations that affect liquid intake
  • Excessive loss of liquids through normal pathways
  • Excessive loss of liquids through unusual pathways
  • Pharmacological preparations
  • Therapeutic regime

Suggestions of use

  • This label is used for patients suffering from vascular, cellular or intracellular dehydration. It should be used with caution, because many of the liquid balance problems require the collaboration of the nursing professional and the doctor. This diagnosis should not be used by routine, or in the face of a potential problem, in patients who have a medical order of strict diet. Independent nursing treatments for liquid volume deficit are used to prevent fluid loss (for example, diaphoresis) and encourage oral fluid intake. For a diagnosis such as the risk of liquid volume related to an absolute diet order, there is no independent nursing action to prevent or treat
  • Some aspect of the diagnostic declaration. The treatment of the volume of liquids related to the strict diet state requires, for example, a medical order for intravenous treatment.
  • There should be no deficit of the volume of liquids to describe patients at risk of bleeding, who have bleeding or who are in hypovolemic shock, since these situations usually represent collaboration problems.
  • Incorrect: Risk of deficit of the volume of liquids related to postpartum bleeding
  • Correct: possible complication of childbirth: postpartum bleeding
  • Correct: Postpartum bleeding risk related to uterine atony
  • The most appropriate is to use the tag deficit of liquid volume such as diagnosis (real or potential) for patients who do not drink enough oral fluids, especially in an increase in fluid loss (for example, diarrhea, vomiting or vomiting or burns).
  • The real liquid volume deficit could also be the etiology of other nursing diagnoses, such as deterioration of the oral mucosa.

Suggested alternative diagnostics

  • Oral mucosa, deterioration of the
  • ineffective renal perfusion, risk of
  • Volume of liquids, risk of deficit of
  • Volume of liquids, risk of imbalance of

NOC Results

  • Liquid balance: liquid balance in intracellular and extracellular spaces of the body
  • Nutritional status: food and liquid intake: amount of food and liquids ingested for a period of 24 hours
  • Hydration: adequate water in the intracellular and extracellular spaces of the body

Evaluation objectives and criteria

  • • The deficit of the volume of liquids is eliminated, as evidenced by the balance of liquids, the appropriate hydration and the adequate nutritional status: food and liquid intake
  • • A liquid balance is achieved, as evidenced by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or not compromised):
    • serum electrolytes
    • Radial pulse frequency
    • Stable body weight
    • Peripheral pulses
    • blood pressure

Other examples

The patient will be able to:

  • • Have a normal urine concentration. Specify the specific gravity with reference figures
  • • Have hemoglobin and hematocrit levels in the normal range
  • • Have the central venous pressure and pulmonary trunk pressure in the expected range
  • • Do not experience abnormal thirst
  • • Have a balanced intake and expense for 24 hours
  • • Show good hydration (wet mucous membranes, ability to sweat)
  • • Have an adequate oral or intravenous fluid intake

NIC Interventions

  • Hypolemia management: expansion of the volume of intravascular fluids in a patient with poor volume
  • Liquid management: Promotion of liquid balance and prevention of complications resulting from an anomalous or unwanted amount of liquids
  • Shock prevention: detection and treatment of a patient at risk of imminent shock
  • Intravenous therapy (IV): Administration and control of liquids and medications via IV
  • Liquid surveillance: Patient data collection and analysis to regulate liquid balance

Nursing Activities

Notes : (a) Some of these activities are specific for patients with bleeding. Before including these activities in the care plan, consult the previous use suggestions, (b) the central objective of the activities for this nursing diagnosis is the restoration of the volume of liquids.

Valuations

  • • Monitor color, quantity and frequency of fluid loss
  • • Especially monitor the loss of fluids with high electrolytes (for example, diarrhea, wound drainage, nasogastric suction, diaphoresis, ileostomy drainage)
  • • Monitor bleeding (for example, check all patent or hidden blood secretions)
  • • Identify the contributing factors that could aggravate dehydration (for example, medications, fever, stress, medical orders)
  • • Monitor the relevant results for the balance of liquids (for example, hematocrit, ureic nitrogen in blood or bun)
  • • Evaluate the presence of vertigo or postural hypotension
  • • Evaluate the orientation to person, time and place
  • • Consult the patient’s previous instructions to determine whether it is appropriate to replace liquids for a patient suffering from a terminal disease
  • • (NIC) Liquid management:
    • Monitor the state of hydration (for example, moisture of mucous membranes, adaptation of pulses and orthostatic blood pressure, as necessary)
    • Weigh the patient daily and control the evolution
    • Maintain a precise record of intake and spending

Patient and family education

  • • Indicate the patient to inform the nursing staff if they are thirst

Collaboration activities

  • • Inform and record a production of less than _______ mi.
  • • Inform and record a production greater than ______ mi.
  • • Record electrolyte anomalies
  • • (NIC) Liquid management:
    • Organize the availability of blood products for a transfusion, if necessary
    • Administer to prescribed nasogastric restitution based on expenses, as appropriate
    • Administer IV treatment, according to prescription

Others

  • • Perform frequent oral hygiene
  • • Specify the amount of liquids to be ingested in 24 hours, quantifying the desired intake during day, afternoon and night shifts
  • • Ensure that the patient is well hydrated before surgery
  • • Place the patient in the trendelenburg position or raise their legs if it is mortgage, unless it is contraindicated
  • • (NIC) Liquid management:
    • Promote oral intake (for example, provide a straw to drink, offer fluids between meals, change cold water regularly, make frozen palettes with the child’s favorite juice, cut the jelly into funny cubes, wear small vessels of medications), according to proceed
    • Insert urinary catheter, if necessary
    • Give liquids, if adequate

At home

  • • Teach family caregivers how to monitor intake and elimination (for example, in comfortable or urinal)
  • • Teach caregivers the signs of the complications of the deficit of the volume of liquids and when to call the doctor or the emergency service
  • • Teach family caregivers to handle intravenous treatment; Evaluate the caregiver’s ability to manage liquids

Babies and Children

  • • Calculate the daily needs for the maintenance of child’s fluids based on weight. The same amount of lost liquids or a higher amount must be replaced.
  • • Carefully monitor hydration; Babies are vulnerable to fluid loss.
  • • To measure liquid expenditures in babies, diapers should be counted or weighed. A gram of wet diaper equals 1 mi of urine.
  • • Offer liquids to the child’s taste (for example, milk, gelatin, icy juices, snow cones)
  • • Turn the drink into a game (for example, play a tea meeting)
  • • Prepare a table and give the child a picture when the fluid intake is adequate
  • • To motivate children to drink liquids, provide a straw to drink, make juice palettes, cut colored jelly in different shapes

Older people

  • • Make sure the patient drinks a specific amount of water regularly, even if it is not thirst
  • • Use the checklists of the units, if necessary, to ensure that patients drink adequate amounts of water
  • • Older people have a risk of liquid loss and dehydration; Carefully monitor intake and expenses