Domain 2: nutrition
Class 5: hydration
Diagnostic Code: 00028
Nanda label: Risk of liquid volume deficit
Diagnostic focus: liquid volume
Approved 1978 • Revised 2010, 2013, 2017, 2020 • Evidence level 2.1
NANDA Nursing Diagnosis Definition
NANDA Nursing Diagnosis « Risk of liquid volume deficit » is the possibility of suffering from vascular, cellular or intracellular dehydration. Susceptible to experiencing decreased intravascular, interstitial, and/or intracellular fluid volumes, which may compromise health. The risk factors, NOC and NIC of the NANDA diagnosis “Risk of fluid volume deficit” are detailed below.
- 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
- People in weight
- People with external conditions that affect the needs of liquids
- People with internal conditions that affect liquid needs
- 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
- It should not be used as routine in patients who are on strict diet.
- Consult the use suggestions for the volume deficit of liquids.
- The diagnosis of liquid volume deficit is used in patients who are risk of loss of body fluids, while the label risk of electrolytic imbalance should be applied to those who are at risk of loss or increase in fluids, or in both situations.
Suggested alternative diagnostics
- Liquid balance, disposition to improve the
- Volume of liquids, deficit of
- Volume of liquids, risk of imbalance of
Note : There is a long list of noc results associated with risk factors for the diagnosis of liquid volume deficit risk.
- The results used to evaluate and measure the real presence of the diagnosis are included here, as well as some results that resolve selected risk factors (for example, inadequate fluid intake).
- Burning scar: magnitude of the healing of a burn
- Liquid balance: water 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 amount of water in the intracellular and extracellular spaces of the body
- Thermoregulation: balance between production, gain and heat loss
Evaluation objectives and criteria
- Also see the objectives and evaluation criteria for the deficit of the volume of liquids.
- The deficit of the volume of liquids is prevented, as shown by the balance of liquids, hydration and nutritional status: food and liquid intake
Note : Because the risk factors of the liquid volume deficit are so numerous, only a selection of interventions is included to treat them.
- Wound care: burns: prevention of complications of wounds caused by burns and facilitation of its healing
- Risk identification: Analysis of possible risk factors, determination of health risks, and prioritization of risk reduction strategies for a person or group
- Electrolyte management: Hypematremia: Promote sodium balance and prevention of complications that result from abnormally high sodium serum levels
- Diarrhea management: control and relief of diarrhea
- Hypolemia management: expansion of the volume of intravascular fluids in a patient with volume deficiency
- Liquid management: favor the balance of liquids and the prevention of complications that result from concentrations of abnormal or undesirable liquids
- Vomit management: prevention and relief of vomiting
- Monitoring of vital signs: collection and analysis of cardiovascular and respiratory data, as well as body temperature, to determine and prevent complications
- Intravenous therapy (IV): Administration and control of liquids and medications via IV
- Surveillance: Collection, interpretation and synthesis, continuously, of patient data to make clinical decisions
- Electrolyte surveillance: Patient data collection and analysis to regulate electrolyte balance
- Liquid surveillance: Patient data collection and analysis to regulate liquid balance
Note : Nursing activities for the risk of liquid volume are mainly surveillance and prevention, and consist of reducing risk factors. The interventions and activities are essentially the same as used for the deficit of the actual fluid volume and for the disposition to improve the balance of liquids. Consult the use suggestions for the deficit of the volume of liquids before including those activities in the care plan.