Domain 2. Nutrition
Class 5. Hydration
Diagnostic Code: 00028
Nanda label: Risk for deficient fluid volume
Diagnostic focus: Fluid volume
Nursing diagnosis is a health care term that is used in reference to identifying potential risks patients are facing. The risk for deficient fluid volume nursing diagnosis focuses on scenarios where the patient has an inadequate amount of necessary fluids in their body, thus putting them at risk of developing serious health complications.
NANDA Nursing Diagnosis Definition
The official definition of the risk for deficient fluid volume nursing diagnosis as published by the North American Nursing Diagnosis Association (NANDA) is “at risk for decreased intravascular, interstitial and/or intracellular fluid volume”.
Risk Factors
A variety of different factors can contribute to a patient laying at risk of having a depleted fluid volume including excessive losses from excretion of sweat, urination and/or vomiting; dietary restriction; dehydration due to other medical conditions such as diabetes or extreme heat; and lack of sufficient intake.
At Risk Population
Certain populations may be particularly at risk of losing fluids than others. Infants who cannot effectively take in liquids and adults with impaired swallowing situations need to closely monitored when it comes to fluid levels. In addition, certain elderly adults have an increased risk of developing this deficiency due to decrease renal water conservation.
Associated Conditions
- Decreased cardiac output: Reduced force of muscular contraction by the heart weakens the delivery of neciditated oxygen to the vital organs of the body.
- Decreased oxygenation: Oxygen insufficiency affects the entire body and can lead to symptoms, including fatigue, confusion and difficulty breathing.
- Decreased urine output: Lack of sufficient fluids in the body diminish the number of functioning nephrons in kidneys, which negatively affects urine production.
Suggestions of Use
If you notice that your patient may be at risk for developing a fluid volume deficiency it is important to take action immediately. Start by assessing the individual’s vital signs – looking for a decrease in heart rate and body temperature – and utilize laboratory tests, such as kidney and liver function test, to evaluate overall bodily functioning.
Suggested Alternative NANDA Nursing Diagnosis
- Ineffective tissue perfusion: This diagnosis, also known as low circulating blood volume, focuses on the issue of insufficient nutrients and oxygen being delivered to the cell.
- Impaired physical mobility: Actions such as standing up, sitting down, walking, and balance coordination can be affected by the levels of fluids present in the body.
- Imbalanced nutrition: Fluid production is an essential part of maintaining good nutritive balance. Lack of proper fluid consumption can lead to an imbalance in dietary requirements and cause various deficiencies.
Usage Tips
When diagnosing a patient with the risk for deficient fluid volume nursing diagnosis its important to identify the underlying condition causing the disorder and guiding treatment plans appropriately. Utilizing evidence-based practice, such as ensuring the chart is updated with vital signs and providing estimates of fluid losses can give you confidence in the veracity of your order.
NOC Outcomes
- Fluid Balance: Ability to maintain an adequate fluid intake to meet metabolic needs.
- Activity Tolerance: Patient’s capacity to successfully experience activities without undue fatigue, pain or other physical discomfort or disease-related side effects.
- Tissue Perfusion: Adequacy of the circulation of vital nutrients, metabolic substrates and oxygen to cells in the body.
Evaluation Objectives and Criteria
When evaluating the response to a patient suffering from a potential deficiency of fluids it is important to keep track of IV infusion, daily weights, intake and output measurements, changes in patient condition, and any I&O log documented. Additionally, monitoring signs of edema, ability to complete activities or walk, and information of the diet and patients willingness to eat should be noted.
NIC Interventions
- Fluid/Electrolyte Management: Monitoring and managing the patient’s individual fluid and electrolyte needs.
- Nutrient Monitoring: Observe the patient’s oral intake of foods and fluids and monitoring resulting biochemical and hematological changes.
- Skin Care: Skin integrity evaluation and topical treatments to prevent serious impairment of the skin surface.
Nursing Activities
It is important to provide clear instructions to patients who are identified at risk for depleted fluid volumes. As a registered nurse, you should maintain an ongoing assessment of the patient to ensure safety, counsel search on fluid exchange principles and measure the body’s response, review possible causes of fluid depletion, and create a plan of care to replenish lost fluids if necessary.
Conclusion
Inadequate fluid volume can put a patient in a detrimental situation due to extreme dehydration. While there are various possible causes of a decrease in an individual’s expected fluid balances, healthcare providers can prevent such difficulties from arising by continuously monitoring the patient’s health, intake and outputs, and providing appropriate interventions when needed.
FAQs:
- What is the risk for deficient fluid volume nursing diagnosis?
Answer: The risk for deficient fluid volume nursing diagnosis is a consideration of what is called “at risk for decreased intravascular, interstitial and/or intracellular fluid volume”, according to the North American Nursing Diagnosis Association (NANDA). - What are the risk factors?
Answer: Several common factors can lead to a decline in necessary fluids in a patient’s body, such as excessive loss from sweating, urination and vomiting; dehydration due to other medical conditions; dietary restrictions; and insufficient consumption of fluids. - Which populations are particularly prone to lose fluids?
Answer: Those who have difficulty taking in liquids, such as infants and people with impaired swallowing, as well as elderly adults, are most likely to experience issues with their fluid levels. - What interventions can be taken to prevent a decrease in fluid volume?
Answer: Healthcare professionals can assess the individual’s vital signs and perform laboratory tests, while also providing guidance on sufficient fluid intake and monitoring fluide exchange principles. - What forms of evaluation should be conducted?
Answer: When evaluating treatments over a period of time, it is important to note any changes in patient condition, document IV infusions and monitors, weigh the patient each day, record I&O log, and examine evidence of edema, activity fatigue, and diet progression.