NURSING DIAGNOSIS: Risk for fluid volume deficit

related to:
  1. decreased oral intake associated with anorexia, fatigue, and nausea if present;
  2. increased insensible fluid loss associated with diaphoresis and hyperventilation if present;
  3. excessive loss of fluid associated with vomiting and/or diarrhea if present with initial infection or as a side effect of antimicrobial therapy.
Desired Outcome
The client will not experience fluid volume deficit as evidenced by:
  1. normal skin turgor
  2. moist mucous membranes
  3. stable weight
  4. B/P and pulse within normal range for client and stable with position change
  5. usual mental status
  6. BUN and Hct within normal range
  7. balanced intake and output
  8. urine specific gravity within normal range.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of fluid volume deficit:
    1. decreased skin turgor
    2. dry mucous membranes, thirst
    3. sudden weight loss of 2% or greater
    4. postural hypotension and/or low B/P
    5. weak, rapid pulse
    6. neck veins flat when client is supine
    7. change in mental status
    8. elevated BUN and Hct
    9. decrease in urine output with increased specific gravity (reflects an actual rather than a potential fluid volume deficit).
  2. Implement measures to prevent or treat fluid volume deficit:
    1. perform actions to reduce nausea and vomiting if present (e.g. administer antimicrobial agents with food unless contraindicated, administer prescribed antiemetics)
    2. perform actions to control diarrhea if present (e.g. consult physician about another antimicrobial agent if onset of diarrhea seems related to initiation of antimicrobial therapy, administer prescribed antidiarrheal agents)
    3. perform actions to reduce fever (see Diagnosis 3, action b) in order to reduce insensible fluid loss associated with diaphoresis and hyperventilation
    4. maintain a fluid intake of at least 2500 ml/day unless contraindicated; if oral intake is inadequate or contraindicated, maintain intravenous fluid therapy as ordered.