Nursing Care Plan : Nanda Nursing Diagnosis

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Nursing Diagnosis for Deficient Fluid Volume

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
Hemoconcentration
Increased serum sodium
Hypotension
Thirst
Increased pulse rate
Decreased skin turgor
Dry mucous membranes
Weakness
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)

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Fluid Balance
Hydration

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Fluid Monitoring
Fluid Management
Fluid Resuscitation

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.

Nursing Diagnosis

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