Fluid balance is an essential aspect of maintaining overall health and wellness. When the body is not getting enough fluids, it can lead to a variety of problems and complications. In the nursing field, this is referred to as “Risk for Deficient Fluid Volume” and is classified as a NANDA nursing diagnosis.
NANDA Nursing Diagnosis Definition
According to NANDA International, the official definition of “Risk for Deficient Fluid Volume” is: “At risk for decreased intravascular, interstitial, and/or intracellular fluid as evidenced by changes in vital signs and/or weight, and reported fluid intake and output.”
Defining Characteristics (Subjectives and Objectives)
- Decreased blood pressure
- Decreased urine output
- Dry mucous membranes
- Increased heart rate
- Lack of access to fluids
- Medications that increase urine output
- Prolonged bed rest
Individuals who are at a higher risk for developing “Risk for Deficient Fluid Volume” include:
- Elderly adults
- Infants and young children
- Individuals with chronic illnesses
- Individuals with limited mobility
- Individuals with swallowing difficulties
- Electrolyte imbalances
- Kidney damage
Suggestions for Use
- Encourage increased fluid intake
- Monitor vital signs and fluid intake and output
- Educate patient and family on the importance of fluid balance
- Assess for and address any barriers to fluid intake
- Administer medications as ordered to promote fluid balance
Suggested Alternative NANDA Diagnoses
- Ineffective Tissue Perfusion
- Acute Confusion
- Impaired Skin Integrity
- Impaired Swallowing
- Impaired Urinary Elimination
- This diagnosis should be used in conjunction with other diagnoses that may be contributing to the fluid imbalance, such as impaired urinary elimination or impaired swallowing.
- It is important to consider the patient’s cultural and religious beliefs when implementing interventions, as these may affect their fluid intake and preferences.
- It is also important to monitor the patient’s weight as an indicator of fluid balance. A sudden or consistent weight loss may indicate a fluid deficit.
- In cases where the patient is unable to take fluids orally, alternative methods such as IV fluids may be necessary.
- Fluid Balance: This outcome measures the patient’s ability to maintain adequate fluid levels within their body.
- Hydration Status: This outcome measures the patient’s overall hydration status, including factors such as skin turgor and mucous membrane moisture.
- Skin Integrity: This outcome measures the integrity of the patient’s skin, which can be affected by fluid imbalances and dehydration.
- Urinary Elimination: This outcome measures the patient’s ability to effectively eliminate urine, which can be affected by fluid imbalances.
- Fluid Management: This intervention involves monitoring and managing the patient’s fluid intake and output to maintain adequate fluid levels within the body.
- Skin Care: This intervention involves assessing and caring for the patient’s skin to prevent breakdown and promote integrity, especially in cases of fluid imbalances and dehydration.
- Urinary Diversion: This intervention involves the use of alternative methods for urinary elimination, such as catheters, in cases where the patient is unable to void on their own.
- Oral Care: This intervention is use to promote oral hygiene and prevent infection, especially in cases where the patient has dry mouth or difficulty swallowing due to fluid imbalances.
Risk for Deficient Fluid Volume is a serious concern that can lead to a variety of problems and complications. By understanding the NANDA nursing diagnosis and utilizing appropriate interventions, nurses can help to promote fluid balance and prevent further complications in at-risk patients.