Nursing diagnosis: risk for deficient Fluid Volume
Risk factors may include
Increased fluid needs—hypermetabolic state or fever, inflammatory processes
Renal parenchymal damage or infarctions limiting the kidney’s ability to concentrate urine (hyposthenuria)
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Maintain adequate fluid balance as evidenced by individually appropriate urine output with a near-normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor, and prompt capillary refill.
Nursing intervention with rationale:
1. Maintain accurate intake and output (I&O). Weigh daily.
Rationale: Client may reduce fluid intake during periods of crisis because of malaise and anorexia. Dehydration from vomiting, diarrhea, and fever may reduce urine output and precipitate a vaso-occlusive crisis.
2. Note urine characteristics and specific gravity.
Rationale: The kidney can lose its ability to concentrate urine, resulting in excessive losses of dilute urine and fixation of the specific gravity.
3. Monitor vital signs, comparing with client’s usual or previous readings. Take BP in lying, sitting, and standing positions, if possible.
Rationale: Reduction of circulating blood volume can occur from increased fluid loss, resulting in hypotension and tachycardia.
4. Observe for fever, changes in level of consciousness, poor skin turgor, dryness of skin and mucous membranes, and pain.
Rationale: Symptoms are reflective of dehydration and hemoconcentration with consequent vaso-occlusive state.
5. Monitor vital signs closely during blood transfusions and note presence of dyspnea, crackles, rhonchi, wheezes, diminished breath sounds, cough, frothy sputum, and cyanosis.
Rationale: Client’s heart may already be weakened and prone to failure because of chronic demands placed on it by the anemic state. Heart may be unable to tolerate the added fluid volume from transfusions or rapid IV fluid administered to treat crisis or shock.
6. Administer IV fluids, as indicated.
Rationale: Replaces fluid deficits; may reverse renal concentration of RBCs and reduce potential for kidney failure. Fluids must be given immediately, especially in CNS involvement, to decrease hemoconcentration and prevent further infarction.
7. Monitor laboratory studies, for example: Hgb/Hct
Rationale: Elevations may indicate hemoconcentration. Post-transfusion Hgb level of 8 to 9 g/dL is generally recommended to avoid the risk of hyperviscosity that may occur several days after transfusion when RBCs sequestered in the spleen may return to the circulation and increase the Hgb levels.
8. Serum and urine electrolytes
Rationale: Kidneys’ loss of ability to concentrate urine may result in serum depletions of Na+, K–, and Cl–, necessitating replacement.