Nursing diagnosis: risk for imbalanced Fluid Volume
Risk factors may include
Active loss or failure of regulatory mechanisms specific to underlying disease process or trauma; complications of nutrition therapy—high-glucose solutions, hyperglycemia (hyperosmolar nonketotic coma and severe dehydration)
Inability to obtain or ingest fluids
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Display moist skin, moist mucous membranes, stable vital signs, and individually adequate urinary output; be free of edema and excessive weight loss or inappropriate gain.
Nursing intervention with rationale:
1. Assess for clinical signs of dehydration such as thirst, dry skin and mucous membranes, hypotension, or fluid excess, including peripheral edema, tachycardia, and adventitious breath sounds.
Rationale: Early detection and intervention may prevent occurrence of excessive fluctuation in fluid balance. Note: Severely malnourished clients have an increased risk of developing refeeding syndrome, such as life-threatening fluid overload, intracellular electrolyte shifts, and cardiac strain occurring during initial 3 to 5 days of therapy.
2. Incorporate knowledge of caloric density of enteral formulas into assessment of fluid balance.
Rationale: Enteric solutions are usually concentrated and do not meet free water needs.
3. Provide additional water and flush tubing, as indicated.
Rationale: With higher calorie formula, additional water is needed to prevent dehydration or hyperglycemic complications.
4. Record intake and output (I&O), calculate fluid balance, and measure urine specific gravity.
Rationale: Excessive urinary losses may reflect developing HHNC. Specific gravity is an indicator of hydration and renal function.
5. Weigh daily, or as indicated; evaluate changes.
Rationale: Rapid weight gain reflecting fluid retention can predispose or potentiate heart failure (HF) or pulmonary edema. Gain of more than 0.5 lb/day indicates fluid retention and not deposition of lean body mass.
6. Monitor laboratory studies, such as the following: Serum potassium and phosphorus
Rationale: Hypokalemia and phosphatemia can occur because of intracellular shifts during initial refeeding and may compromise cardiac function if not corrected.
7. Monitor laboratory studies, such as Hematocrit (Hct)
Rationale: Reflects hydration and circulating volume.
8. Monitor laboratory studies, such as Serum albumin
Rationale: Hypoalbuminemia and decreased colloidal osmotic pressure leads to third spacing of fluid and edema.
9. Monitor laboratory studies, such as Serum transferrin
Rationale: Reacts quickly to changes in protein status.
10. Dilute formula or change from hypertonic to isotonic formula, as indicated.
Rationale: May decrease gastric intolerance, reducing occurrence of diarrhea and associated fluid losses.