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NCLEX & CGFNS Practice Questions
Deficient Fluid Volume
  • Actual
  • Risk for (Potential)

Related To: [Check those that apply]

  • Inadequate fluid intake
  • Active fluid loss (diuresis, abnormal drainage or bleeding, diarrhea)
  • Electrolyte and acid-base imbalances
  • Failure of regulatory mechanisms
  • Increased metabolic rate (fever, infection)
  • Fluid shifts (edema or effusions)

As evidenced by: [Check those that apply]

  • 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

Patient’s Diagnosis: –
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Objective/Expected Outcome;The patient will:

  • experiences adequate fluid volume and electrolyte balance as evidenced by: urine output greater than 30 ml per hr, normotensive blood pressure (BP), heart rate (HR) 100 beats per min, consistency of weight, and normal skin turgor.
  • Others

Note: you need to indicate time frame/target as objective must be measurable.

Nursing Interventions Scientific Rationale
Obtain patient history to ascertain the probable cause of the fluid disturbance. This will help to guide interventions.
Assess or instruct patient to monitor weight daily and consistently, with same scale, and preferably at the same time of day. To facilitate accurate measurement and follow trends.
Evaluate fluid status in relation to dietary intake. Determine if patient has been on a fluid restriction. Most fluid enters the body through drinking, water in foods, and water formed by oxidation of foods.
Monitor and document vital signs. Sinus tachycardia may occur with hypovolemia to maintain an effective cardiac output.
Assess skin turgor and mucous membranes for signs of dehydration. The skin in elderly patients loses its elasticity; therefore skin turgor should be assessed over the sternum or on the inner thighs. Longitudinal furrows may be noted along the tongue.
Assess color and amount of urine. Report urine output less than 30 ml per hr for 2 consecutive hours. Concentrated urine denotes fluid deficit.
Monitor temperature. Febrile states decrease body fluids through perspiration and increased respiration.
Monitor serum electrolytes and urine osmolality and report abnormal values. Elevated hemoglobin and elevated blood urea nitrogen (BUN) suggest fluid deficit. Urine-specific gravity is likewise increased.
Document baseline mental status and record during each nursing shift. Dehydration can alter mental status.
Evaluate whether patient has any related heart problem before initiating parenteral therapy. Cardiac and elderly patients often have precarious fluid balance and are prone to develop pulmonary edema.
Encourage patient to drink prescribed fluid amounts. Oral fluid replacement is indicated for mild fluid deficit.
Provide oral hygiene. To promote interest in drinking.
Obtain and maintain a large-bore intravenous (IV) catheter. Parenteral fluid replacement is indicated to prevent shock.
Maintain IV flow rate. Elderly patients are especially susceptible to fluid overload.

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