Domain 2. Nutrition
Class 5. Hydration
Diagnostic Code: 00025
Nanda label: Risk for imbalanced fluid volume
Diagnostic focus: Balanced fluid volume
Nursing diagnosis is an essential step involved in the process of delivering quality nursing care. The ability to recognize and identify risk factors related to a patient’s condition can help to prevent complications or further decline in health. As such, nurses routinely detect and diagnose situations that could have damaging effects on their patient’s health. Risk for imbalanced fluid volume is one such commonly diagnosed nursing problem that requires careful assessment and ongoing monitoring of an individual’s hydration status.
NANDA Nursing Diagnosis Definition
The NANDA International (NANDA-I) definition for “Risk for imbalanced fluid volume” specifies that this diagnosis implies susceptibility to extremes of fluid volume loss and/or gain that could compromise normal metabolic processes, leading to health problems.
Risk factors for developing risk for imbalanced fluid volume include:
- Excessive fluid loss – Dehydration from increased fluid excretion through sweat, urine, tears, vomiting etc., as well as increased losses due to diarrhea, progressive illness, burns or high fever can lead to severe dehydration.
- Excessive fluid intake – Overhydration or consuming excessive amounts of fluids in one sitting can place an excess strain on the body, resulting in serious health conditions like heart failure, edema, electrolyte disturbances and renal failure.
- Medication side effects – Certain medications and treatments can lead to fluid retention, while others can result in excessive fluid loss.
At Risk Populations
People at greater risk of developing an imbalanced fluid volume include:
- Older adults – Due to age-related changes, older adults are more likely to experience imbalanced fluid volumes.
- People with chronic illnesses – Conditions that can disturb the normal balance of fluids, such as diabetes, kidney diseases, liver diseases, and COPD, may increase the risk of an imbalanced fluid volume.
- Infants and children – Children are less capable of recognizing changes in their body, so they can easily become dehydrated before they realize what is happening. Additionally, infants and children have a higher baseline fluid requirement than adults, making them more prone to imbalances.
Imbalanced fluid volumes can lead to the following conditions when left unchecked:
- Impaired functioning – Many bodily functions require the right balance of fluids, so when that balance is off certain organs or systems can be affected.
- Weakness, fatigue, confusion – A lack of fluids can reduce the amount of oxygen carried throughout the body and impede cognitive functions, leading to pronounced weakness, fatigue, and confusion.
- Reduced alertness – The symptoms of dehydration, such as reduced daytime alertness, slowed reaction times, and confusion, can be life-threatening if not addressed quickly.
Suggestions for Use
When diagnosing risk for imbalanced fluid volumes, nurses should consider the patient’s history and physical condition, as well as any other relevant factors. Additionally, nurses should document any changes in hydration status, including changes in blood pressure, urine output, and skin turgor. It is also important to monitor intravenous lines to ensure that fluids are not being administered too quickly or too slowly.
Suggested Alternative NANDA Nursing Diagnosis
Alternative NANDA nursing diagnoses for imbalanced fluid volume include:
- Risk for decreased cardiac output – This diagnosis indicates a risk of the heart not delivering enough blood to meet the needs of the body.
- Risk for imbalanced nutrition: less than body requirements – This diagnosis takes into account the possibility of inadequate nutritional intake, which can lead to dehydration.
- Hyperthermia – This diagnosis recognizes a risk of the body being unable to maintain its temperature in a safe range, due to an imbalance of fluid volume.
To manage risk for imbalanced fluid volumes, nurses should instruct patients on proper hydration protocols and potential risk factors for dehydration. Additionally, nurses should ensure that medicated patients receive the correct dosages at the proper times, as some medications can affect hydration status.
Nursing interventions for imbalanced fluid volume tend to focus on the following Outcome NOCs:
- Fluid Balance – Refers to an optimal balance of fluid levels in the body.
- Oral Health Comfort – Refers to a level of comfort achieved by maintaining proper hydration.
- Thermoregulation – Refers to the ability of the body to maintain a safe internal temperature.
- Nutritional Status – Refers to the maintenance of healthy nutritional levels through proper hydration.
- Activity Tolerance – Refers to endurance and energy levels, which are increased by proper hydration.
Evaluation Objectives and Criteria
Evaluations for risk for imbalanced fluid volume should measure the success of the plan of care in achieving the desired outcome NOCs, as well as the patient’s current hydration status. Evaluation criteria might include:
- Fluid Intake and Output – Whether the patient’s intake and output are within healthy ranges.
- Weight – Whether the patient’s weight is within an acceptable range.
- Lab Values – Whether the patient’s lab values are within normal ranges.
- Clinical Symptoms – Whether the patient is exhibiting symptoms associated with dehydration or overhydration.
Interventions for risk for imbalanced fluid volume may involve the following Nursing Interventions Classification (NIC) categories:
- Hydration Therapy – Providing IV medication, involving frequent assessment of IVs for reordering or replacement, administering oral and tube feedings, monitoring electrolyte levels.
- Fluid Monitoring – Assessing urinary output, measuring daily weights, checking respiration rates, and recording temperature and pulse.
- Oral Care – Encouraging mouth care practices, providing sips of fluid, avoiding mouthwash or toothpaste containing alcohol.
- Pain Management – Assisting with position changes to reduce discomfort, providing comfort measures such as relaxation techniques, offering medication as needed.
- Hemodynamic Monitoring – Measuring central venous pressures, assessing cardiac outputs, evaluating gas exchange, and completing vitals.
When caring for a patient with risk for imbalanced fluid volume, nurses should complete activities such as:
- Education – Providing individualized instruction about the importance of maintaining an adequate hydration level and information regarding foods and liquids that contribute to hydration.
- Coordination – Working with a multidisciplinary team to identify appropriate interventions, medications and treatments.
- Monitoring – Closely observing the patient’s response to treatments, changing interventions as needed.
Risk for imbalanced fluid volume is a potentially serious nursing diagnosis that requires assessment, monitoring, and close collaboration with the patient and other healthcare professionals. By understanding the causes and risk factors for an imbalanced fluid volume, nurses can identify the issue on the earliest onset, improving the standard of care.
Q1: What is Risk for Imbalanced Fluid Volume?
Answer: Risk for imbalanced fluid volume is a nursing diagnosis that involves susceptibility to extremes of fluid loss or gain that could compromise normal metabolic processes and lead to health problems.
Q2: What are some Risk Factors for Imbalanced Fluid Volume?
Answer: Risk factors for developing risk for imbalanced fluid volume include excessive fluid loss, excessive fluid intake, and medication side effects.
Q3: Who is At Risk for Imbalanced Fluid Volume?
Answer: People at greater risk of developing an imbalanced fluid volume include older adults, people with chronic illnesses, infants and children.
Q4: What are some Associated Conditions of Imbalanced Fluid Volume?
Answer: Imbalanced fluid volumes can lead to impaired functioning, weakness, fatigue, confusion, and reduced alertness if left unchecked.
Q5: How Can Nurses Manage Risk for Imbalanced Fluid Volume?
Answer: To manage risk for imbalanced fluid volumes, nurses should instruct patients on proper hydration protocols, monitor medicated patients, and ensure that fluid intake and output are within healthy ranges.