Nursing diagnosis: risk for deficient Fluid Volume
Risk factors may include
Fluid restrictions, actual blood loss—systemic heparinization or disconnection of the shunt
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Maintain fluid balance as evidenced by stable vital signs, good skin turgor, moist mucous membranes, absence of bleeding, and appropriate weight.
Nursing intervention with rationale:
1. Measure all sources of intake and output (I&O). Have client keep diary.
Rationale: Aids in evaluating fluid status, especially when compared with weight. Note: Urine output is an inaccurate evaluation of renal function in dialysis clients. Some individuals have water output with little renal clearance of toxins, whereas others have oliguria or anuria.
2. Weigh daily as well as before and after dialysis run.
Rationale: Weight loss over precisely measured time is a measure of ultrafiltration and fluid removal. Dry weight determines how much excess fluid has been removed and serves as a guide for subsequent dialysis run time and solution.
3. Monitor BP, pulse, and hemodynamic pressures, if available, during dialysis.
Rationale: Hypotension, tachycardia, and falling hemodynamic pressures suggest volume depletion.
4. Ascertain whether diuretics and antihypertensives are to be withheld.
Rationale: Dialysis potentiates hypotensive effects if these drugs have been administered.
5. Verify continuity of shunt or access catheter.
Rationale: Disconnected shunt or open access permits exsanguination.
6. Apply external shunt dressing. Permit no puncture of shunt.
Rationale: Minimizes stress on cannula insertion site to reduce inadvertent dislodgement and bleeding from site.
7. Place client in a supine or Trendelenburg position, as necessary.
Rationale: Maximizes venous return if hypotension occurs.
8. Assess for oozing or frank bleeding at access site, mucous membranes, or incisions and wounds. Hematest stools or any drainage.
Rationale: Systemic heparinization during dialysis prolongs clotting times and places client at risk for bleeding, especially during the first 4 hours after procedure.
9. Monitor laboratory studies, as indicated, such as the following: Hemoglobin/hematocrit (Hgb/Hct)
Rationale: May be reduced because of anemia, hemodilution, or actual blood loss.
10. Reduce rate of ultrafiltration during dialysis, as indicated.
Rationale: Reduces the amount of water being removed and may correct hypotension or hypovolemia.