Nursing Diagnosis for Pneumonia | Risk for Deficient Fluid Volume

Nursing diagnosis: Risk for Deficient Fluid Volume

Risk factors may include

Excessive fluid loss—fever, profuse diaphoresis, mouth breathing and hyperventilation, vomiting

Decreased oral intake

Possibly evidenced by

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Fluid Balance

Demonstrate fluid balance evidenced by individually appropriate parameters, such as moist mucous membranes, good skin

turgor, prompt capillary refill, and stable vital signs.

Nursing intervention with rationale:

1. Assess vital sign changes, such as increased temperature, prolonged fever, tachycardia, and orthostatic hypotension.

Rationale: Elevated temperature or prolonged fever increases metabolic rate and fluid loss through evaporation. Orthostatic BP changes and increasing tachycardia may indicate systemic

fluid deficit.

2. Assess skin turgor, moisture of mucous membranes—lips and tongue.

Rationale: Indirect indicators of adequacy of fluid volume, although oral mucous membranes may be dry because of mouth breathing and supplemental oxygen. Presence of these symptoms reduces oral

3. Note reports of nausea and vomiting.

Rationale: Presence of these symptoms reduces oral intake.

4. Monitor intake and output (I&O), noting color and character of urine. Calculate fluid balance. Be aware of insensible losses. Weigh as indicated.

Rationale: Provides information about adequacy of fluid volume and replacement needs.

5. Force fluids to at least 3,000 mL per day or as individually appropriate.

Rationale: Meets basic fluid needs, reducing risk of dehydration.

6. Administer medications, as indicated, such as antipyretics, antiemetics.

Rationale: Useful in reducing fluid losses.

7. Provide supplemental IV fluids as necessary.

Rationale: In the presence of reduced intake or excessive loss, use of parenteral route may correct or prevent deficiency.