Risk for Deficient Fluid Volume | Nursing Diagnosis for Leukemia

Nursing diagnosis: risk for deficient Fluid Volume

Risk factors may include
Excessive losses—vomiting, hemorrhage, diarrhea
Decreased fluid intake—nausea, anorexia
Increased fluid need—hypermetabolic state, fever, predisposition for kidney stone formation and tumor lysis syndrome

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

Desired Outcomes/Evaluation Criteria—Client Will
Hydration
Demonstrate adequate fluid volume, as evidenced by stable vital signs; palpable pulses; urine output, specific gravity, and pH within normal limits.
Risk Control
Identify individual risk factors and appropriate interventions.
Initiate behaviors or lifestyle changes to prevent development of dehydration.

Nursing intervention with rationale:
1. Monitor intake and output (I&O). Calculate insensible losses and fluid balance. Note decreased urine output in presence of adequate intake. Measure urine specific gravity and pH.
Rationale: Tumor lysis syndrome occurs when destroyed cancer cells release toxic levels of potassium, phosphorus, and uric acid. Elevated phosphorus and uric acid levels can cause crystal formation in the renal tubules, impairing filtration and leading to renal failure.

2. Weigh daily.
Rationale: Measure of adequacy of fluid replacement and kidney function. Continued intake greater than output may indicate renal insult or obstruction.

3. Monitor blood pressure (BP) and heart rate.
Rationale: Changes may reflect effects of hypovolemia associated with bleeding or dehydration.

4. Evaluate skin turgor, capillary refill, and general condition of mucous membranes.
Rationale: Indirect indicators of fluid status.

5. Note presence of nausea or fever.
Rationale: Affects intake, fluid needs, and route of replacement.

6. Encourage fluids of up to 3 to 4 L/day when oral intake is resumed.
Rationale: Promotes urine flow, prevents uric acid precipitation, and enhances clearance of antineoplastic drugs.

7. Inspect skin and mucous membranes for petechiae and ecchymotic areas; note bleeding gums, frank or occult blood in stools and urine, and oozing from invasive line sites.
Rationale: Suppression of bone marrow and platelet production places client at risk for spontaneous or uncontrolled bleeding.

8. Implement measures to prevent tissue injury and bleeding: gentle brushing of teeth or gums with soft toothbrush, cotton swab, or sponge-tipped applicator; using electric razor instead of sharp razors when shaving; avoiding forceful nose blowing and needlesticks when possible; and using sustained pressure such as sandbags or pressure dressings on oozing puncture or intravenous (IV) sites.
Rationale: Fragile tissues and altered clotting mechanisms increase the risk of hemorrhage following even minor trauma.

9. Limit oral care to mouth rinse, if indicated, such as a mixture of 1/4 tsp baking soda and 1/8 tsp salt in 8 oz water, or may use hydrogen peroxide in water or saline for bleeding or infected oral tissue. Avoid mouthwashes with alcohol.
Rationale: When bleeding is present, even gentle brushing may cause more tissue damage. Alcohol has a drying effect and may be painful to irritated tissues.

10. Administer medications, as indicated, for example: Antiemetics: 5-HT3 receptor antagonist drugs, such as ondansetron (Zofran) or granisetron (Kytril)
Rationale: Relieves nausea and vomiting associated with administration of chemotherapy agents and may enhance oral intake.