Risk for Deficient Fluid Volume | Nursing Care Plan for Hemodialysis

Nursing diagnosis: risk for deficient Fluid Volume

Risk factors may include
Ultrafiltration
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
Hydration
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.

Risk for Imbalanced Fluid Volume | NCP Tptal Nutritional Support

Nursing diagnosis: risk for imbalanced Fluid Volume

Risk factors may include
Active loss or failure of regulatory mechanisms specific to underlying disease process or trauma; complications of nutrition therapy—high-glucose solutions, hyperglycemia (hyperosmolar nonketotic coma and severe dehydration)
Inability to obtain or ingest fluids

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

Desired Outcomes/Evaluation Criteria—Client Will
Fluid Balance
Display moist skin, moist mucous membranes, stable vital signs, and individually adequate urinary output; be free of edema and excessive weight loss or inappropriate gain.

Nursing intervention with rationale:
1. Assess for clinical signs of dehydration such as thirst, dry skin and mucous membranes, hypotension, or fluid excess, including peripheral edema, tachycardia, and adventitious breath sounds.
Rationale: Early detection and intervention may prevent occurrence of excessive fluctuation in fluid balance. Note: Severely malnourished clients have an increased risk of developing refeeding syndrome, such as life-threatening fluid overload, intracellular electrolyte shifts, and cardiac strain occurring during initial 3 to 5 days of therapy.

2. Incorporate knowledge of caloric density of enteral formulas into assessment of fluid balance.
Rationale: Enteric solutions are usually concentrated and do not meet free water needs.

3. Provide additional water and flush tubing, as indicated.
Rationale: With higher calorie formula, additional water is needed to prevent dehydration or hyperglycemic complications.

4. Record intake and output (I&O), calculate fluid balance, and measure urine specific gravity.
Rationale: Excessive urinary losses may reflect developing HHNC. Specific gravity is an indicator of hydration and renal function.

5. Weigh daily, or as indicated; evaluate changes.
Rationale: Rapid weight gain reflecting fluid retention can predispose or potentiate heart failure (HF) or pulmonary edema. Gain of more than 0.5 lb/day indicates fluid retention and not deposition of lean body mass.

6. Monitor laboratory studies, such as the following: Serum potassium and phosphorus
Rationale: Hypokalemia and phosphatemia can occur because of intracellular shifts during initial refeeding and may compromise cardiac function if not corrected.

7. Monitor laboratory studies, such as Hematocrit (Hct)
Rationale: Reflects hydration and circulating volume.

8. Monitor laboratory studies, such as Serum albumin
Rationale: Hypoalbuminemia and decreased colloidal osmotic pressure leads to third spacing of fluid and edema.

9. Monitor laboratory studies, such as Serum transferrin
Rationale: Reacts quickly to changes in protein status.

10. Dilute formula or change from hypertonic to isotonic formula, as indicated.
Rationale: May decrease gastric intolerance, reducing occurrence of diarrhea and associated fluid losses.