RISK FOR IMBALANCED FLUID VOLUME
At risk for a decrease, increase, or rapid shift from one to the other
of intravascular, interstitial, and/or intracellular ﬂuid. This refers to
body ﬂuid loss, gain, or both
• Receiving apheresis
• Intestinal obstruction
• Abdominal surgery
• Traumatic injury
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac function
• Fluid and electrolytes
• Physical regulation
The patient will
• Remain hemodynamically stable.
• Not experience electrolyte imbalance.
• Maintain adequate urine output.
• Identify risk factors contributing to possible imbalanced ﬂuid volume.
SUGGESTED NOC OUTCOMES
Fluid Balance; Hydration; Vital Signs
INTERVENTIONS AND RATIONALES
Determine: Assess for conditions that may contribute to imbalanced
ﬂuid volume. Prompt treatment of the underlying cause may prevent
serious complications of ﬂuid imbalance.
Monitor vital signs and other assessment parameters frequently.
Changes in heart rate and rhythm, blood pressure, and breath
sounds may indicate altered ﬂuid status.
Monitor intake and output to evaluate need for ﬂuid replacement.
Perform: Collect and evaluate urine output frequently. Measure urine
speciﬁc gravity as indicated. Decreased urine volume and elevated
speciﬁc gravity indicate hypovolemia.
Collect and evaluate serum electrolyte levels. Fluid alterations may
affect electrolyte levels.
Administer intravenous ﬂuids as indicated. Proactive ﬂuid manage-
ment may prevent serious imbalances.
Inform: Educate patient and family regarding ﬂuid restrictions or
need for increased ﬂuids, depending on underlying condition. Knowl-
edge will enhance feeling of participation and sense of control.
Attend: Provide encouragement and support for cooperation with
prescribed treatment regimen. Positive reinforcement will promote
Manage: Coordinate care with other members of healthcare team to
effectively manage underlying medical condition and prevent any
alteration in ﬂuid balance.
SUGGESTED NIC INTERVENTIONS
Fluid Management; Fluid Monitoring; Intravenous Therapy
Noble, K. A. (2008). Fluid and electrolyte imbalance: A bridge over troubled
water. Journal of Perianesthesia Nursing, 23, 267–272.