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Nursing Diagnosis: Fluid Volume, risk for deficit
Risk factors may include
- Excessive losses through normal routes (e.g., vomiting, diarrhea) and/or abnormal routes (e.g., indwelling tubes, wounds)
- Hypermetabolic state
- Impaired intake of fluids
Desired Outcomes
- Display adequate fluid balance as evidenced by stable vital signs, moist mucous membranes, good skin turgor, prompt capillary refill, and individually adequate urinary output.
13 Cancer Nursing Care Plan (NCP)
- Anticipatory Grieving — Cancer Nursing Care Plan (NCP)
- Situational Low Self-Esteem — Cancer Nursing Care Plan (NCP)
- Acute Pain — Cancer Nursing Care Plan (NCP)
- Altered Nutrition: Less Than Body Requirements — Cancer Nursing Care Plan (NCP)
- Risk for Fluid Volume Deficit — Cancer Nursing Care Plan (NCP)
- Fatigue — Cancer Nursing Care Plan (NCP)
- Risk for Infection — Cancer Nursing Care Plan (NCP)
- Risk for Altered Oral Mucous Membranes — Cancer Nursing Care Plan (NCP)
- Risk for Impaired Skin Integrity — Cancer Nursing Care Plan (NCP)
- Risk for Constipation/Diarrhea — Cancer Nursing Care Plan (NCP)
- Risk for Altered Sexuality Patterns — Cancer Nursing Care Plan (NCP)
- Risk for Altered Family Process — Cancer Nursing Care Plan (NCP)
- Fear/Anxiety — Cancer Nursing Care Plan (NCP)
Risk for Fluid Volume Deficit — Cancer Nursing Care Plan (NCP)
| Nursing Interventions | Rationale |
| Monitor I&O and specific gravity; include all output sources, e.g., emesis, diarrhea, draining wounds. Calculate 24-hr balance. | Continued negative fluid balance, decreasing renal output and concentration of urine suggest developing dehydration and need for increased fluid replacement. |
| Weigh as indicated. | Sensitive measurement of fluctuations in fluid balance. |
| Monitor vital signs. Evaluate peripheral pulses, capillary refill. | Reflects adequacy of circulating volume. |
| Assess skin turgor and moisture of mucous membranes. Note reports of thirst. | Indirect indicators of hydration status/degree of deficit. |
| Encourage increased fluid intake to 3000 mL/day as individually appropriate/tolerated. | Assists in maintenance of fluid requirements and reduces risk of harmful side effects, e.g., hemorrhagic cystitis in patient receiving cyclophosphamide (Cytoxan). |
| Observe for bleeding tendencies, e.g., oozing from mucous membranes, puncture sites; presence of ecchymosis or petechiae. | Early identification of problems (which may occur as a result of cancer and/or therapies) allows for prompt intervention. |
| Minimize venipunctures (e.g., combine IV starts with blood draws). Encourage patient to consider central venous catheter placement. | Reduces potential for hemorrhage and infection associated with repeated venous puncture. |
| Avoid trauma and apply pressure to puncture sites. | Reduces potential for bleeding/hematoma formation. |
| Provide IV fluids as indicated. | Given for general hydration and to dilute antineoplastic drugs and reduce adverse side effects, e.g., nausea/vomiting, or nephrotoxicity. |
| Monitor laboratory studies, e.g., CBC, electrolytes, serum albumin. | Provides information about level of hydration and corresponding deficits. |
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