- Risk for fluid volume deficit related to inadequate fluid intake.
- Altered tissue perfusion, related to decreased blood circulation or inade-
quate fluid replacement.
Before beginning fluid replacement therapy, goals should include:- Patient will not develop fluid volume deficit or excess as a result of IV
fluid replacement. - Patient will remain hydrated.
- Vital signs and urine output will remain in normal ranges.
When fluid replacement therapy is underway, make sure to monitor:- Vital signs.
- Fluid intake and output.
- Daily weight.
- Signs and symptoms of fluid volume excess (overload) which include
cough, dyspnea (difficulty breathing), jugular vein distention (JVD) (neck
vein engorgement), moist rales (abnormal breath sounds). - Signs and symptoms of fluid volume deficit (dehydration) which include
thirst, dry mucous membranes, poor skin turgor, decreased urine output,
tachycardia, slight decrease in systolic blood pressure. - Lab results especially BUN, hemoglobin and hematocrit.
- Types of IV fluids being infused.
- IV site for infiltration or phlebitis.
The patient should be taught:- To recognize signs and symptoms of fluid volume excess and fluid
volume deficit. - How to measure fluid intake and output.
- How to weigh himself or herself.
The nurse must frequently evaluate the patient’s- Urine output (normal limits).
- Breath sounds (normal limits).
- Lab results (normal limits).
- Vital signs (normal limits).
CHAPTER 10 Fluid and Electrolyte Therapy^163