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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

  • Maintain fluid balance as evidenced by stable/appropriate weight and vital signs, good skin turgor, moist mucous membranes, absence of bleeding.

Risk for Deficient Fluid Volume-Hemodialysis Nursing Care Plan

Nursing actionsRationale
Measure all sources of I&O. Have patient keep diary.Aids in evaluating fluid status, especially when compared with weight. Note: Urine output is an inaccurate evaluation of renal function in dialysis patients. Some individuals have water output with little renal clearance of toxins, whereas others have oliguria or anuria.
Weigh daily before/after dialysis run.Weight loss over precisely measured time is a measure of ultrafiltration and fluid removal.

 

Monitor BP, pulse, and hemodynamic pressures if available during dialysis.Hypotension, tachycardia, falling hemodynamic pressures suggest volume depletion.

 

Note/ascertain whether diuretics and/or antihypertensives are to be withheld.Dialysis potentiates hypotensive effects if these drugs have been administered.
Verify continuity of shunt/access catheter.Disconnected shunt/open access permits exsanguination.
Apply external shunt dressing. Permit no puncture of shunt.Minimizes stress on cannula insertion site to reduce inadvertent dislodgement and bleeding from site.
Place patient in a supine/Trendelenburg’s position as necessary.Maximizes venous return if hypotension occurs.
Assess for oozing or frank bleeding at access site or mucous membranes, incisions/wounds. Hematest/guaiac stools, gastric drainage.Systemic heparinization during dialysis increases clotting times and places patient at risk for bleeding, especially during the first 4 hr after procedure
Administer IV solutions (e.g., normal saline [NS])/volume expanders (e.g., albumin) during dialysis as indicated;Saline/dextrose solutions, electrolytes, and NaHCO3 may be infused in the venous side of continuous arteriovenous (CAV) hemofilter when high ultrafiltration rates are used for removal of extracellular fluid and toxic solutes. Volume expanders may be required during/following hemodialysis if sudden/marked hypotension occurs.
Blood/PRCs if needed.Destruction of RBCs (hemolysis) by mechanical dialysis, hemorrhagic losses, decreased RBC production may result in profound/progressive anemia requiring corrective action.
Reduce rate of ultrafiltration during dialysis as indicated.Reduces the amount of water being removed and may correct hypotension/hypovolemia.
Administer protamine sulfate as appropriate.May be needed to return clotting times to normal or if heparin rebound occurs (up to 16 hr after hemodialysis).
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