Domain 2: nutrition
Class 5: hydration
Diagnostic Code: 00025
Nanda label: imbalance risk of liquid volume
Diagnostic focus: liquid volume balance
Approved 1998 • Revised 2008, 2013, 2017, 2020 • Evidence level 2.1
NANDA Nursing Diagnosis Definition
Nanda nursing diagnosis « imbalance risk of liquid volume » is defined as: susceptible to a decrease, increase or rapid change from one space to another of the intravascular, interstitial and/or/or intracellular, which can compromise health.
- Alteration of fluid intake
- Difficulty accessing water
- Excessive sodium intake
- Inappropriate knowledge about liquid needs
- INEFICA MANAGEMENT OF MEDICATION
- Insufficient muscle mass
- People in weight
- People with external conditions that affect the needs of liquids
- People with internal conditions that affect liquid needs
- Active loss of liquid volume
- Deviations that affect the absorption of liquids
- Deviations that affect the elimination of liquids
- Deviations that affect liquid intake
- Deviations that affect vascular permeability
- Excessive loss of liquids through normal pathways
- Excessive loss of liquids through unusual pathways
- Pharmacological preparations
- Therapeutic regime
Suggestions of use
The Association of Operating Room Nurses proposed this diagnosis and may have specific applications in that environment. The diagnosis of imbalance of the volume of liquids should be used when the patient is at risk of liquid volume and excess fluid volume. When there is only the risk of fluid loss (and not fluid increase), liquid volume deficit risk should be used.
Suggested alternative diagnostics
- Liquid balance, disposition to improve the
- Volume of liquids, risk of deficit of
- Volume of liquids, risk of excess of (no nanda-i)
Note : The following results are mainly used to evaluate and measure the incidence of diagnosis. A selection of results focuses on the risk factors of the volume imbalance of liquids.
- Burning scar: magnitude of the healing of a burn
- Liquid balance: water balance in intracellular and extracellular spaces of the body
- Severity of liquid overload: severity of excess fluids in intracellular and extracellular spaces of the body
- Hydration: adequate amount of water in the intracellular and extracellular spaces of the body
- Recovery after a procedure: degree to which an individual recovers its normal operation after the application of procedures that require anesthesia or sedation
Evaluation objectives and criteria
- See the objectives and evaluation criteria for liquid volume deficit, excess fluid volume and disposal to improve liquid balance.
Note : Of course, interventions depend on specific risk factors. Here interventions for assessment and surveillance are included, as well as some selected to deal with specific risk factors.
- Wound care: burns: prevention of complications of wounds caused by burns and facilitation of its healing
- Risk identification: Analysis of possible risk factors, determination of health risks and prioritization of risk reduction strategies for a person or group
- Liquid management: Promote liquid balance and prevent complications resulting from an abnormal or unwanted amount of liquids
- Management of liquids and electrolytes: regulation and prevention of complications derived from the alteration of liquid and electrolyte concentrations
- Surveillance: Collection, interpretation and synthesis of patient data, continuously, to make clinical decisions
- Liquid surveillance: Patient data collection and analysis to regulate liquid balance
- See nursing activities for liquid volume deficit, excess fluid volume and disposal to improve liquid balance.