A nursing diagnosis is a statement that describes a problem related to a patient's disease. A nurse makes a nursing diagnosis by interviewing and examining a patient to find out what issues they have because of the disease or illness they suffer from. The information the nurse gathers from this process gives the nurse enough evidence to back up the diagnosis. A care plan is also made based on nursing diagnoses.
Fluid and Electrolyte Imbalance
Fluid inside the cells is called intracellular fluid, and fluid outside the cells is called extracellular fluid. Electrolytes are substances such as sodium and potassium and are found in body water or fluids. "Textbook of Basic Nursing" by Caroline Bunker Rosdahl and Mary T. Kowalski states that for a person to be healthy, a normal balance needs to exist between the body's fluids, electrolytes, acids and bases. An imbalance in electrolytes or fluids in the body can lead to excessive amounts of fluids in the body or dehydration. This condition can occur as a result of hormone imbalance, a dysfunction in body systems that regulates fluid and electrolytes or other issues.
According to "Pediatric Nursing by Parul Datta" by Jaypee Brothers and Medical, dehydration is the most common fluid imbalance. This condition can be described as a deficiency in fluids and is characterized by symptoms such as low blood pressure, low urine output, weight loss, increased sodium in the body, increased heart rate, dry mucus membranes and confusion or mental status changes. It can be caused by excessive vomiting, diarrhea, bleeding or inadequate fluid intake. Another problem associated with fluid and electrolyte imbalance is excess fluid in the body. This problem might stem from kidney, heart or liver failure, along with a failure in regulatory mechanisms. Assessment of a patient with fluid volume excess might reveal elevated blood pressure, swollen areas in the skin, engorged neck veins, weight gain,cough, low sodium in the body and increased pulse rate.
Before a nursing diagnosis is made, a thorough physical assessment is done along with investigation of a patient's chart for information such as lab values and medical history. A nurse can make a nursing diagnosis of "excess fluid volume" for a patient who shows signs of having excessive body fluids. The nurse does not base her nursing diagnosis on the patient's medical diagnosis. For example, a patient suffering from congestive heart failure might show signs of excessive body fluids. In this case, the medical diagnosis is congestive heart failure and having too much body fluid is a problem associated with this medical diagnosis.
After making a nursing diagnosis, the nurse makes a care plan for the patient. A care plan focuses on alleviating or eliminating the problem the nurse identified. For a nursing diagnosis of excessive fluid volume, the focus of the care plan is to maintain a patient's fluid and electrolyte balance as evidenced by absence of symptoms associated with excess fluid volume.
The nurse implements her care plan after outlining the interventions necessary to reach the goal of the care plan. Some interventions for a patient with the nursing diagnosis of excess fluid volume are weighing the patient and administering diuretic drugs as ordered by a physician. To evaluate or measure the success of the care plan, the nurse assesses the patient for signs associated with excess fluid volume and if they are absent or diminished, the care plan is deemed successful. If not, the nurse creates a new care plan.