Overview
- Initiating intake and output (I&O) measurements can be done any time the potential for fluid or nutrition imbalance exists. Consider the client's general condition and medical diagnosis in making this determination.
- Aseptic technique is used when administering nutritional support to clients who are malnourished because they are at increased risk for infection. This risk is further increased because nutritional-support substances may provide a medium for microorganism growth.
- Monitoring and regulating fluid administration is crucial to prevent a potentially lethal fluid overload.
- I&O and daily weights are used to assess nutritional status and fluid balance.
- Always check the placement of a central line or feeding tube when providing nutritional support. Infusion of hyperosmotic solutions into the thoracic cavity or aspiration into the pulmonary tree could result in major respiratory compromise.
- Appropriate precautions are necessary with infusion procedures to minimize the risk of injury. To prevent exposure to infectious microorganisms, use standard precautions and wear gloves when contact with body fluids is likely. Safety precautions are also crucial to prevent needlesticks or other injuries. Discard needles and other equipment in proper receptacles. Never reach into a trash can to retrieve an item. Reusable equipment, such as infusion pumps, must be cleaned on a regular basis and in between uses according to agency policy.
- Review the client's medication regimen to determine if there are medications that may contribute to fluid or nutrition imbalances.
- A personal or client history of latex allergy requires appropriate precautions, including the use of hypoallergenic nonlatex gloves.
- Some major nursing diagnostic labels related to fluid and nutrient balance include excess fluid volume, deficient fluid volume, risk for imbalanced fluid volume, decreased cardiac output, and imbalanced nutrition (less than body requirements or more than body requirements).
- Infusion of fluids and nutritional supplements to dying clients is controversial in terms of its palliative versus lifesustaining potential. Consider the desires of the client and family, doctor's orders, and agency policies.