Nursing Care Plan Preterm Infant | Fluid Volume Deficit

Nursing diagnosis: Fluid volume deficit may be related to extremes of age and weight (premature, under 2500 g), excessive fluid losses (thin skin, lack of insulating fat, increased environmental temperature, immature kidney/failure to concentrate urine).

Desired Outcomes: Be free of signs of dehydration or glycosuria with fluid intake approximating output and pH, Hct, and urine specific gravity WNL. Display weight gain of 20–30 g/day.

Nursing intervention with rationale:
1. Obtain daily serial weights using same scale at same time of day.
Rationale: Weight is the most sensitive indicator of fluid balance. Weight loss should not exceed 15% of total body weight or 1%–2% of total body weight per day. Inadequate weight gain may be related to water imbalance or inadequate caloric intake.

2. Calculate fluid balance (total intake minus total output) each shift and cumulative balance each 24-hr period. Maintain hourly records of infusing IV fluids/feedings. Determine output through measuring urine from collecting bag or through weighing/counting diapers. Also record amount of blood taken for laboratory testing.
Rationale: Output should be 1–3 ml/kg/hr, while fluid therapy needs are approximately 80–100 ml/kg/day on the 1st day of life, increasing to 120–140 ml/kg/day by the 3rd day after delivery. Lower gestational age has a negative impact on the glomerular filtration rate (GFR) and is further limited by conditions that impair renal blood flow or oxygen content (e.g., dehydration, respiratory distress), often resulting in oliguria/anuria. Positive fluid balance and corresponding weight gain in excess of 20–30 g/day suggest fluid excess.

3. Measure urine specific gravity after each voiding, or every 2–4 hr, by aspirating urine from diaper if infant cannot tolerate adhesive or urine collecting bag.
Rationale: Although renal immaturity and inability to concentrate urine usually result in low specific gravity in the preterm infant (normal range is 1.006–1.013), urine specific gravity may vary, providing an indication of the level of hydration. Low levels indicate excessive fluid volume; levels >1.013 indicate insufficient fluid intake and dehydration.

4. Test urine with Dextrostix per protocol.
Rationale: Even in cases of hypoglycemia, glycosuria occurs as immature kidneys begin excreting glucose, which may lead to osmotic diuresis, increasing risk of dehydration.

5. Minimize insensible fluid losses through use of clothing, thermoneutral temperatures, and warm or humidified oxygen.
Rationale: Preterm infant loses large amounts of water through skin, because blood vessels are close to surface and insulating fat levels are decreased or absent. Phototherapy or use of radiant warmer may increase insensible losses by 50%, necessitating increased intake to as much as 200 ml/kg/day. Note: Infants weighing <1500 g (3 lb 5 oz) are most susceptible to insensible fluid losses.

6. Monitor BP, pulse, and mean arterial pressure (MAP).
Rationale: A loss of 25% of blood volume results in shock, with MAP of less than 25 mm Hg indicating hypotension. Note: BP is related to weight, that is, the smaller the baby, the lower the MAP.

7. Evaluate skin turgor, mucous membranes, and status of anterior fontanel.
Rationale: Fluid reserves are limited in the preterm infant. Minimal fluid losses/shifts can quickly lead to dehydration, as noted by poor skin turgor, dry mucous membranes, and depressed (sunken) fontanels.

8. Note lethargy, high-pitched cry, abdominal distension, increased apnea, twitching, hypotonia, or seizure activity.
Rationale: These signs reflect hypocalcemia, which is most likely to occur during the first 10 days of life.

9. Assess IV site every hour. Note edema or failure of fluid infusion. Do not check needle position by lowering fluid below needle level.
Rationale: Swelling may indicate that infiltration of fluid is occurring or that tape is too tight. Back-up of blood caused by lowering fluid may clog needle.

10. Administer potassium chloride, 10% calcium gluconate, and 50% magnesium sulfate, as indicated. Monitor infant for potential bradycardia via cardiac monitor; observe infusion site for signs of irritation or edema.
Rationale: Correction of electrolyte imbalances is necessary to maintain or achieve homeostasis. Calcium administered through umbilical venous catheter may cause liver necrosis; if administered through umbilical artery, it may contribute to NEC. Early recognition and prompt intervention may limit untoward effects of infiltration of medication, such as sloughing, calcification, and necrosis. Note: Calcium replacement is ineffective in presence of magnesium deficit.


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