The nursing diagnosis of Excess Fluid Volume is made for a patient with chronic kidney disease. Which of the following data is most important for the nurse to collect for this patient based on the nursing diagnosis?
A.
daily weight
B.
vital signs
C.
intake and output
D.
skin turgor
The Correct answer and Explanation is:
Correct Answer: A. Daily weight
Explanation:
In patients with chronic kidney disease (CKD), the nursing diagnosis of “Excess Fluid Volume” is a critical concern due to the kidneys’ reduced ability to excrete fluids efficiently. This can lead to fluid retention, which poses significant risks such as pulmonary edema, hypertension, and heart failure. Among the options provided, monitoring daily weight is the most important and effective data point for assessing fluid balance in these patients.
Importance of Daily Weight:
Daily weight measurements provide a direct, quantifiable indication of fluid status. A sudden increase in weight can signal fluid retention, even before other clinical signs or symptoms, such as edema or hypertension, become apparent. A gain of 1 kg (approximately 2.2 pounds) is roughly equivalent to 1 liter of fluid retained, making weight a sensitive indicator of changes in fluid volume. This makes daily weight monitoring a crucial tool in managing and preventing complications associated with fluid overload.
Comparison with Other Options:
- B. Vital Signs: While vital signs like blood pressure and heart rate are important, they can be influenced by various factors and may not be as sensitive or specific for detecting early fluid overload as daily weight. Elevated blood pressure could indicate fluid overload, but it may not appear until the condition has advanced.
- C. Intake and Output: Tracking intake and output is essential in managing fluid balance, but it may not always reflect true fluid status. Patients with CKD may retain fluid despite normal intake and output records, especially if kidney function is severely impaired. Therefore, intake and output monitoring should complement, not replace, daily weight measurements.
- D. Skin Turgor: Assessing skin turgor is more commonly associated with dehydration rather than fluid overload. While decreased skin turgor can indicate dehydration, it is less useful in detecting fluid excess.
In conclusion, daily weight is the most crucial data to collect for a patient with CKD and a nursing diagnosis of Excess Fluid Volume. It provides an early and reliable indication of fluid retention, allowing for timely intervention and management to prevent serious complications. Regular and accurate weight monitoring, ideally at the same time each day and under similar conditions, is essential for effectively managing fluid volume in these patients.