The nursing diagnosis established for a client with acute glomerulonephritis is excess fluid volume related to plasma protein deficit and sodium and water retention
Which of the following provides the nurse with the most accurate indication of fluid balance for this client? 1. Daily weight
2. Intake and output records
3. Serum sodium levels
4. Vital signs
1. Daily weight
Rationale:
Daily weight provides the most accurate indication of fluid balance because of the pathophysiology of acute glomerulonephritis. Albumin is lost, causing decreased osmotic pressure and fluid shifting into the interstitial spaces. Accurate weights will provide data to indicate that treatments are effective in pulling fluids from interstitial spaces into the vascular system and then out via kidneys. Intake and output records, serum sodium levels, and vital signs will all provide data indicating fluid balance; however, they are not as accurate as daily weight for determining fluid balance.
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