This comprehensive nursing care plan and management guide is here to assist you in providing optimal care for patients diagnosed with dehydration or fluid volume deficit. Explore the nursing assessment, interventions, goals, and nursing diagnosis specific to dehydration, enabling you to effectively address the needs of these patients. Enhance your understanding of dehydration management and ensure the delivery of quality care through this guide.
Table of contents
What is fluid volume deficit?
Fluid volume deficit (also known as hypovolemia) is a state or condition where the fluid output exceeds the fluid intake. It occurs when the body loses both water and electrolytes from the ECF in similar proportions. Common sources of fluid loss are the gastrointestinal tract, polyuria, and increased perspiration. Risk factors for deficient fluid volume are as follows: vomiting, diarrhea, GI suctioning, sweating, decreased intake, nausea, inability to gain access to fluids, adrenal insufficiency, osmotic diuresis, hemorrhage, coma, third-space fluid shifts, burns, ascites, and liver dysfunction. Fluid volume deficit may be an acute or chronic condition managed in the hospital, outpatient center, or home setting.
Appropriate management is vital to prevent potentially life-threatening hypovolemic shock. Older patients are more likely to develop fluid imbalances. The management goals are to treat the underlying disorder and return the extracellular fluid compartment to normal, restore fluid volume, and correct any electrolyte imbalances.
Here are the common factors or etiology for fluid volume deficit:
- Abnormal losses through the skin, GI tract, or kidneys.
- Decrease in intake of fluid (e.g., inability to intake fluid due to oral trauma)
- Movement of fluid into third space.
- Abnormal drainage
- Inadequate fluid intake
- Increased metabolic rate (e.g., fever, infection)
Signs and Symptoms
The following are the common signs and symptoms presented for dehydrated patients presenting fluid volume deficit that can help guide your nursing assessment:
- Alterations in mental state
- Patient complaints of weakness and thirst that may or may not be accompanied by tachycardia or weak pulse
- Weight loss (depending on the severity of fluid volume deficit)
- Concentrated urine, decreased urine output
- Dry mucous membranes, sunken eyeballs
- Weak pulse, tachycardia
- Decreased skin turgor
- Decreased blood pressure, hemoconcentration
- Postural hypotension
Goals and Outcomes
Here are some example goals and outcomes for fluid volume deficit:
- Patient is normovolemic as evidenced by systolic BP greater than or equal to 90 mm HG (or patient’s baseline), absence of orthostasis, HR 60 to 100 beats/min, urine output greater than 30 mL/hr and normal skin turgor.
- Patient demonstrates lifestyle changes to avoid progression of dehydration.
- Patient verbalizes awareness of causative factors and behaviors essential to correct fluid deficit.
- Patient explains measures that can be taken to treat or prevent fluid volume loss.
- Patient describes symptoms that indicate the need to consult with health care provider.
Nursing Assessment and Rationales
Nursing assessment is a vital aspect of the care plan for patients with hypovolemia, a condition that can result in a decrease in fluid volume in the body, as it helps identify the underlying causes of hypovolemia, monitor the patient’s fluid status, and implement appropriate nursing interventions to promote optimal health outcomes. A thorough nursing assessment includes careful evaluation of vital signs, fluid intake and output, and electrolyte levels, and provides critical information for the development of a comprehensive care plan.
Monitor and document vital signs, especially blood pressure (BP) and heart rate (HR).
Changes in BP and HR can indicate hypovolemia, electrolyte imbalances, or compensation mechanisms. Irregular pulse and weak pulse may suggest electrolyte imbalances and hypovolemia.
Assess skin turgor and oral mucous membranes for signs of dehydration.
Skin turgor and mucous membrane moisture provide valuable indicators of hydration status. Decreased skin turgor and dry mucous membranes are signs of dehydration.
Monitor BP for orthostatic changes and monitor HR for orthostatic changes.
Orthostatic hypotension, indicated by a significant drop in BP and/or HR upon standing, can be a sign of fluid volume deficit.
Assess alteration in mentation/sensorium, such as confusion, agitation, or slowed responses. Changes in mentation can result from electrolyte imbalances, acidosis, or decreased cerebral perfusion caused by fluid volume deficit.
Assess color and amount of urine; report urine output less than 30 ml/hr for two consecutive hours.
Monitoring urine output helps assess renal function and adequacy of fluid replacement. Urine output below 30 ml/hr may indicate inadequate fluid volume.
Monitor and document temperature.
Fever increases insensible water loss, contributing to fluid volume deficit. Monitoring temperature helps identify potential fluid imbalance.
Monitor fluid status in relation to dietary intake.
Monitoring fluid intake and output helps evaluate fluid balance and adequacy of dietary fluid intake.
Note the presence of nausea, vomiting, and fever.
Nausea, vomiting, and fever can lead to fluid losses and contribute to fluid volume deficit.
Auscultate and document heart sounds; note rate, rhythm, or other abnormal findings.
Dysrhythmias can result from electrolyte imbalances and fluid volume deficit. Monitoring heart sounds helps identify cardiovascular complications.
Monitor serum electrolytes and urine osmolality; report abnormal values.
Abnormal electrolyte levels and urine osmolality can indicate fluid volume imbalance and guide appropriate interventions.
Ascertain whether the patient has any related heart problem before initiating parenteral therapy.
Patients with pre-existing heart conditions may be more susceptible to fluid volume deficit and dehydration, and careful monitoring and management are required.
Weigh the patient daily with the same scale, preferably at the same time of day.
Daily weight measurements provide valuable data on fluid balance and can help detect changes indicative of fluid volume deficit or excess.
Identify the possible cause of the fluid disturbance or imbalance.
Understanding the underlying cause of fluid volume deficit helps tailor interventions and address the root problem.
Monitor active fluid loss from wound drainage, tubes, diarrhea, bleeding, and vomiting; maintain an accurate input and output record.
Monitoring fluid losses helps determine the extent of fluid volume deficit and guides appropriate fluid replacement.
During treatment, monitor closely for signs of circulatory overload, such as headache, flushed skin, tachycardia, venous distention, elevated central venous pressure (CVP), shortness of breath, increased BP, tachypnea, and cough.
Vigilant monitoring for signs of circulatory overload helps prevent complications associated with excessive fluid replacement.
Monitor and document hemodynamic status, including CVP, pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP) if available in the hospital setting.
Monitoring hemodynamic parameters provides valuable information on fluid status and guides appropriate interventions.
Monitor for the existence of factors causing deficient fluid volume, such as gastrointestinal losses, difficulty maintaining oral intake, fever, uncontrolled type II diabetes mellitus, and diuretic therapy.
Identifying and addressing factors contributing to fluid volume deficit helps prevent further imbalances and complications.
Educate the patient and family members about the importance of maintaining hydration and recognizing signs of fluid volume deficit.
Patient and family education promotes understanding of the condition, encourages adherence to fluid replacement strategies, and enables early detection of fluid volume deficit.
Collaborate with the healthcare team to develop an individualized fluid replacement plan based on the patient’s specific needs and underlying condition.
Tailoring the fluid replacement plan to the patient’s unique requirements ensures optimal management of fluid volume deficit and prevents fluid overload.
Monitor laboratory studies, such as complete blood count (CBC), electrolyte levels, and renal function tests, as indicated.
Regular monitoring of laboratory values helps assess the severity of fluid volume deficit, guide appropriate fluid replacement therapies, and monitor the patient’s response to treatment.
Assess the patient’s readiness and ability to manage oral fluid intake. Provide assistance, if needed, to ensure adequate hydration.
Some patients may require support in managing their oral fluid intake due to physical limitations, cognitive impairments, or other factors. Assisting with hydration promotes optimal fluid balance.
Implement measures to prevent and manage complications associated with fluid volume deficit, such as deep vein thrombosis (DVT) prophylaxis, regular repositioning, and skin care. Fluid volume deficit increases the risk of complications such as DVT and pressure ulcers. Implementing preventive measures reduces the likelihood of these complications.
Collaborate with the dietitian to develop a balanced diet plan that meets the patient’s nutritional needs while considering fluid restrictions, if applicable.
Adequate nutrition supports overall health and helps optimize fluid balance.
Assess the patient’s understanding of the fluid management plan and provide education on self-care strategies to prevent fluid volume deficit.
Patient education promotes self-management and empowers the patient to take an active role in maintaining fluid balance.
Continuously evaluate and reassess the effectiveness of interventions and modify the fluid management plan as needed.
Regular evaluation and modification of the fluid management plan ensure ongoing optimization of fluid volume balance and prevention of complications.
Nursing interventions are crucial in managing hypovolemia and dehydration by restoring fluid balance, preventing complications, and promoting health, and may include monitoring vital signs, administering fluids, and managing underlying conditions.
1. Urge the patient to drink the prescribed amount of fluid.
Oral fluid replacement is indicated for mild fluid deficit and is a cost-effective method for replacement treatment. Older patients have a decreased sense of thirst and may need ongoing reminders to drink. Being creative in selecting fluid sources (e.g., flavored gelatin, frozen juice bars, sports drink) can facilitate fluid replacement. Oral hydrating solutions (e.g., Rehydralyte) can be considered as needed.
2. Aid the patient if they cannot eat without assistance, and encourage the family or SO to assist with feedings as necessary.
Dehydrated patients may be weak and unable to meet prescribed intake independently.
3. If the patient can tolerate oral fluids, give what oral fluids the patient prefers. Provide fluid and straw at bedside within easy reach. Provide fresh water and a straw.
Most elderly patients may have a reduced sense of thirst and may require continuing reminders to drink.
4. Emphasize the importance of oral hygiene.
A fluid deficit can cause a dry, sticky mouth. Attention to mouth care promotes interest in drinking and reduces the discomfort of dry mucous membranes.
5. Provide a comfortable environment by covering the patient with light sheets.
Drop situations where patients can experience overheating to prevent further fluid loss.
6. Plan daily activities.
Planning conserves the patient’s energy.
Interventions for severe hypovolemia:
7. Insert an IV catheter to have IV access.
Parenteral fluid replacement is indicated to prevent or treat hypovolemic complications.
8. Administer parenteral fluids as prescribed. Consider the need for an IV fluid challenge with an immediate infusion of fluids for patients with abnormal vital signs.
Fluids are necessary to maintain hydration status. Determination of the type and amount of fluid to be replaced and infusion rates will vary depending on clinical status.
9. Administer blood products as prescribed.
Blood transfusions may be required to correct fluid loss from active gastrointestinal bleeding.
10. Maintain IV flow rate. Stop or delay the infusion if signs of fluid overload transpire, refer to physician respectively.
Most susceptible to fluid overload are elderly patients and require immediate attention.
11. Assist the physician with inserting the central venous line and arterial line, as indicated.
A central venous line allows fluids to be infused centrally and for monitoring of CVP and fluid status. An arterial line allows for the continuous monitoring of BP.
12. Provide measures to prevent excessive electrolyte loss (e.g., resting the GI tract, administering antipyretics as ordered by the physician).
Fluid losses from diarrhea should be concomitantly treated with antidiarrheal medications, as prescribed. Antipyretics can decrease fever and fluid losses from diaphoresis.
13. Begin to advance the diet in volume and composition once ongoing fluid losses have stopped.
The addition of fluid-rich foods can enhance continued interest in eating.
14. Encourage to drink bountiful amounts of fluid as tolerated or based on individual needs.
A patient may have restricted oral intake in an attempt to control urinary symptoms, reducing homeostatic reserves and increasing the risk of dehydration or hypovolemia.
15. Enumerate interventions to prevent or minimize future episodes of dehydration.
A patient needs to understand the value of drinking extra fluid during bouts of diarrhea, fever, and other conditions causing fluid deficits.
16. Educate patient about possible causes and effects of fluid loss or decreased fluid intake.
Enough knowledge aids the patient in taking part in their plan of care.
17. Emphasize the relevance of maintaining proper nutrition and hydration.
Increasing the patient’s knowledge level will assist in preventing and managing the problem.
18. Teach family members how to monitor output in the home. Instruct them to monitor both intake and output.
An accurate measure of fluid intake and output is an important indicator of a patient’s fluid status.
19. Refer patient to home health nurse or private nurse to assist patient, as appropriate.
Continuity of care is facilitated through the use of community resources.
20. Identify an emergency plan, including when to ask for help.
Some complications of deficient fluid volume cannot be reversed in the home and are life-threatening. Patients progressing toward hypovolemic shock will need emergency care.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
References and Sources
Additional references and recommended readings for this fluid volume deficit care plan guide:
- Corrigan, A., Gorski, L., Hankins, J., Perucca, R., & Alexander, M. (2009). Infusion nursing: An evidence-based approach. Elsevier Health Sciences.
- Docherty, B., & McIntyre, L. (2002). Nursing considerations for fluid management in hypovolaemia. Professional nurse (London, England), 17(9), 545-549.
- Marik, P. E., Monnet, X., & Teboul, J. L. (2011). Hemodynamic parameters to guide fluid therapy. Annals of intensive care, 1(1), 1.
- McGee, S., Abernethy III, W. B., & Simel, D. L. (1999). Is this patient hypovolemic?. Jama, 281(11), 1022-1029.
- Meyers, K. A. (1988). Nursing management of hypovolemic shock. Critical care nursing quarterly, 11(1), 57-67.
- Pellico, L. H., Bautista, C., & Esposito, C. (2012). Focus on adult health medical-surgical nursing.
- Saavedra, J. M., Harris, G. D., Li, S., & Finberg, L. (1991). Capillary refilling (skin turgor) in the assessment of dehydration. American journal of diseases of children, 145(3), 296-298.
- Scales, K. (2014). NICE CG 174: intravenous fluid therapy in adults in hospital. British journal of nursing (Mark Allen Publishing), 23(8), S6-S8.
- Shimizu, M., Kinoshita, K., Hattori, K., Ota, Y., Kanai, T., Kobayashi, H., & Tokuda, Y. (2012). Physical signs of dehydration in the elderly. Internal medicine, 51(10), 1207-1210.
- Shires, T., COLN, D., Carrico, J., & LIGHTFOOT, S. (1964). Fluid therapy in hemorrhagic shock. Archives of surgery, 88(4), 688-693.
- Sinert, R., & Spektor, M. (2005). Clinical assessment of hypovolemia. Annals of emergency medicine, 45(3), 327-329.
4 thoughts on “Fluid Volume Deficit (Dehydration & Hypovolemia) Nursing Care Plan and Management”
AMAZING……..GOD BLESS YOU
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Great article but complications related to dehydration should be added.
Thank you very much
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