Which mechanism would the nurse use to explain a patients insensible water loss of an estimated 900 mL day?

Use this guide to help you formulate nursing care plans for deficient fluid volume (dehydration).

Deficient Fluid Volume (also known as Fluid Volume Deficit (FVD), 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.

SEE ALSO: Nursing Diagnosis Complete List and Guide » 

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.

• Causes
• Signs and Symptoms
• Goals and Outcomes
• Nursing Assessment and Rationales for Fluid Volume Deficit
• Nursing Interventions for Fluid Volume Deficit
• Recommended Resources
• See also
• References and Sources

Causes

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)
• Bleeding
• Movement of fluid into third space.
• Diarrhea
• Diuresis
• 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 for Fluid Volume Deficit

Assessment is necessary to identify potential problems that may have led to fluid volume deficit and name any episode that may occur during nursing care.

1. Monitor and document vital signs, especially BP and HR.
A decrease in circulating blood volume can cause hypotension and tachycardia. Alteration in HR is a compensatory mechanism to maintain cardiac output. Usually, the pulse is weak and irregular if electrolyte imbalance also occurs. Hypotension is evident in hypovolemia.

2. Assess skin turgor and oral mucous membranes for signs of dehydration.
Signs of dehydration are also detected through the skin. The skin of elderly patients losses elasticity; hence skin turgor should be assessed over the sternum or on the inner thighs. Longitudinal furrows may be noted around the tongue.

3. Monitor BP for orthostatic changes (changes seen when changing from supine to standing position). Monitor HR for orthostatic changes.
A common manifestation of fluid loss is postural hypotension. It is manifested by a 20-mm Hg drop in systolic BP and a 10 mm Hg drop in diastolic BP. The incidence increases with age.

4. Assess alteration in mentation/sensorium (confusion, agitation, slowed responses).
Alteration in mentation/sensorium may be caused by abnormally high or low glucose, electrolyte abnormalities, acidosis, decreased cerebral perfusion, or developing hypoxia. Impaired consciousness can predispose a patient to aspiration regardless of the cause.

5. Assess color and amount of urine. Report urine output less than 30 ml/hr for two (2) consecutive hours.
Normal urine output is considered normal, not less than 30ml/hour. Concentrated urine denotes fluid deficit.

6. Monitor and document temperature.
Febrile states decrease body fluids by perspiration and increased respiration. This is known as insensible water loss.

7. Monitor fluid status in relation to dietary intake.
Most fluid comes into the body through drinking, water in food, and water formed by the oxidation of foods. Verifying if the patient is on a fluid restraint is necessary.

8. Note the presence of nausea, vomiting, and fever.
These factors influence intake, fluid needs, and route of replacement.

9. Auscultate and document heart sounds; note rate, rhythm, or other abnormal findings.
Cardiac alterations like dysrhythmias may reflect hypovolemia or electrolyte imbalance, commonly hypocalcemia. MI, pericarditis, and pericardial effusion with/ without tamponade are common cardiovascular complications.

10. Monitor serum electrolytes and urine osmolality, and report abnormal values.
Elevated blood urea nitrogen suggests fluid deficit. Urine-specific gravity is likewise increased.

11. Ascertain whether the patient has any related heart problem before initiating parenteral therapy.
Cardiac and older patients are often susceptible to fluid volume deficit and dehydration due to minor changes in fluid volume. They also are susceptible to the development of pulmonary edema.

12. Weigh daily with the same scale, and preferably at the same time of day.
Weight is the best assessment data for possible fluid volume imbalance. An increase in 2 lbs a week is considered normal.

13. Identify the possible cause of the fluid disturbance or imbalance.
Establishing a database of history aids accurate and individualized care for each patient.

14. Monitor active fluid loss from wound drainage, tubes, diarrhea, bleeding, and vomiting; maintain accurate input and output record.
Fluid loss from wound drainage, diarrhea, bleeding, and vomiting cause decreased fluid volume and can lead to dehydration.

15. During treatment, monitor closely for signs of circulatory overload (headache, flushed skin, tachycardia, venous distention, elevated central venous pressure [CVP], shortness of breath, increased BP, tachypnea, cough).
Close monitoring for responses during therapy reduces complications associated with fluid replacement.

16. Monitor and document hemodynamic status, including CVP, pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP) if available in the hospital setting.
These direct measurements serve as an optimal guide for therapy.

17. Monitor for the existence of factors causing deficient fluid volume (e.g., gastrointestinal losses, difficulty maintaining oral intake, fever, uncontrolled type II diabetes mellitus, diuretic therapy).
Early detection of risk factors and early intervention can decrease the occurrence and severity of complications from deficient fluid volume. The gastrointestinal system is a common site of abnormal fluid loss.

Nursing Interventions for Fluid Volume Deficit

The following are the therapeutic nursing interventions for fluid volume deficit:

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 Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

• Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
  An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
• Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
  A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
• NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
  The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
• Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
  Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
  Useful for creating nursing care plans related to mental health and psychiatric nursing.
• Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
  Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
• Maternal Newborn Nursing Care Plans (3rd Edition)
  If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
• Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
  An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
• All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
  Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

See also

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 Deficient Fluid Volume care plan guide:

1. Ackley, B. J., Ladwig, G. B., Msn, R. N., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care. Mosby.
2. Carpenito-Moyet, L. J. (2006). Handbook of nursing diagnosis. Lippincott Williams & Wilkins.
3. Corrigan, A., Gorski, L., Hankins, J., Perucca, R., & Alexander, M. (2009). Infusion nursing: An evidence-based approach. Elsevier Health Sciences.
4. Docherty, B., & McIntyre, L. (2002). Nursing considerations for fluid management in hypovolaemia. Professional nurse (London, England), 17(9), 545-549.
5. Marik, P. E., Monnet, X., & Teboul, J. L. (2011). Hemodynamic parameters to guide fluid therapy. Annals of intensive care, 1(1), 1.
6. McGee, S., Abernethy III, W. B., & Simel, D. L. (1999). Is this patient hypovolemic?. Jama, 281(11), 1022-1029.
7. Meyers, K. A. (1988). Nursing management of hypovolemic shock. Critical care nursing quarterly, 11(1), 57-67.
8. Pellico, L. H., Bautista, C., & Esposito, C. (2012). Focus on adult health medical-surgical nursing.
9. 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.
10. Scales, K. (2014). NICE CG 174: intravenous fluid therapy in adults in hospital. British journal of nursing (Mark Allen Publishing), 23(8), S6-S8.
11. 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.
12. Shires, T., COLN, D., Carrico, J., & LIGHTFOOT, S. (1964). Fluid therapy in hemorrhagic shock. Archives of surgery, 88(4), 688-693.
13. Sinert, R., & Spektor, M. (2005). Clinical assessment of hypovolemia. Annals of emergency medicine, 45(3), 327-329.

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