Dehydration

Dehydration Nursing Care Plans Diagnosis and Interventions

Dehydration NCLEX Review Care Plans

Nursing Study Guide on Dehydration

Dehydration refers to the deficit of fluids in the body to carry out normal bodily functions. Fluid balance is an important aspect of the body’s overall health. It is responsible for maintaining renal and cardiac functions as well as electrolyte balance.

A shortfall in the body’s fluid level, such as in cases of dehydration, can lead to serious health conditions.

Dehydration can occur in both children and adults. However, babies, children, and the elderly are likely to get more serious symptoms and complications from severe dehydration.

Dehydration can easily be prevented by regular fluid intake. It can also be easily treated upon early detection and management.

Signs and Symptoms of Dehydration

The signs and symptoms of dehydration are related to how much water is lost. They can be mild, moderate, to severe and usually start with thirst and dark-colored urine.

The signs and symptoms of dehydration can also differ in children and adults.

Dehydration in Infants and Children

  • Dry mouth, lips, and tongue
  • Absence of tears when crying
  • Dry diapers for three hours or more
  • Sunken eyes and cheeks
  • Sinking of the soft spot on top of the skull
  • Irritability

Dehydration in Adults

  • Extreme thirst
  • Infrequent urination
  • Dark-colored urine
  • String-smelling urine
  • Fatigue
  • Dizziness or light-headedness
  • Confusion

Causes and Risk Factors of Dehydration

Dehydration occurs due to two main mechanisms: inadequate fluid intake and losing fluid more than what is taken. However, there can be different factors as to why these mechanisms occur. These may include:

  • Illness – most illnesses can cause increased fluid loss due to the increased metabolic demands. However, some illnesses have a higher rate of fluid loss such as diarrhea and vomiting. These two conditions are the most common causes of dehydration in infants and children.
  • Sweating – extensive sweating after an episode of fever, exercise, or manual labor especially in hot weather can cause dehydration. Children and teens are more prone to dehydration from sweating as they are likely to ignore the symptoms such as thirst.
  • Alcohol – Alcohol is a diuretic and therefore can increase the frequency of urination. The headache that comes after a hangover is a symptom of dehydration.
  • Increased urination – several conditions and medications can cause increased urinary frequency. One of the most common medical conditions that can cause dehydration is diabetes. The body compensates for the high blood sugar level by producing more urine to excrete the excess sugar in the bloodstream. on the other hand, certain drugs can also cause dehydration such as diuretics and antihypertensive drugs.

Complications of Dehydration

  1. Heat injury. One of the functions of fluids in the body is thermoregulation. Dehydration can cause mild to severe heat injuries including life-threatening heatstroke.
  2. Urinary and renal problems. Dehydration predisposes the body to kidney stones, urinary tract infections, and kidney failure.
  3. Seizures. Seizures can occur because of electrolyte imbalances caused by dehydration.
  4. Hypovolemic shock. This condition is one of the most serious complications of dehydration. It occurs when there is severely low blood volume resulting in low blood pressure leading to a drop in oxygen delivery.

Diagnosis of Dehydration

The diagnosis of dehydration is often reliant on the presence of the signs and symptoms and the results of physical examination. Other procedures such as blood tests and urine tests can also be performed to confirm the diagnosis.

  • Physical Examination –this will include the assessment of the presence of signs and symptoms and basic vitals signs measurement. Having low blood pressure is highly associated with dehydration and it is taken after standing up from a lying or sitting position. Also, a higher than normal heart rate may be noted in dehydration which is part of the body’s compensatory mechanism.
  • Blood tests – electrolyte levels and kidney functions test may be performed to confirm the diagnosis. Higher electrolytes level may be expected as they may be diluted due to low blood volume secondary to dehydration.
  • Urinalysis – a simple urine test may help check for the presence of dehydration. It is also a helpful way to check for infections that are likely in dehydrated individuals.

Treatment for Dehydration

Dehydration can easily be corrected through the replacement of the lost fluid. However, several factors need to be taken into accounts such as the severity of dehydration, age of the patient, and the cause of the fluid loss. The treatment may also be slightly different for children and adults.

In Babies:

  • Seeking the help of a healthcare provider is strongly recommended when dehydration is suspected in an infant. If the dehydration is due to diarrhea, increasing the frequency of feeding and giving extra fluids are recommended. However, it is discouraged to give fruit juices as it may make diarrhea worse.
  • Hospitalization may be necessary in cases of moderate to severe dehydration.

In Children:

  • It is recommended that dehydrated children be given fluids with electrolytes because pure water can dilute the little electrolytes left in their system.
  • Offer fluids more frequently.
  • Hospital management may be necessary in severe cases of dehydration. Treatment may include intravenous fluid infusion.

In Adults:

  • Most adults can reverse dehydration through increasing oral fluid intake.
  • Working in cooler places can help reduce water loss.
  • Sports drinks containing electrolytes and carbohydrates are often helpful.
  • Hospital management of dehydration may be required in severe cases or if the individual is not responding to earlier treatments.

Nursing Care Plans for Dehydration

Nursing Care Plan 1

Nursing Diagnosis: Fluid Volume Deficit related to dehydration due to fever as evidenced by temperature of 39.0 degrees Celsius, skin turgidity, dark yellow urine output, profuse sweating, and blood pressure of 89/58.

Desired Outcome: Within 48 hours of nursing interventions, the patient will have a stabilized temperature within the normal range and will verbalize feeling more comfortable.

InterventionsRationales
Commence a fluid balance chart, monitoring the input and output of the patient.To monitor patient’s fluid volume accurately and effectiveness of actions to reverse dehydration.
Start intravenous therapy as prescribed. Encourage oral fluid intake.To replenish the fluids lost from profuse sweating, and to promote better blood circulation around the body.
Educate the patient (or guardian) on how to fill out a fluid balance chart at bedside.To help the patient or the guardian take ownership of the patient’s care, encouraging them to drink more fluids as needed, or report any changes to the nursing team. 
Monitor patient’s serum electrolytes and recommend electrolyte replacement therapy (oral or IV) to the physician as needed.Sodium is one of the important electrolytes that are lost when a person is sweating. Hyponatremia or low serum sodium level may cause brain swelling.
Remove excessive clothing, blankets, and linens. Adjust the room temperature.To regulate the temperature of the environment and make it more comfortable for the patient.
Administer the prescribed antibiotic and anti-pyretic medications.Use the antibiotic to treat bacterial infection if present, which is the underlying cause of the patient’s hyperthermia. Antibiotics are not required if the infection is viral.
Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.
Offer a tepid sponge bath.To facilitate the body in cooling down and to provide comfort.
Elevate the head of the bed.Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.

Nursing Care Plan 2

Nursing Diagnosis: Fluid Volume Deficit related to blood volume loss secondary to gastrointestinal bleeding as evidenced by hematemesis, HB of 70, skin pallor, blood pressure level of 85/58, and lightheadedness

Desired Outcome: The patient will have an absence of GI bleeding, a hemoglobin (HB) level of over 100, blood pressure level within normal range, full level of consciousness, and normal skin color.

InterventionsRationales
Assess vital signs, particularly blood pressure level.Hypovolemia due to GI bleeding may lower blood pressure levels and put the patient at risk for hypotensive episodes that lead to shock.
Commence a fluid balance chart, monitoring the input and output of the patient. Include episodes of vomiting, gastric suctioning, and other gastric losses in the I/O charting.To monitor patient’s fluid volume accurately.
Start intravenous therapy as prescribed. Electrolytes may need to be replaced intravenously.     Encourage oral fluid intake of at least 2000 mL per day if not contraindicated.To replenish the fluids and electrolytes lost from vomiting or other gastric losses, and to promote better blood circulation around the body.
Educate the patient (or guardian) on how to fill out a fluid balance chart at bedside.To help the patient or the guardian take ownership of the patient’s care, encouraging them to drink more fluids as needed, or report any changes to the nursing team. 
Administer blood transfusion as prescribed.To increase the hemoglobin level and treat anemia, dehydration, and hypovolemia related to GI bleeding.

Nursing Care Plan 3

Nursing Diagnosis: Risk for Fluid Volume Deficit due to osmotic diuresis secondary to diabetes

Desired Outcome: The patient will demonstrate adequate hydration and balanced fluid volume

InterventionsRationales
Assess vital signs and signs of dehydration.Hyperglycemia may cause Kussmaul’s respirations and/or acetone breath. Hypotension and tachycardia may result from hypovolemia, or low levels of intravascular volume.
Commence a fluid balance chart, monitoring the input and output of the patient.To monitor patient’s fluid volume accurately and effectiveness of actions to monitor signs of dehydration.
Start intravenous therapy as prescribed. Encourage oral fluid intake of at least 2500 mL per day if not contraindicated.To replenish the fluids lost from polyuria and to promote better blood circulation around the body.
Educate the patient (or guardian) on how to fill out a fluid balance chart at bedside.To help the patient or the guardian take ownership of the patient’s care, encouraging them to drink more fluids as needed, or report any changes to the nursing team. 
Monitor patient’s serum electrolytes and recommend electrolyte replacement therapy (oral or IV) to the physician as needed.Sodium is one of the important electrolytes that are lost when a person is passing urine. Hyponatremia or low serum sodium level may cause brain swelling.
Encourage proper oral hygiene.Dehydration may cause dryness of the oral mucosa. Proper mouth care can also encourage the patient to have more interest in drinking fluids.

Other Possible Nursing Diagnosis:

  • Fatigue
  • Risk for Seizures
  • Risk for Shock
  • Acute Confusion
  • Failure to Thrive (Infants)

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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