Last updated on May 18th, 2022 at 06:51 am
Dehydration Nursing Care Plans Diagnosis and Interventions
Dehydration NCLEX Review and Nursing Care Plans
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
- 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.
- Urinary and renal problems. Dehydration predisposes the body to kidney stones, urinary tract infections, and kidney failure.
- Seizures. Seizures can occur because of electrolyte imbalances caused by dehydration.
- 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 Diagnosis for Dehydration
Nursing Care Plan for Dehydration 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.
| Nursing Interventions for Dehydration | Rationales |
| 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 for Dehydration 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.
| Nursing Interventions for Dehydration | Rationales |
| 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 for Dehydration 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
| Nursing Interventions for Dehydration | Rationales |
| 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. |
Nursing Care Plan for Dehydration 4
Risk for Deficient Volume (Dehydration)
Nursing Diagnosis: Risk for Deficient Volume (Dehydration) related to fluid loss via normal channels, contractions with force, and premature placental separation secondary to precipitous labor.
As a risk nursing diagnosis, the Risk for Deficient Volume is entirely unrelated to any signs and symptoms since it has not yet developed in the patient, and safety precautions will be initiated instead.
Desired Outcomes:
- The patient will determine personal risk factors and suitable actions.
- To avoid the development of a fluid volume deficit, the patient will display behaviors or make lifestyle modifications.
- The patient will verbalize her awareness of the reasons causing the fluid deficit and the activities required to correct it.
| Nursing Interventions for Dehydration | Rationale |
| Keep an eye on the intake and outflow balance. | This approach ensures that the patient’s fluid is still in a normal state. |
| Encourage oral consumption of fluids. | This intervention aims to assist in the replacement of fluid losses. |
| Medication for dehydration should be administered as directed. | This intervention will repair and rule out any underlying problems. |
| Examine the proper usage of drugs. | Evaluate other medications that have the potential to cause or exacerbate dehydration. |
| Examine the patient’s vital signs, primarily her blood pressure. | Dehydration or hypovolemia can cause blood pressure to drop, putting the patient at increased risk for hypotensive crises that might result in death if not addressed immediately. |
| As directed, administer uterotonic drugs and other medications. Uterotonic drugs are used to avoid postpartum hemorrhage that may also lead to hypovolemia or dehydration. This type of medication is utilized as the first-line treatment in cases of precipitous labor. | |
| As directed, insert an indwelling catheter into the patient. | This technique tries to evaluate the patient’s urinary output precisely, indicating the risk of volume deficiency. |
| Begin a fluid balance chart, and track the patient’s input and output. The amount of blood-soaked pads used within 24 hours should also be monitored. | This intervention seeks to monitor the patient’s fluid balance correctly and check for any severe complications. |
| Begin intravenous treatment as directed. Electrolytes may need to be supplied intravenously. | This intervention tries to replace fluids and electrolytes eliminated due to dehydration and improve circulation throughout the body. |
| Instruct the patient and significant others on how to complete a fluid balance sheet at the bedside. | This intervention encourages the patient or significant others to take charge of their care by persuading them to drink more fluids. This method also tries to notify the healthcare personnel of any developments. |
| Establish an emergency strategy, including when to seek assistance. | Some effects of low fluid volume are fatal and cannot be corrected at home. Patients on the verge of hypovolemia or severe dehydration will require immediate care, especially women who underwent precipitous labor. Provide the following safety precautions: Bed placed in a supine positionFrequent monitoring of the patientGentle restraintsProvide side rails Fluid shifts can produce cerebral edema and mentation abnormalities, especially in mothers who have had a precipitous labor. |
| Keep an eye on the patient’s vital signs and central venous pressure. Observe for temperature rises and postural hypotension. | Tachycardia and different degrees of hypotension are evident, depending on fluid loss. Central venous pressure measurements can assist in determining the extent of fluid deficiency and responsiveness to replacement therapy. Fever speeds up metabolism and enhances fluid loss. Vital signs are one of the most critical parameters to monitor, especially after precipitous labor. |
| Encourage patients to drink as many liquids as they can tolerate or as their bodies require. | In an attempt to regulate urinary symptoms, a patient may have decreased oral intake, diminishing homeostatic resources and raising the likelihood of dehydration or hypovolemia. |
| List interventions that can be used to prevent or reduce future instances of dehydration. | A patient must understand the importance of drinking additional water during episodes of diarrhea, fever, and other illnesses that may cause fluid deficits to worsen. |
| Educate the patient on the various causes and implications of fluid loss or decreased fluid intake related to precipitous labor. | Sufficient understanding allows the patient to participate in their treatment regimen. |
Nursing Care Plan for Dehydration 5
Risk for Deficient Fluid Volume (Dehydration)
Nursing Diagnosis: Risk for Deficient Fluid Volume (Dehydration) related to low serum protein level, augmented blood sugar levels, and incapacity to respond to thirst mechanisms due to NPO (nothing by mouth) status.
Desired Outcomes:
- The patient will be normovolemic if systolic blood pressure is 90 mm Hg or above, there is no orthostasis, the heart rate is 60 to 90 beats per minute, the urine output should be at least 30 ml per hour, and skin turgor is acceptable.
- The patient will describe the procedures that can be used to treat and prevent fluid volume loss.
- The patient will recount symptoms that point to the need for a visit with a health care practitioner.
| Nursing Interventions for Dehydration | Rationale |
| Examine for the following signs and symptoms of low fluid volume: Skin integrity Tachycardia Hypotension High urine specific gravity | Skin dryness and low skin turgidity come from diminished fluid content. When there is a fluid volume shortage, the heart rate increases to compensate. A lack of fluid volume reduces circulatory volume and contributes to a drop in blood pressure. Urine becomes more diluted when fluid volume decreases. |
| Evaluate urine production every hour. | Substantially lower urine production than fluid intake indicates a fluid volume imbalance, hence needing extra fluid to avoid dehydration. |
| Keep an eye on laboratory studies as directed: Protein levels in the blood. Sugar levels in the blood. | Protein levels are typically checked every 3 to 7 days; decreased plasma protein levels might cause fluid leakage from intravascular regions due to low colloidal pressures. Hyperglycemia generated by a high glucose concentration in the TPN solutions might result in a hyperosmolar, nonketotic unconsciousness with consequent dehydration due to osmotic diuresis. |
| Unless contraindicated, advise an increase in oral fluid intake. In combination with TPN, administer maintenance or bolus liquids as directed. | Patients in NPO (nothing by mouth) situation who only receive TPN may be getting insufficient fluids, mainly because TPN begins at moderate administration rates; hence, extra fluids may be necessary. |
| Weigh the patient every day in the first week of TPN administration and then once a week. | Daily weights are required to establish whether or not nutritional requirements are fulfilled. Weight can also be used to determine fluid volume conditions. A daily weight reduction of more than half a pound may suggest a fluid volume deficiency. |
| Infuse 10 percent dextrose in water until the total parenteral nutrition infusion is restarted; if the infusion is interrupted, infuse another 10 percent dextrose in water until the Total parenteral nutrition infusion is restarted again. | This replacement infusion supplies essential fluid while also shielding the patient from hypoglycemia; hypoglycemia can occur when the patient’s physiologically adjusted high glucose concentration is abruptly discontinued. |
| Parenteral fluids should be administered as directed. Consider if individuals with aberrant vital signs require an IV fluid supplement with an urgent infusion of fluids. | Fluids are required to keep the body hydrated. The type and amount of fluid to be restored and the rate of infusion will be determined by the patient’s condition. |
Nursing Care Plan for Dehydration 6
Risk for Deficient Fluid Volume (Dehydration)
Nursing Diagnosis: Risk for Deficient Fluid Volume (Dehydration) related to the vascular nature of the surgical region, difficulties in limiting hemorrhage, restricted intake preoperatively and post-obstructive diuresis secondary to prostatectomy.
Desired Outcomes:
- The patient will maintain adequate hydration as demonstrated by stabilized vital signs, palpable peripheral pulses, excellent capillary refill, hydrated mucosal membranes, and sufficient urine output.
- There should be no active bleeding.
- The client will verbalize individual dietary and fluid limits.
- The client will exhibit actions to maintain fluid status and avoid or restrict relapse.
- The client will demonstrate the balanced fluid volume as demonstrated by stable vital signs and controlled intake and output.
| Nursing Interventions for Dehydration | Rationale |
| Keep track of intake and output. . | This marker indicates adequate fluid and replacement needs. Monitoring is critical for quantifying blood loss and evaluating urine output during bladder irrigations. Significant diuresis may develop after removing the urinary tract obstruction during the early recovery process |
| Watch vital signs for accelerated pulse and respiration, lowered blood pressure, diaphoresis, pale complexion, impaired capillary refill, and dry mucous membranes. | Dehydration or hypovolemia must be treated as soon as possible to avoid approaching shock. Thus, hypertension, arrhythmia, nausea, and vomiting are symptoms of “TURP syndrome,” requiring prompt medical attention. |
| Examine uneasiness, disorientation, and behavioral changes. | These symptoms may represent poor cerebral perfusion (hypovolemia) or cerebral edema caused by an excessive amount of solution received into the venous sinusoids during the TUR procedure (TURP syndrome). |
| Avoid unnecessary movement by anchoring the catheter. | Moving or dragging the catheter may result in hemorrhage or clot development, catheter clogging, and bladder distension. |
| Unless prohibited, increase fluid consumption to 3000 mL/day. | This intervention removes germs and debris from the kidneys and bladder (clots). Water intoxication or fluid excess may occur if not adequately monitored. |
| Examine catheter drainage, noting any severe or ongoing bleeding. | For the perineal approach, bleeding is relatively uncommon during the first 24 hours. Continued severe hemorrhage or a repeat of active bleeding necessitates clinical examination and immediate management. |
| Examine the color and consistency of the urine. The color is brilliant crimson with bright red clots. Dark maroon with dark clots and high viscosity. There is bleeding but no clots. | Usually implies arterial hemorrhage and necessitates aggressive treatment. The most prevalent type of hemorrhage is a venous source. Usually goes away on its own. Blood dyscrasias or systemic clotting issues may be present. |
| Evaluate the dressings and wound drains. If necessary, weigh the dressings. Take note of the hematoma development. | Bleeding may be visible or hidden inside perineum layers. |
| Minimize rectal temperature recording and the use of rectal tubes or enemas. | Recurrent irritation to the prostatic bed and more tremendous pressure on the prostatic capsule may occur with the risk of blood clots. |
| Keep an eye on laboratory tests as directed: RBCs Hb/Hct Platelet count and coagulation assays | Helpful in determining loss of blood or replenishment requirements. Complications such as clotting factor deficiency and disseminated intravascular coagulation may suggest a worsening concern. |
| As directed, administer IV treatment or blood products. | If oral intake is insufficient, extra fluids or blood transfusions may be required. |
| Retain traction on the indwelling urinary catheter and bind it to the inner thigh. | Traction on the 30-mL balloon inserted in the prostatic urinary fossa produces tension on the prostatic capsule’s vascular supply, which aids in the prevention and management of hemorrhage. |
| Traction should be released within 4–5 hours. Record the duration of the application and, if applicable, the release of traction. | Extended traction may result in lifelong damage or urine control issues. |
| As directed, use bowel softeners and laxatives. | Constipation and straining for feces can minimize the incidence of rectal-perineal hemorrhage. |
| Evaluate urine output and drainage system during bladder irrigation. | Retention can develop due to postoperative edema, internal bleeding, or bladder spasms. Urine output can also be used to determine the fluid balance state. |
| In order to emphasize the importance of excellent nutrition, encourage the patient to add fruits and fiber to the diet and adequate fluid consumption. | This treatment accelerates healing and reduces dehydration, lowering the risk of postoperative hemorrhage. |
| Highlight the importance of appropriate nutrition and hydration. | Improving the patient’s understanding will aid in preventing and managing the condition. |
| Educate members of the family on how to check output in the home. Teach them to keep track of both intake and output. | A precise measurement of fluid intake and output is a critical sign of a patient’s fluid condition. |
| Refer the patient to a home health nurse or a private nurse for assistance as needed. | The use of local resources promotes the continuum of care. |
| Create an emergency plan, indicating when to seek assistance. | Some effects of low fluid volume are life-threatening and cannot be corrected at home. Patients who are on the brink of hypovolemic shock will require immediate care. |
More Dehydration 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. (2022). 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. (2020). 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
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