Fluid Volume Deficit Nursing Diagnosis and Nursing Care Plan

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Fluid Volume Deficit Nursing Care Plans Diagnosis and Interventions

Fluid Volume Deficit NCLEX Review and Nursing Care Plans

Deficient fluid volume, also referred to as Fluid Volume Deficit (FVD), hypovolemia, and even dehydration, is a state in which the fluid volume homeostasis is disturbed due to various factors such as blood loss or body fluid and electrolyte loss.

Its incidence is hard to quantify due to non-specific symptoms such as weakness, fatigue, dizziness, muscle cramps, and thirst. Severe hypovolemia may lead to complications such as hypovolemic shock, ischemic stroke, and liver failure.

Causes of Deficient Fluid Volume

Common causes of deficient fluid volume may be classified into renal and extrarenal causes. Renal causes include diuretic excess, mineralocorticoid deficiency, ketonuria, osmotic diuresis, cerebral salt wasting syndrome, and salt-wasting nephropathies; and extrarenal causes which include vomiting, diarrhea, third spacing of fluid, burns, pancreatitis, trauma, and bleeding.

Risk Factors to Deficient Fluid Volume

Risk factors to deficient fluid volume are diseases that lead to disturbance of fluid volume homeostasis, which include vomiting, diarrhea, kidney diseases, or decreased blood clotting ability. Note that these are just risk factors and not all people who exhibit these will develop hypovolemia.

Signs and Symptoms of Deficient Fluid Volume

Managing deficiency in fluid volume is an important part of patient care especially those patients who are inpatient, in which specific management must be adjusted according to patient needs.

No universal protocol exists that fits all patients and thus, to properly care for and manage the fluids of a specific patient, it is important to determine if this patient is fluid deficient or overloaded. The distinction between such conditions may be done through examination of the patient’s vital signs, physical examination findings, and laboratory findings. The following lists the typical findings in hypovolemia:

  1. Physiologic Indicators
    • Weight: The gold standard for determining the fluid status of a patient is through his or her weight. This diagnostic modality is sensitive for fluid volume status in that a decrease in weight indicates a fluid deficit.
    • Heart rate: Tachycardia or a heart rate of more than 100 beats per minute is indicative of fluid deficit as it may serve as a compensatory response to hypovolemia.
    • Blood pressure: Hypotension is a typical finding of hypovolemia as it indicates that compensatory mechanisms can no longer accommodate for the hypovolemic state that the body of the patient is in.
    • Orthostatic vital signs: Orthostatic hypotension is a condition in which lowering of at least 20 mm Hg of systolic blood pressure or 10 mm Hg of diastolic blood pressure upon switch from spending 5 minutes in the supine position to quiet standing. It is typically exhibited by dehydrated or geriatric patients.
    • Respiratory rate: Patients undergoing hypovolemic shock may be observed to have tachypnea or increased respiratory rate as compensation from metabolic acidosis brought about by lactic acid build-up due to poor tissue perfusion.
  2. Physical Examination Findings
    • Fontanelle: Sunken fontanelle is indicative of a hypovolemic infant.
    • Tear production: Decreased tear production especially in infants and children is indicative of fluid deficiency.
    • Peripheral pulses: Fast and thready pulses are indicative of fluid deficiency.
    • Skin turgor and eyeball appearance: Dehydration, in severe cases, may present with flaccid or tented skin and sunken eyeballs.
    • The tactile temperature of skin: Peripheral vasoconstriction, which causes hypoperfusion of skin, occurs in patients undergoing hypovolemic shock; thus, a common finding for such patients is cool and clammy skin in patients undergoing hypovolemic shock.
  3. Laboratory Findings
    • BUN/creatinine: Elevated BUN/creatinine parameters may be expected in patients with fluid deficiency as they will exhibit decreased renal blood flow.
    • Transaminases: “Shock liver” or ischemic hepatitis is damage to hepatocytes due to poor blood flow and oxygen transport to the liver brought by the fluid deficit. It can be detected through increased AST or ALT. 

Fluid Volume Deficit Nursing Diagnosis

Fluid Volume Deficit Nursing Care Plan 1

Cholera

Nursing Diagnosis: Deficient Fluid Volume related to acute diarrhea secondary to cholera as evidenced by rapid heart rate, loss of skin elasticity, dry mucous membranes, and low blood pressure, “rice-water stools”, vomiting, thirst, leg cramps, and restlessness/ irritability.

Desired Outcome: The goal of nursing care for cholera is to reverse the deficiency in fluid volume, regain the balance in the patient’s nutrition, eliminate infection, repair skin function, and ease the patient’s anxiety.

Fluid Volume Deficit Nursing InterventionsRationale
Monitor the amount of fluid that enters and leaves the patient’s body (intake and output).Monitoring intake helps the clinician determine if the patient is taking in the correct amount of fluid and nutrients, while monitoring output, which may be done through checking for stools, insensible water losses, and urine, to determine if there are any abnormal losses.
Determine the patient’s weight every day.Weight is the gold standard measurement for the patient’s fluid status. It is also indicative of the patient’s nutrition. Monitoring the patient’s weight will ensure that management is properly taking place and that the patient is recovering.
Keep the patient hydrated.The patient is losing high quantities of fluid due to diarrhea which is characteristic of cholera. Replacing lost fluid is essential for patient’s recovery, which may be given either enterally (more ideal because it is the normal route to which patients replace fluids) or parenterally (for patients who are unable to tolerate the enteral route).
Employ pharmacologic management.Empiric antimicrobial therapy is not an essential therapeutic component but is recommended to address the etiologic agent of the disease. The vaccine may also be given to at-risk patients for them to avoid getting the disease.

Fluid Volume Deficit Nursing Care Plan 2

Typhoid Fever

Nursing Diagnosis: Deficient Fluid Volume related to acute diarrhea secondary to typhoid fever as evidenced by sunken eyes, dry skin and mucous membranes, and lethargy, rose spots,  fever, gastrointestinal symptoms, abdominal distension, and pea soup stool.

Desired Outcome: The goal of nursing care for typhoid fever includes returning the homeostasis of fluid in the patient’s body, improving patient’s nutritional status, relieving pain, and helping the patient return to his or her normal way of life or activities of daily living (ADL), as well as maintaining the body temperature within normal range.

Fluid Volume Deficit Nursing InterventionsRationale
To give supportive measures to help patients resume activities of daily living or ADLs.         Proper education is a prerequisite to involve the family in helping the patient resume his or her normal daily activities. Bed rest is a must and this must be explained adequately to the patient and his or her family.
Ensure proper hydration.The patient must be encouraged to increase his or her fluid intake, in addition to IV fluid administration by the medical team. Adherence to this may be checked through monitoring the hydration status and fluid intake of the patient.
Ensure proper nutrition.The provision of nutritious meals such as those rich in protein and vitamin C must be encouraged. Monitoring the number of calories taken and the risk of weight loss, if any, must be done.
Relieve pain experienced by the patient.The pain must be relieved through warm compresses or administration of analgesics as this is very uncomfortable for the patient.
Maintain normal body temperature.Improvements in body temperature must be done through antipyretics as needed, because additional fluid loss may be exhibited by the patient through profuse diaphoresis brought by high temperatures. Abnormal functioning of body enzymes may also be expected. Fever is also very uncomfortable for the patient.

Fluid Volume Deficit Nursing Care Plan 3

Diabetes mellitus

Nursing Diagnosis: Deficient Fluid Volume related to polyuria and osmotic diuresis  secondary to diabetes mellitus as evidenced by thirst, headache, dry mucous membranes, dizziness, tiredness, and dark yellow colored urine.

In severe cases, dehydration related to DM may present as hypotension, sunken eyes, weak pulse and/or tachycardia, and neurologic symptoms such as confusion and lethargy. Other signs and symptoms relevant to DM include an increase in blood glucose levels.

Desired Outcome: The goal of nursing care to lower the risk for developing Deficient Fluid Volume in patients with Diabetes mellitus (DM) is to stabilize the parameters related to hydration.

Fluid Volume Deficit Nursing InterventionsRationale
Commence a thorough assessment of the patient’s history of risk factors for volume depletion such as vomiting and excessive urination.Assessment of these risk factors may aid in determining the amount of fluid lost, which therefore aids in determining how much fluid must be replaced.
Observe the patient’s vital signs.Vital signs may also give ideas as to the hydration status of the patient and must be monitored.
Observe the patient’s peripheral pulses, capillary refill, and mucous membranes.The patient’s peripheral pulses, capillary refill, and mucous membranes are indicative of the patient’s hydration status and adequacy of circulating volume.
Monitor the patient’s input and output and specific gravity of urine.Monitoring I&O and specific gravity of urine help the clinician determine the patient’s hydration status, kidney function, and if the therapy is working for the patient.
Monitor patient’s weight daily.As the gold standard for the fluid status of the patient, the patient’s weight must be monitored daily to determine if fluid replacement therapy is working.

Fluid Volume Deficit Nursing Care Plan 4

Older Adult

Nursing Diagnosis: Risk for Deficient Fluid volume related to advanced age

Desired Outcome: The goal of nursing care to lower the risk for developing Deficient Fluid Volume in older adult patients include maintenance of the patient’s health parameters such as mental status and vital signs to normal limits, and for the patient to avoid exhibiting signs of dehydration such as drying of mucous membranes and “tenting” of skin.

Fluid Volume Deficit Nursing InterventionsRationale
Determine the parameters such as amount, color, and frequency of ways that the body loses fluid such as urine, stools, and vomit.Determining these parameters enable the clinician to determine the patient’s hydration and nutritional status.
Determine skin turgor by gently pinching the skin over the forehead, clavicle, sternum, and abdomen.Dehydration may be determined through observing for skin turgor. Tenting is a sign of dehydration, as well as furrows in the tongue.
Monitor the patient’s fluid intake.The fluid intake of the patient must be adequate to ensure proper hydration.
Observe the patient’s mental status.Assessing the patient’s mentation allows the clinician to determine if the patient is dehydrated as abnormalities in it are indicative of fluid deficit.
Measure the patient’s parameters at the same time of day and the same scale.Consistency in measuring and recording the patient’s parameters ensures more valid and comparable results.
Make sure to assess if the patient is able to drink by himself or herself. Make the fluids accessible and within reach. Cups must have lids if possible.Determining if the patient can drink independently helps assess proper hydration and to address the problem if necessary. Spills are avoided if the patient is given cups with lids.
Monitor intake & output of the patient.The intake & output of the patient must be monitored to ensure a proper and normal fluid and nutritional status.

Fluid Volume Deficit Nursing Care Plan 5

Chikungunya Infection

Nursing Diagnosis: Deficient Fluid Volume related to fluid loss secondary to Chikungunya infection as evidenced by weakness, thirst, dry skin and mucous membranes, sunken eyeballs, decreased urine output, and concentrated urine, fever and joint pain.

Desired Outcome: The goal of nursing care for Chikungunya infection includes returning the body temperature of the patient back to normal, restoring the patient’s body fluid homeostasis, easing out pain, and helping improve skin integrity.

Fluid Volume Deficit Nursing InterventionsRationales
Return the body temperature of the patient back to normal.Fever is a common manifestation of chikungunya infection, which may be uncomfortable for the patient. Supportive management may be employed to maintain the patient’s body temperature to normal, such as by giving tepid sponge bath and giving antipyretic medications.
Restore the patient’s body fluid homeostasis.Patients with Chikungunya infection are at risk for dehydration, which may be monitored by observing for signs such as skin turgor and drying of mucous membranes. The patient must be encouraged to drink adequate amounts of fluid and parenteral fluids should also be administered.
Ease out the pain experienced by the patient.Pain that is the usual manifestation of Chikungunya may be uncomfortable and disabling for the patient. The pain must be relieved to help the patient feel more comfortable and sleep better.
Help improve the patient’s skin integrity.Macular or maculopapular rashes usually appear to the skin of patients with Chikungunya. It is very pruritic, but the patients must be encouraged not to rub or scratch these. Clipping the nails and administering antibiotics may be warranted.

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

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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