Hypovolemia is a condition characterized by decreased intravascular fluid volume, which can lead to compromised tissue perfusion and potentially life-threatening complications. This nursing diagnosis focuses on identifying and treating fluid volume deficits, preventing complications, and restoring normal fluid balance.
Causes (Related to)
Hypovolemia can develop from various conditions and factors that affect fluid balance:
- Active fluid loss through:
- Medical conditions such as:
- Diabetes insipidus
- Diabetic ketoacidosis
- Addison’s disease
- Gastrointestinal disorders
- Trauma
- Contributing factors including:
- Restricted fluid intake
- Limited access to fluids
- Altered mental status
- Advanced age
- Impaired thirst mechanism
Signs and Symptoms (As evidenced by)
Hypovolemia presents with distinctive signs and symptoms that nurses must recognize for proper diagnosis and treatment.
Subjective: (Patient reports)
- Thirst
- Weakness
- Dizziness
- Fatigue
- Muscle cramps
- Postural dizziness
- Anxiety
Objective: (Nurse assesses)
- Decreased blood pressure
- Increased heart rate
- Decreased urine output
- Poor skin turgor
- Dry mucous membranes
- Delayed capillary refill
- Sunken eyes
- Weight loss
- Decreased central venous pressure
- Weak peripheral pulses
Expected Outcomes
The following outcomes indicate successful management of hypovolemia:
- The patient will maintain stable vital signs
- The patient will demonstrate adequate urine output
- The patient will show improved skin turgor and moist mucous membranes
- The patient will maintain an appropriate fluid balance
- The patient will verbalize understanding of fluid replacement needs
- The patient will demonstrate weight stability
- The patient will report resolved symptoms of hypovolemia
Nursing Assessment
Monitor Vital Signs
- Check blood pressure, pulse, and respiratory rate
- Assess for orthostatic hypotension
- Monitor temperature
- Document trends in vital signs
Evaluate Fluid Status
- Track intake and output
- Measure daily weights
- Assess skin turgor
- Check mucous membranes
- Monitor urine characteristics
Assess Perfusion
- Check capillary refill
- Assess peripheral pulses
- Monitor skin temperature
- Evaluate mental status
- Note extremity color
Review Lab Values
- Monitor hemoglobin and hematocrit
- Check electrolyte levels
- Assess BUN and creatinine
- Track serum osmolality
- Monitor acid-base balance
Identify Risk Factors
- Review medication history
- Assess comorbidities
- Document recent fluid losses
- Evaluate dietary intake
- Check environmental conditions
Nursing Care Plans
Nursing Care Plan 1: Decreased Cardiac Output
Nursing Diagnosis Statement:
Decreased Cardiac Output related to reduced preload secondary to hypovolemia as evidenced by tachycardia, hypotension, and decreased peripheral pulses.
Related Factors:
- Reduced blood volume
- Compromised venous return
- Compensatory mechanisms
- Altered contractility
Nursing Interventions and Rationales:
- Monitor vital signs q2-4h
Rationale: Identifies trends and effectiveness of interventions - Administer prescribed IV fluids
Rationale: Restores intravascular volume - Position patient supine with legs elevated
Rationale: Improves venous return
Desired Outcomes:
- The patient will maintain stable vital signs
- The patient will demonstrate improved peripheral perfusion
- The patient will show adequate urine output
Nursing Care Plan 2: Risk for Shock
Nursing Diagnosis Statement:
Risk for Shock related to significant fluid volume deficit as evidenced by decreased blood pressure and altered tissue perfusion.
Related Factors:
- Hypovolemia
- Fluid shifts
- Impaired compensatory mechanisms
- Compromised circulation
Nursing Interventions and Rationales:
- Monitor shock parameters
Rationale: Enables early intervention - Maintain patent IV access
Rationale: Ensures immediate access for fluid resuscitation - Document ongoing fluid losses
Rationale: Guides replacement needs
Desired Outcomes:
- The patient will maintain adequate tissue perfusion
- The patient will demonstrate stable hemodynamic parameters
- The patient will show no progression to the shock state
Nursing Care Plan 3: Deficient Fluid Volume
Nursing Diagnosis Statement:
Deficient Fluid Volume related to active fluid loss as evidenced by decreased skin turgor, dry mucous membranes, and oliguria.
Related Factors:
- Excessive fluid loss
- Inadequate intake
- Altered regulatory mechanisms
- Barriers to fluid access
Nursing Interventions and Rationales:
- Maintain accurate I&O records
Rationale: Guides fluid replacement therapy - Monitor daily weights
Rationale: Indicates fluid status trends - Assess hydration status q4h
Rationale: Enables early intervention
Desired Outcomes:
- The patient will maintain adequate hydration
- The patient will demonstrate improved skin turgor
- The patient will achieve fluid balance
Nursing Care Plan 4: Impaired Tissue Perfusion
Nursing Diagnosis Statement:
Impaired Tissue Perfusion related to decreased circulating volume as evidenced by altered peripheral pulses and delayed capillary refill.
Related Factors:
- Reduced cardiac output
- Vasoconstriction
- Altered blood flow
- Compromised circulation
Nursing Interventions and Rationales:
- Assess peripheral circulation q2h
Rationale: Identifies perfusion changes - Monitor skin temperature
Rationale: Indicates tissue perfusion status - Document neurovascular checks
Rationale: Detects perfusion complications
Desired Outcomes:
- The patient will maintain adequate tissue perfusion
- The patient will demonstrate improved peripheral circulation
- The patient will show normal capillary refill
Nursing Care Plan 5: Anxiety
Nursing Diagnosis Statement:
Anxiety related to physiological changes and health status as evidenced by expressed concerns and increased tension.
Related Factors:
- Altered health status
- Physical discomfort
- Uncertainty about outcome
- Treatment regime
Nursing Interventions and Rationales:
- Provide clear explanations
Rationale: Reduces fear of the unknown - Maintain calm environment
Rationale: Decreases stress response - Teach coping strategies
Rationale: Empowers patient control
Desired Outcomes:
- The patient will report decreased anxiety
- The patient will demonstrate effective coping
- The patient will verbalize understanding of the condition
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Mandal M. Ideal resuscitation fluid in hypovolemia: The quest is on and miles to go! Int J Crit Illn Inj Sci. 2016 Apr-Jun;6(2):54-5. doi: 10.4103/2229-5151.183020. PMID: 27308250; PMCID: PMC4901826.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
- Taghavi S, Nassar Ak, Askari R. Hypovolemic Shock. [Updated 2023 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513297/
- Traber DL. Fluid resuscitation after hypovolemia. Crit Care Med. 2002 Aug;30(8):1922. doi: 10.1097/00003246-200208000-00051. PMID: 12163826.
