Hypovolemia Nursing Diagnosis and Nursing Care Plan

Hypovolemia Nursing Care Plans Diagnosis and Interventions

Hypovolemia NCLEX Review and Nursing Care Plans

Fluids make up between 50 and 60 percent of the body. When a person has hypovolemia, they lose more than 15% of the total amount of fluid in their circulatory system. Hypovolemia becomes life-threatening when the body does not have enough fluid (blood) volume circulating in the system.

The term hypovolemia refers to two different health conditions:

  • Volume depletion. Volume depletion explains the loss of sodium from the extracellular space, including intravascular and interstitial fluid, that happens throughout gastrointestinal bleeding, nausea, diarrhea, and increased urination.
  • Dehydration. Dehydration characterizes the depletion of intracellular and total body water, which leads to severe cellular desiccation and raises plasma concentrations of sodium and osmolality.

The prognosis for patients diagnosed with hypovolemia differs. Each instance is dependent on identifying and addressing the source of the blood or fluid loss.

When hypovolemia is diagnosed and treated early, the prognosis is usually favorable. When therapy starts to replace the fluid lost in the body, symptoms will reduce and eventually disappear as the fluids resume average level.

However, untreated instances or delayed treatment can have a fatal effect, including irreversible organ damage or death.

Stages of Hypovolemia

Stage 1

The initial stage of hypovolemia is defined as a blood volume loss of less than 15%, or 750 milliliters (ml). This stage’s symptoms include:

  • A pulse rate that is fewer than 100 beats per minute
  • A respiration rate of 14–20 breaths per minute
  • Blood pressure within typical ranges
  • There was some mild anxiousness but no other changes in mental status.

Stage 2

Stage 2 is characterized by 15–30% of blood volume or 750–1,500 ml loss. This hypovolemia stage’s symptoms usually involve:

  • An elevated pulse rate of at least 100 beats per minute
  • A breathing rate of 20–30 breaths per minute
  • Blood pressure is lower than average.
  • Mild agitation

Stage 3

This stage indicates 30–40% blood loss or 1,500–2,000 ml. This stage’s indications entail:

  • A pulse rate of more than 120 beats per minute
  • Breathing rates of 30–40 breaths per minute
  • Blood pressure is too low.
  • The patient appears confused or lethargic.

Stage 4

Perhaps the most severe stage indicates that the patient has lost more than 40% of his blood volume or more than 2,000 ml. The fourth hypovolemia stage’s symptoms involve:

  • A pulse rate greater than 140 beats per minute.
  • A respiratory rate greater than 35 breaths per minute.
  • The patient’s blood pressure is extremely low.

Signs and Symptoms of Hypovolemia

The following are some of the most typical early signs of hypovolemia:

  • Fatigue
  • Vertigo
  • Hypotension
  • Extreme thirst
  • Elevated heart rate
  • Weakness
  • Cramps in the legs
  • Reduced urine production
  • Dry mucosal membranes
  • Decreased skin elasticity
  • Accelerated respiration

Hypovolemia that leads to hypovolemic shock is a potentially fatal condition. Refer the patient to the physician at once if the patient is experiencing any of the following severe symptoms of hypovolemic shock:

  • Stomach ache
  • Chest discomfort
  • Confusion
  • Irritability or agitation
  • Excessive drowsiness or a lack of responsiveness
  • Clammy, cold skin
  • Skin discoloration — purple and blue patches on light skin, grayish or greenish on yellow-toned skin, and white or gray discolorations on dark skin.

Causes of Hypovolemia

Hypovolemia can be caused by conditions that cause blood or bodily fluid loss, insufficient fluid consumption, and dehydration. Volume depletion can be caused by a variety of factors, including:

  • Blood loss as a result of an exterior injury or internal hemorrhage
  • Diarrhea and vomiting that is chronic or severe
  • Significant burns
  • Sweating excessively
  • Using diuretics
  • Ongoing dialysis
  • Addison’s disease and other adrenal disorders

Many illnesses that induce hypovolemia are severe or life-threatening and necessitate immediate medical attention. These are some examples:

  • Ectopic pregnancy
  • Internal bleeding, most commonly from the gastrointestinal tract
  • Severe burns
  • Aortic aneurysm rupture or other vascular anomalies
  • Severe damage or trauma

Risk Factors to Hypovolemia

Risk factors of hypovolemia that involve bleeding include:

  • Fractured hip bones
  • Head and neck lacerations
  • Damage to abdominal organs, including the liver, spleen, and kidneys, results from accidents or bad falls.
  • A rupture in the heart or a large blood artery, or a weakened area in a massive blood vessel with the potential to burst
  • Ulcers and other digestive system problems
  • An embryo that develops outside of a woman’s womb (ectopic pregnancy)
  • The placenta ripping out from the uterine wall of a pregnant woman (placental abruption)
  • A ruptured cyst in the ovaries
  • Severe hemorrhage during labor or delivery or in the 24 hours afterward
  • Endometriosis, a condition in which the tissue that usually surrounds the uterus of a woman develops outside of it

Among the risk factors related to hypovolemia that do not involve bleeding are:

  • Dehydration
  • Vomiting and diarrhea
  • High body temperature
  • Excessive sweating
  • Other gastrointestinal issues, such as stomas or fistulas
  • Diuretics and renal disease
  • Fluids become trapped in one portion of the body due to an illness such as pancreatitis or intestinal blockage.

Complications of Hypovolemia

Complications of uncontrolled hypovolemia can be severe or even fatal when it already causes hypovolemic shock.

Without prompt treatment, hypovolemia complications may include:

  • Renal disease. Hypovolemia caused by fluid deficiency can lead to renal hypoperfusion, which can progress to acute renal failure if left untreated.
  • Brain injury. Hypovolemia and low mean arterial blood pressure are severe threats to cerebral perfusion in brain injury. After inflammation, hemorrhage, and trauma, the latter causes intracranial hypertension, causing circulation to be more pressure-dependent.
  • Acute tubular necrosis. Acute tubular necrosis is a kidney condition characterized by the destruction of the kidney’s tubule cells, which can result in acute renal failure.
  • Disseminated intravascular coagulation. Disseminated intravascular coagulation is a pathological disease defined by extensive stimulation of the coagulation pathways, resulting in blood clot formation in tiny blood capillaries.
  • Multiple organ dysfunction syndromes. Hypovolemia leads to multiple organ dysfunction syndromes due to a lack of blood circulation to different organs.
  • Cardiac arrest and heart failure. Hypovolemia, caused by decreased intravascular volume, is a notable cause of cardiac arrest and heart failure. It can also be caused by excessive sweating, acute diarrhea, vomiting, or even significant vasodilation.
  • Acute respiratory distress syndrome or lung injury. Hypovolemic shock frequently increases ventilatory minute volume, which causes breathlessness or hyperventilation and a reduction in arterial Pco2.
  • Coma or even death. Excessive fluid loss causes the heart to work harder to pump adequate blood to the body. As fluid loss worsens, hypovolemia can result in organ failure and death.

Diagnosis of Hypovolemia

  • Physical examination. Throughout a physical exam, the healthcare provider will look for dryness on the patient’s skin and mucosal membranes in the mouth, tongue, and nose, which is a symptom of dehydration and may be an indication of hypovolemia.
  • Monitoring of a patient’s vital signs such as pulse, body temperature, and blood pressure. The healthcare professional will assess the patient’s vitals while sitting and standing to evaluate the changes. During this procedure, the doctor will assess the symptoms, particularly if the patient becomes dizzy in the upright position, which is a sign of hypovolemia.
  • Laboratory tests. Blood and urine tests aim to measure the patient’s kidney functions, which could indicate another underlying problem.
  • Imaging Tests (CT Scan, Electrocardiogram, or Ultrasound). These tests may be beneficial for visualizing different organs and checking if hypovolemia has caused any complications.

Treatment for Hypovolemia

Since hypovolemia can promptly develop into hypovolemic shock and induce organ damage, it is crucial to treat hypovolemia as soon as it appears. At this stage, treatment may include:

  1. Oral and IV Medications, such as:

  • Oral Rehydration Salts. Doctors usually recommend oral rehydration liquids in cases of mild hypovolemia.
  • Colloid Solutions. Colloid solutions are intravenous fluids containing complex carbohydrates and proteins.
  • Crystalloid Solutions. Crystalloid solutions are IV fluids that comprise electrolytes, most commonly sodium chloride or a sodium chloride combination. Other examples include sodium lactate, potassium chloride, and calcium chloride in water.
  • Vasopressors. Vasopressors are medicines that tighten blood arteries and raise blood pressure.
  • Volume expansion. Saline or lactated Ringer’s solution, followed by plasma proteins or other plasma expanders, may provide sufficient volume expansion until whole blood can be supplied.
  1. Blood Transfusions.

  • Plasma Transfusion. Plasma is the liquid component of blood. It includes essential proteins and other nutrients for good health. Blood plasma transfusions are administered to patients suffering from hypovolemia, liver cirrhosis, chronic infections, or burn injuries.
  • Platelet Transfusion. Platelet transfusion, also referred to as platelet concentrate, is used to treat or prevent bleeding in patients with hypovolemia since they may have low platelet counts.
  • Red Blood Cell Transfusion. This kind of transfusion raises a patient’s hemoglobin and serum iron while increasing oxygen levels in the blood.
  1. In addition to fluid replacement therapy, the doctor will address the underlying causes of the hypovolemia, which include:

  • Treating an underlying infection or disease.
  • Treating wounds that cause excessive bleeding
  • Providing nutrients that are deficient (like sodium or electrolytes).

Prevention of Hypovolemia

The following measures must be taken to prevent hypovolemia or hypovolemic shock:

  1. Early detection is critical. Patients with diseases that reduce blood volume should be identified as at-risk.
  2. Monitor patient’s input and output accurately. Estimate fluid loss and refill as needed to prevent hypovolemia, leading to hypovolemic shock.

Hypovolemia Nursing Diagnosis

Hypovolemia Nursing Care Plan 1

Anxiety

Nursing Diagnosis: Anxiety related to modifications in medical status, fear of dying and unfamiliar surroundings secondary to hypovolemia as evidenced by uncertainty, difficulties concentrating, increased alertness, increased inquiry, and sympathetic stimulation.

Desired Outcomes:

Nursing Stat Facts
Nursing Stat Facts
  • The patient will express a decrease in his or her degree of anxiousness.
  • The patient will demonstrate suitable coping strategies.
Hypovolemia Nursing InterventionsRationale
Evaluate the patient’s previous coping mechanisms.      Anxiety and strategies for reducing perceived anxiety are incredibly individualized. When interventions are compatible with the patient’s established coping mechanism, they are most effective. However, in cases of severe hypovolemia, these approaches may be ineffective.  
The nurse must express her acknowledgment of the patient’s anxiety.  Acknowledging the patient’s feelings validates them and expresses acceptance of such feelings.  
Evaluate the patient’s anxiety level.  Acute hypovolemic situations can increase the patient’s anxiety levels and significantly affect family members or other individuals around them.  
Motivate the patient to express his or her emotions verbally.  Discussing anxiety-provoking scenarios and anxious sentiments regarding hypovolemia can help the patient understand the situation as less frightening.  
Maintain a quiet setting for the patient to reduce unnecessary environmental forces. Consider giving the patient anesthesia if medical equipment causes anxiety.  Excessive discussion, noise, and equipment near the patient may exacerbate anxiety.  
Explain to the patient what hypovolemia is. Also, discuss all procedures as needed, making explanations simple.  Information about their condition and all the procedures they may undergo reduces patients’ anxiety. Sometimes, anxious patients can only comprehend short, straightforward, brief directions.  
When talking with the patient, maintain a confident and calm approach. Ensure that the patient and significant others will be thoroughly observed and prompt interventions will be given.  The patient may be able to perceive the healthcare staff’s anxiety. In a quiet and non-threatening environment, the patient’s sense of calmness grows. The presence of a trustworthy individual may make the patient feel less worried.  

Hypovolemia Nursing Care Plan 2

Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output related to heart rate and rhythm changes, reduced ventricular filling (preload) secondary to hypovolemia as evidenced by abnormal arterial blood gasses (ABGs), cerebral hypoxia and acidosis, capillary refill time greater than 3 seconds, cardiac arrhythmias, altered level of consciousness, cold, clammy skin, reduced urine output (less than 30 ml per hour), significantly reduced blood pressure, pulse pressure, and peripheral pulses and palpitations.

Desired Outcome: The patient will maintain appropriate cardiac output as shown by strong peripheral pulses, systolic blood pressure within 20 mm Hg of baseline, heart rate 60 to 100 beats per minute with a steady rhythm, urine output 30 ml/hr or higher, dry and warm skin, and normal state of consciousness.

Hypovolemia Nursing InterventionsRationale
Conduct an electrocardiogram. Examine the patient’s ECG for any dysrhythmias.      Cardiac dysrhythmias can arise due to hypovolemia, a low perfusion status, acidosis, hypoxia, or an adverse reaction to several cardiac medications.  
Observe both the peripheral and central pulses. Capillary filling time should also be examined.  The pulses are weak, and the stroke volume and cardiac output are low. At the same time, the capillary refill is extremely slow and perhaps nonexistent.  
Examine the patient’s respiratory rhythm and rate and the breath sounds.  Hypovolemia is distinguished by quick, shallow respirations and incidental breath disturbances such as crackles and wheezes.  
Thoroughly observe the patient’s blood oxygen saturation and arterial blood gas levels.    Pulse oximetry measures oxygen saturation. The typical oxygen saturation level should be 90 percent or greater. As hypovolemia worsens, aerobic metabolism ceases, and lactic acidosis develops, leading to a rise in carbon dioxide and a decrease in PH.  
Administer blood and fluid replacement to the patient as directed.  In hypovolemia, maintaining a balanced circulating blood volume is a top priority.  
Examine the patient’s skin color, warmth, and moisture.  A compensatory increase in sympathetic nervous system activation and poor cardiac output and desaturation can cause cool, pallid, clammy skin.    

Hypovolemia Nursing Care Plan 3

Ineffective Tissue Perfusion

Nursing Diagnosis: Ineffective Tissue Perfusion related to reduced stroke volume, reduced preload, impaired venous return, and significant loss of blood secondary to hypovolemia as evidenced by changed mental status, cold, clammy skin, pallid complexion, cyanosis, prolonged capillary refill, vertigo, deep respirations, and a feeble, thready pulse.

Desired Outcome: The patient will retain optimum tissue perfusion to vital organs as indicated by dry and warm skin, continuous and steady peripheral pulses, vital signs within the patient’s accepted value, balanced input and output, absence of inflammation, normal ABG levels, 15/15 GCS level of consciousness, and lack of chest discomfort.

Hypovolemia Nursing InterventionsRationale
Examine the patient for symptoms of ineffective tissue perfusion.      Specific clusters of signs and symptoms emerge for a variety of reasons. Evaluation of clinical manifestations establishes a foundation for future comparison.  
Examine the patient for sudden changes or persistent alterations in mental health status.  Restlessness and anxiety are early symptoms of hypovolemia, but confusion and loss of consciousness appear later.  
Help the patient with position modifications.  Repositioning the patient gently from supine to sitting or standing can lessen the danger of orthostatic BP fluctuations. With posture changes, older patients with hypovolemia are particularly vulnerable to such pressure reductions.  
If necessary, administer oxygen therapy to the patient.  The administration of oxygen therapy increases the amount of oxygen carried by circulating hemoglobin in the blood.  
Provide IV fluids to the patient as directed.  Adequate fluid intake keeps filling pressures stable and maximizes cardiac output for tissue perfusion.  
Examine the patient’s skin for pale complexion, cyanosis, discoloration, and cold or clammy skin. Each pulse’s quality should be evaluated.  The absence of peripheral pulses must be reported or addressed as soon as possible. Systemic vasoconstriction caused by decreased cardiac output might manifest as decreased skin perfusion and pulse loss. As a result, assessment is essential for consistent comparison.  

Hypovolemia Nursing Care Plan 4

Deficient Fluid Volume

Nursing Diagnosis: Deficient Fluid Volume related to active fluid volume loss as a result of unusual bleeding, diarrhea, increased urination, or aberrant drainage, internal fluid changes, insufficient fluid consumption or severe dehydration, regulatory system failure, or trauma secondary to hypovolemia as evidenced by capillary refill time of more than 3 seconds, alterations in level of consciousness, cold, clammy skin, reduced skin turgor, vertigo, dry mucous membranes, extreme thirst, pulse pressure constriction, orthostatic hypotension, palpitations, and urinary output that can range between average (>30ml/hr) and as low as 20 ml/hr.

Desired Outcome: The patient will be normovolemic, and his or her heart rate is 60 to 100 beats per minute, systolic blood pressure is greater than or equal to 90 mm Hg, there is no orthostasis, urine output is more than 30ml/hr, and skin turgor is normal.

Hypovolemia Nursing InterventionsRationale
Monitor the patient’s blood pressure for orthostatic changes, such as those found after moving from a reclining to a standing position.  Postural hypotension is a typical symptom of fluid loss. The prevalence rises with age. Take note of the following orthostatic hypotension implications: A fall in BP of more than 10 mm Hg means that the circulating blood volume drops by 20%.A drop in BP of more than 20 to 30 mm Hg means that the circulating blood volume is reduced by 40%.  
Examine the patient for abnormalities in the level of consciousness.        Confusion, agitation, migraine, and a shift in consciousness may suggest probable hypovolemia.  
Thoroughly observe the patient for signs of loss of fluid.  Diarrhea, vomiting, wound leakage, significant blood loss, excessive sweating, high body temperature, frequent urination, wounds, and trauma are all causes of fluid loss that can lead to hypovolemia.    
Look for indications of dehydration in the patient’s skin turgor and mucous membranes.  Skin turgor deficiency is a late symptom of dehydration. A loss of interstitial fluid causes it. It could also be a sign of hypovolemia.  
If the only observable impairment is a head injury, investigate for additional causes of hypovolemia such as long-bone breakage, internal hemorrhage, and other external injuries.  Hemorrhage is the most common cause of hypovolemia after trauma. That is why it is necessary to observe other causes of hypovolemia to provide accurate interventions thoroughly.  
Keep track of the patient’s intake and output.  An accurate assessment of input and output is critical for recognizing negative fluid balance and directing therapy. A fluid deficiency is indicated by concentrated urine.  

Hypovolemia Nursing Care Plan 5

Fatigue

Nursing Diagnosis: Fatigue related to blood loss secondary to hypovolemia as evidenced by accelerated heartbeat, shallow respiration, and a sense of lethargy and exhaustion.

Desired Outcomes:

  • The patient will be able to perform activities of daily living (ADLs).
  • The patient will have an improved heartbeat and respirations.
  • The patient will no longer experience extreme lethargy or exhaustion.
Hypovolemia Nursing InterventionsRationale
Examine the patient’s results of any laboratory or diagnostic tests, such as the following:
Blood glucose levels
Hemoglobin/hematocrit
BUN
Saturation of oxygen during rest and activity    
Changes in these physiological markers can be correlated with other measurement data to identify possible causes of the patient’s fatigue.    
Assess the patient’s prospects for fatigue alleviation, readiness to participate in fatigue-reduction techniques, and degree of family and social support.  These approaches will encourage active participation in the planning, implementing, and evaluation of therapeutic management. Social support will be required to help the patient implement modifications to reduce fatigue induced by hypovolemia.    
Observe any changes in the patient’s blood pressure, respiration rate, or heart rate in response to activities.  Tolerance deviates considerably depending on the stage of hypovolemia progression, dietary status, and electrolyte imbalances.  
Encourage the patient to consume enough nutrients.      Aside from treating the patient’s hypovolemia, he will also need a well-balanced diet of carbohydrates, fats, proteins, vitamins, and minerals to supply energy sources.  
Encourage the patient to perform an exercise conditioning program as necessary.  Hypovolemia-induced fatigue can be alleviated by cardiovascular and muscular exercises, increasing functional capacity.    
Assist the patient in developing practices that encourage healthy rest or sleeping habits.  Patients suffering from hypovolemia may experience difficulty sleeping. Thus, encouraging relaxation before sleep and allowing for several hours of undisturbed sleep can help patients regain energy.  

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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