Fluid volume deficit also known as dehydration can be a common occurrence and nursing diagnosis for many patients. Dehydration is when there is a loss of too much fluid from the body. This leads to a lack of water in the body’s cells and blood vessels. It is due to more fluids being expelled from the body than the body takes in.
In this article:
- Causes (Related to)
- Signs and Symptoms (As evidenced by)
- Risk Factors
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Causes (Related to)
There are several reasons an individual may become dehydrated. Below is a brief list of some potential causes:
- Vomiting
- Diarrhea
- Excessive sweating
- Fever
- Frequent urination
- Lack of oral fluid intake
- Medications (i.e. diuretics)
- Other medical conditions (i.e. diabetes)
- Pregnancy and breastfeeding
Signs and Symptoms (As evidenced by)
There are several signs and symptoms that may be present for an individual suffering from dehydration. Some symptoms can be vague and a sign for other conditions as well so it is important the nurse is completing a full assessment and brining all the pieces of the assessment together in making clinical decisions. A brief list of signs and symptoms includes:
- Headache
- Confusion
- Fatigue
- Dizziness/light-headedness
- Weakness
- Dry mouth/dry cough
- Tachycardia with hypotension
- Decreased appetite
- Muscle cramps
- Constipation
- Concentrated urine
- Dry skin
- Feeling of thirst
For very young children or infants who are unable to verbalize, additional signs and symptoms may be present that include:
- Crying without tears
- No wet diapers for 3 hours or longer
- High fevers
- Irritability
- Sunken eyes
- Unusually drowsy
Risk Factors
Some individuals and populations are more at risk of developing dehydration than others. These populations include:
- Elderly patient
- Infants and children
- Individuals with chronic conditions
- Individuals with complex medication regimens (especially those including the use of diuretics)
- Active individuals who may not be rehydrating after exercising
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for fluid volume deficit:
- Patient’s vital signs will remain stable and/or return to patient’s baseline.
- Patient’s intake and output will stabilize.
- Patient’s lab values will return to baseline.
- Patient will verbalize measures to take at home to maintain hydration/prevent dehydration.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to dehydration.
1. Complete a thorough head-to-toe assessment.
This will allow the nurse to assess the entire person and put all data together when making clinical decisions and assist in identifying the cause of dehydration.
2. Assess intake and output.
This will allow the nurse objective data in determining the patient’s net loss of fluid.
3. Assess vital signs.
Vital signs may be abnormal if dehydrated (i.e. tachycardia and/or hypotension).
4. Assess laboratory values.
Patients may have abnormal blood work levels due to dehydration (i.e. abnormal electrolyte levels or renal function).
5. Assess skin turgor.
Loss of skin elasticity can be a sign of dehydration.
6. Assess urine color and concentration.
Dark and concentrated urine can be a sign of dehydration; patients should produce at least 30mL of urine/hour.
7. Auscultate cardiac sounds.
Abnormal cardiac sounds may be heard with severe dehydration and dysrhythmias can develop.
8. Assess cardiac rhythm.
Dysrhythmias may develop if severely dehydrated and if electrolyte abnormalities are present.
9. Assess mental status.
Severe dehydration may cause alteration in mentation.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with dehydration.
1. Encourage/remind patient of the need for oral intake.
As individuals age sometimes there is a loss of thirst, reminding and encouraging individuals may help them to remember the need to continue drinking fluids even if they do not feel they are thirsty.
2. Administer intravenous hydration if needed.
Severely dehydrated patients or patients unable to take oral hydration may require IV hydration to maintain appropriate hydration level.
3. Educate patient and family on possible causes of dehydration.
Education will help allow the patient and family to have a better understanding of the diagnosis and preventative measures they can take in the future to avoid dehydration.
4. Administer electrolyte replacements as needed/as ordered.
Dehydration can lead to electrolyte abnormalities, it is important the nurse monitors for this and provides supplemental replacements when needed.
5. Educate patient and family on how to monitor intake and output.
Patients and family members will need to know how to monitor intake and output once discharged home to ensure they are maintaining appropriate hydration level.
6. Weigh patient daily.
Daily weight measurements will allow the nurse to easily monitor for potential fluid overload when rehydrating patients.
7. Educate patient on the importance of maintaining a proper hydration and nutrition status regularly.
Education will help the patient to become more independent upon discharge and will help them to understand what they can do to prevent further episodes of dehydration.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for dehydration.
Care Plan #1
Diagnostic statement:
Fluid volume deficit related to decreased motivation to drink fluids secondary to dementia, as evidenced by insufficient oral fluid intake and concentrated urine.
Expected outcomes:
- Patient will express increased motivation to drink.
- Patient will consume 60 ounces of fluid daily.
- Patient will display normal urine colour, osmolality, and specific gravity within 1.005 to 1.030.
Assessment:
1. Assess factors precipitating decreased motivation to drink.
The damage to the frontal lobe of patients with dementia leads to the development of apathy, losing their interest in eating or drinking. In severe cases, swallowing difficulties may worsen their motivation to drink. Identifying and targeting these factors may help address the root cause of insufficient fluid intake.
2. Monitor signs and symptoms of dehydration.
Dehydration can lead to dizziness, hypotension, headache, and inability to concentrate, which could put the patient, especially older people with dementia, at increased risk for falls.
3. Monitor fluid intake and output.
An accurate fluid intake and output will provide the status of fluid balance.
4. Note the color of urine, urine osmolality, and specific gravity.
The urine color is normally straw or amber. Dark-coloured urine with a specific gravity greater than 1.030 and a high urine osmolality reflects fluid volume deficit.
5. Note the patient’s fluid preferences, such as type and temperature.
Selecting fluids that the patient enjoys may increase motivation to drink.
Interventions:
1. Serve fresh water, the patient’s preferred oral fluids distributed over 24 hours, prescribed diet, and snacks (e.g., frequent drinks, fresh fruits, fruit juice).
Patients with dementia may lose interest or forget to drink. Consistently offering or serving fluids and snacks distributed over the entire 24 hours with the help of the family may encourage the patient to consume adequate fluid throughout the day. This strategy prevents dehydration and promotes energy.
2. Remind and encourage the intake of fluids regularly.
Patients with dementia do not feel thirsty or forget to drink leading to dehydration. Dehydration can cause impaired alertness, fatigue, increased sleepiness, and confusion in cognitively impaired patients.
3. Administer isotonic IV solutions if prescribed.
Crystalloids such as 0.9 saline or lactated Ringer’s are used for fluid volume replacement.
4. Instruct family members on how to monitor intake and output at home.
- For output: Use a commode “hat” in the toilet, urinal, or bedpan, or use a catheter and closed drainage system.
- For intake: Use common terms such as “cups” or “glasses of water a day.”
Dementia is a lifelong disease which extends the complex management at home. Educating the family about dehydration and maintaining fluid balance is vital for long-term care.
5. Encourage the use of assistive devices or raise side rails as appropriate.
These measures prevent falls. Patients with dehydration may experience orthostatic hypotension which makes them more at risk to experience a fall.
Care Plan #2
Diagnostic statement:
Fluid volume deficit related to excessive urinary output secondary to uncontrolled diabetes, as evidenced by dry mucous membranes and increased thirst.
Expected outcomes:
- Patient will maintain a urine output of 0.5 mL/kg/hour or at least more than 1300 mL/day.
- Patient will maintain glucose level between 60 to 130 mg/dL.
- Patient will maintain elastic skin turgor, moist tongue and mucous membranes.
Assessments:
1. Monitor urine output.
Urine output is an accurate indicator of fluid balance.
2. Monitor blood pressure, heart rate, and body temperature.
In fluid volume deficit, vital sign changes include tachycardia, hypotension, and increased or decreased body temperature.
3. Check skin turgor of older clients on the forehead and axilla; check for dry mucous membranes and sunken eyes.
For older patients, skin turgor may be checked on the forehead and axilla due to the physiologic loss of skin elasticity. Thus, checking the skin turgor on the arm may not be reliable. Poor skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension indicate dehydration.
4. Monitor for signs of Hyperosmolar Hyperglycemic Syndrome (HHS).
HHS is a complication of uncontrolled diabetes characterized by polyuria, polydipsia, weakness, lethargy, malaise, severe dehydration, and altered mental status. HHS is serious and potentially fatal. Hence, early detection and management are crucial.
5. Review laboratory findings (e.g., Random Blood Sugar, hematocrit, serum osmolality BUN, Crea).
The management will rely on the level of blood glucose. Hematocrit can be used to assess hydration status. Increased hematocrit indicates hemoconcentration and dehydration. BUN, Crea, and serum osmolality are elevated in hyperglycemia and dehydration.
Interventions:
1. Administer anti-hyperglycemic medications.
Addressing the underlying diabetes of the patient through antihyperglycemic medications will also manage the excessive urinary output of the patient.
2. Check for treatment adherence.
Uncontrolled diabetes may be due to undiagnosed diabetes or nonadherence to antihyperglycemic medications.
3. Hydrate with isotonic IV solutions as ordered.
The type and amount of fluid depend on the degree of the fluid volume deficit and patient response. Aggressive hydration with electrolyte replacement is the mainstay for managing HHS.
4. Educate on lifestyle modification strategies to address diabetes mellitus.
In addition to pharmacologic treatment, diabetes is managed with proper diet and exercise. Successful control of diabetes would eventually lead to the relief of the fluid deficit brought on by excessive urination.
5. Teach about complications of deficient fluid volume and when to call the health care provider.
Hyperglycemia and dehydration are conditions that could lead to complications. Call a healthcare provider immediately if the patient experiences chest pain, dizziness, focal neural deficits, visual disturbances, or loss of consciousness.
References
- Adeyinka, A.& Kondamudi, N.P. (2022). Hyperosmolar hyperglycemic syndrome. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482142/
- Achival, D. & Blocher, N.C. (2021). Hyperosmolar hyperglycemic state. MedScape. https://emedicine.medscape.com/article/1914705-clinical#b1
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Cleveland Clinic. (2021). Dehydration https://my.clevelandclinic.org/health/treatments/9013-dehydration
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualising client care across the life span (10th ed.). F.A. Davis Company.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Mayo Clinic. (2021). Dehydration https://www.mayoclinic.org/diseases-conditions/dehydration/symptoms-causes/syc-20354086
- Thorek Memorial Hospital. (2014). 14 Surprising causes of dehydration https://www.thorek.org/news/14-surprising-causes-of-dehydration
