Fluid Volume Deficit Nursing Care Plan

Actual Nursing Care Plan example from Nursing for Life Organization

1. Nursing Care Plan
"Fluid volume deficit"
Patient
Problem
( Actual )
Nursing diagnosis \ Fluid volume deficit related to (contributing factor
according to the patient’s condition)

Subjective
Data
 According to the nurse’s observation.
Objective
Data
 According to the patient description.
Objectives
Short term


In 2 days, the patient will…
 Verbalize awareness of causative factors and behaviors essential to
correct fluid deficit.
 Explain measures that can be taken to treat or prevent fluid volume loss
 Describe symptoms that indicate the need to consult with health care
provider.

Long term


In 2 weeks, the patient will…
 Be normovolemic as evidenced by systolic BP greater than or equal to 90
mm HG (or patient’s baseline), absence of orthostasis, HR 60 to 100
beats/min, urine output greater than 30 mL/hr. and normal skin turgor.
 Demonstrate lifestyle changes to avoid progression of dehydration.

Nursing intervention

Assessment

 Assess and document vital signs especially BP and HR.
- Rationale: Decrease in circulating blood volume can cause hypotension
and tachycardia. Alteration in HR is a compensatory mechanism to
maintain cardiac output. Usually, the pulse is weak and may be irregular if
electrolyte imbalance also occurs. Hypotension is evident in hypovolemia.

 Assess skin turgor and oral mucous membranes for signs of dehydration.
- Rationale: Signs of dehydration are also detected through the skin. Skin
of elderly patients’ losses elasticity, hence skin turgor should be assessed
over the sternum or on the inner thighs. Longitudinal furrows may be
noted along the tongue.

2.  Assess alteration in mentation/sensorium (confusion, agitation, slowed
responses)
- Rationale: Alteration in mentation/sensorium may be caused by
abnormally high or low glucose, electrolyte abnormalities, acidosis,
decreased cerebral perfusion, or developing hypoxia. Impaired
consciousness can predispose patient to aspiration regardless of the
cause.

 Assess color and amount of urine. Report urine output less than 30 ml/hr
for 2 consecutive hours.
- Rationale: A normal urine output is considered normal not less than
30ml/hour. Concentrated urine denotes fluid deficit.

 Monitor fluid status in relation to dietary intake.
- Rationale: Most fluid comes into the body through drinking, water in
food, and water formed by oxidation of foods. Verifying if the patient is on
a fluid restraint is necessary.

 Note presence of nausea, vomiting and fever.
- Rationale: These factors influence intake, fluid needs, and route of
replacement.

 Auscultate and document heart sounds; note rate, rhythm or other
abnormal findings.
- Rationale: Cardiac alterations like dysrhythmias may reflect hypovolemia
and/or electrolyte imbalance, commonly hypocalcemia. Note: MI,
pericarditis, and pericardial effusion with/ without tamponade are
common cardiovascular complications.

 Monitor serum electrolytes and urine osmolality, and report abnormal
values.
- Rationale: Elevated blood urea nitrogen suggests fluid deficit. Urine
specific gravity is likewise increased.

 Ascertain whether the patient has any related heart problem before
initiating parenteral therapy.
- Rationale: Cardiac and older patients are often susceptible to fluid volume
deficit and dehydration as a result of minor changes in fluid volume. They
also are susceptible to the development of pulmonary edema.


 Assess Weight daily with same scale, and preferably at the same time of
day.
- Rationale: Weight is the best assessment data for possible fluid volume
imbalance.

3.  Assess for the existence of factors causing deficient fluid volume (e.g.,
gastrointestinal losses, difficulty maintaining oral intake, fever,
uncontrolled type II diabetes mellitus, diuretic therapy).
- Rationale: Early detection of risk factors and early intervention can
decrease the occurrence and severity of complications from deficient fluid
volume. The gastrointestinal system is a common site of abnormal fluid
loss.

Interventions

 Urge the patient to drink prescribed amount of fluid.
- Rationale: Oral fluid replacement is indicated for mild fluid deficit and is a
cost-effective method for replacement treatment. Older patients have a
decreased sense of thirst and may need ongoing reminders to drink. Being
creative in selecting fluid sources (e.g., flavored gelatin, frozen juice bars,
sports drink) can facilitate fluid replacement. Oral hydrating solutions
(e.g., Rehydrate) can be considered as needed.

 Aid the patient if he or she is unable to eat without assistance, and
encourage the family or SO to assist with feedings, as necessary.
- Rationale: Dehydrated patients may be weak and unable to meet
prescribed intake independently.

 If patient can tolerate oral fluids, give what oral fluids patient prefers.
Provide fluid and straw at bedside within easy reach. Provide fresh water
and a straw.
- Rationale: Most elderly patients may have reduced sense of thirst and
may require continuing reminders to drink.

 Emphasize importance of oral hygiene.
- Rationale: Fluid deficit can cause a dry, sticky mouth. Attention to mouth
care promotes interest in drinking and reduces discomfort of dry mucous
membranes.

 Provide comfortable environment by covering patient with light sheets.
- Rationale: Drop situations where patient can experience overheating to
prevent further fluid loss.

 Plan daily activities.
- Rationale: Planning conserves patient’s energy.

 Insert and IV catheter to have IV access.
- Rationale: Parenteral fluid replacement is indicated to prevent or treat
hypovolemic complications.

4.  Administer parenteral fluids as prescribed. Consider the need for an IV
fluid challenge with immediate infusion of fluids for patients with
abnormal vital signs.
- Rationale: Fluids are necessary to maintain hydration status.
Determination of the type and amount of fluid to be replaced and infusion
rates will vary depending on clinical status.

 Administer blood products as prescribed.
- Rationale: Blood transfusions may be required to correct fluid loss from
active gastrointestinal bleeding.

 Maintain IV flow rate. Stop or delay the infusion if signs of fluid overload
transpire, refer to physician respectively.
- Rationale: Most susceptible to fluid overload are elderly patients and
require immediate attention.

 Assist the physician with insertion of central venous line and arterial line,
as indicated.
- Rationale: A central venous line allows fluids to be infused centrally and
for monitoring of CVP and fluid status. An arterial line allows for the
continuous monitoring of BP.

 Provide measures to prevent excessive electrolyte loss (e.g., resting the GI
tract, administering antipyretics as ordered by the physician).
- Rationale: Fluid losses from diarrhea should be concomitantly treated
with antidiarrheal medications, as prescribed. Antipyretics can decrease
fever and fluid losses from diaphoresis.

 Begin to advance the diet in volume and composition once ongoing fluid
losses have stopped.
- Rationale: Addition of fluid-rich foods can enhance continued interest in
eating.

Health Teaching


 Encourage to drink bountiful amounts of fluid as tolerated or based on
individual needs.
- Rationale: Patient may have restricted oral intake in an attempt to control
urinary symptoms, reducing homeostatic reserves and increasing risk of
dehydration or hypovolemia.

 Educate patient about possible cause and effect of fluid losses or
decreased fluid intake.
- Rationale: Enough knowledge aids the patient to take part in his or her
plan of care.

5.  Teach family members how to monitor output in the home. Instruct them
to monitor both intake and output.
- Rationale: An accurate measure of fluid intake and output is an important
indicator of patient’s fluid status.








Evaluation

Achieved ( ) Partially achieved ( ) Not achieved ( )

Evidence by:





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