Fluid Volume Deficit - Hypovolemia; Dehydration
Sue Galanes, RN, MS, CCRN
Meg Gulanick, PhD, RN
NANDA: The state in which an individual experiences vascular,
cellular, or intracellular dehydration
Fluid volume deficit, or hypovolemia, occurs from a loss of body
fluid or the shift of fluids into the third space, or from a reduced fluid
intake. Common sources for fluid loss are the gastrointestinal (GI) tract,
polyuria, and increased perspiration. Fluid volume deficit may be an acute or
chronic condition managed in the hospital, outpatient center, or home setting.
The therapeutic goal is to treat the underlying disorder and return the
extracellular fluid compartment to normal. Treatment consists of restoring
fluid volume and correcting any electrolyte imbalances. Early recognition and
treatment is paramount to prevent potentially life-threatening hypovolemic
shock. Elderly patients are more likely to develop fluid imbalances.
- Inadequate fluid intake
- Active fluid loss (diuresis, abnormal drainage or bleeding,
- Failure of regulatory mechanisms
- Electrolyte and acid-base imbalances
- Increased metabolic rate (fever, infection)
- Fluid shifts (edema or effusions)
- Decreased urine output
- Concentrated urine
- Output greater than intake
- Sudden weight loss
- Decreased venous filling
- Increased serum sodium
- Increased pulse rate
- Decreased skin turgor
- Dry mucous membranes
- Possible weight gain
- Changes in mental status
Patient experiences adequate fluid volume and electrolyte balance
as evidenced by urine output >30 ml per hr, normotensive blood pressure
(BP), heart rate (HR) 100 beats per min, consistency of weight, and normal skin
- (i) independent
- (i) Obtain patient history to ascertain the
probable cause of the fluid disturbance,
- Which can help to guide interventions. This may include
acute trauma and bleeding, reduced fluid intake from changes in cognition,
large amount of drainage postsurgery, or persistent diarrhea.
- (i) Assess or instruct patient to monitor
weight daily and consistently, with same scale, and preferably at the same time
- To facilitate accurate measurement and follow
- (i) Evaluate fluid status in relation to
dietary intake. Determine if patient has been on a fluid restriction.
- Most fluid enters the body through drinking, water in
foods, and water formed by oxidation of foods.
- (i) Monitor and document vital signs.
- Sinus tachycardia may occur with hypovolemia to maintain an
effective cardiac output. Usually the pulse is weak, and may be irregular if
electrolyte imbalance also occurs. Hypotension is evident in
- (i) Monitor blood pressure for orthostatic
changes (from patient lying supine to high Fowler's).
- Note the following orthostatic hypotension
- Greater than 10 mm Hg drop: circulating blood volume is
decreased by 20%.
- Greater than 20-30 mm Hg drop: circulating blood volume is
decreased by 40%.
- (i) Assess skin turgor and mucous membranes
for signs of dehydration.
- The skin in elderly patients loses its elasticity;
therefore skin turgor should be assessed over the sternum or on the inner
thighs. Longitudinal furrows may be noted along the tongue.
- (i) Assess color and amount of urine. Report
urine output less than 30 ml per hr for 2 consecutive hours.
- Concentrated urine denotes fluid deficit.
- (i) Monitor temperature.
- Febrile states decrease body fluids through perspiration
and increased respiration.
- (i) Monitor active fluid loss from wound
drainage, tubes, diarrhea, bleeding, and vomiting; maintain accurate input and
- (c) Monitor serum electrolytes and urine
osmolality and report abnormal values.
- Elevated hemoglobin and elevated blood urea nitrogen (BUN)
suggest fluid deficit. Urine-specific gravity is likewise increased.
- (i) Document baseline mental status and record
during each nursing shift.
- Dehydration can alter mental status.
- (i) Evaluate whether patient has any related
heart problem before initiating parenteral therapy.
- Cardiac and elderly patients often have precarious fluid
balance and are prone to develop pulmonary edema.
- (i) Determine patient's fluid preferences:
type, temperature (hot or cold).
- (i) During treatment, monitor closely for
signs of circulatory overload (headache, flushed skin, tachycardia, venous
distention, elevated central venous pressure [CVP], shortness of breath,
increased BP, tachypnea, cough)
- To prevent complications associated with therapy.
- (c) If hospitalized, monitor hemodynamic
status including CVP, pulmonary artery pressure (PAP), and pulmonary capillary
wedge pressure (PCWP) if available.
- This direct measurement serves as optimal guide for
- (i) independent
- (c) Encourage patient to drink prescribed
- Oral fluid replacement is indicated for mild fluid deficit.
Elderly patients have a decreased sense of thirst and may need ongoing
reminders to drink.
- If oral fluids are tolerated, provide oral fluids patient
prefers. Place at bedside within easy reach. Provide fresh water and a straw.
Be creative in selecting fluid sources (flavored gelatin, frozen juice bars,
- (i) Assist patient if unable to feed self and
encourage caregiver to assist with feedings as appropriate.
- (i) Plan daily activities
- So patient is not too tired at mealtimes.
- (i) Provide oral hygiene
- To promote interest in drinking.
- For more severe hypovolemia:
(c) Obtain and maintain a large-bore intravenous (IV)
- Parenteral fluid replacement is indicated to prevent
- (c) Administer parenteral fluids as ordered.
Anticipate the need for an IV fluid challenge with immediate infusion of fluids
for patients with abnormal vital signs.
- (c) Administer blood products as
- May be required for active GI bleeding.
- (c) Assist the physician with insertion of a
central venous line and arterial line as indicated
- For more effective fluid administration and
- (c) Maintain IV flow rate.
- Elderly patients are especially susceptible to fluid
- Should signs of fluid overload occur, stop infusion and sit
patient up or dangle
- To decrease venous return and optimize breathing.
- (c) Institute measures to control excessive
electrolyte loss (e.g., resting the GI tract, administering antipyretics as
- (c) Once ongoing fluid losses have stopped,
begin to advance the diet in volume and composition.
- (c) For hypovolemia due to severe diarrhea or
vomiting, administer antidiarrheal or antiemetic medications as prescribed, in
addition to IV fluids.
Education/Continuity of Care
- (i) independent
- (i) Describe or teach causes of fluid losses
or decreased fluid intake.
- (i) Explain or reinforce rationale and
intended effect of treatment program.
- (i) Explain importance of maintaining proper
nutrition and hydration.
(i) Teach interventions to
prevent future episodes of inadequate intake.
- Patients need to understand the importance of drinking
extra fluid during bouts of diarrhea, fever, and other conditions causing fluid
- (i) Inform patient or caregiver of importance
of maintaining prescribed fluid intake and special diet considerations
- (i) If patients are to receive IV fluids at
home, instruct caregiver in managing IV equipment. Allow sufficient time for
- Responsibility for maintaining venous access sites and IV
supplies may be overwhelming for caregiver. In addition, elderly caregivers may
not have the cognitive ability and manual dexterity required for this
- (c) Refer to home health nurse as appropriate.
Fluid Monitoring; Fluid Management; Fluid Resuscitation
- See also:
Hypovolemic Shock, Chapter 4, p.
~ Care Plan Index ~
Outcomes Index ~
~ Care Plan Constructor Home ~