Nursing Diagnosis, Care Plan, & Interventions for Fluid Volume Deficit-Student Guide
Introduction
Fluid volume deficit, also known as hypovolemia, is the loss of water and electrolytes from the body. The fluid output from the body exceeds the inflow. The causes for fluid volume deficit can be classified as involuntary loss or voluntary loss. The patient does not consume enough fluids (such as in a conscious effort to lose weight) or cannot retain fluids due to problems with the kidney-pancreas, bladder, or gastrointestinal tract).
Fluid volume deficit is a condition that should be closely monitored as it can quickly deteriorate the patient’s health.
We’ll delve deeper into fluid volume deficit, with the aim of guiding nursing students towards understand it fully. As you read, remember that our top writers are ready to help in case you get stuck with your nursing assignment, or cannot complete it due to other reasons such as a busy schedule. All you need to do is place an order with us!
Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students, for learning purposes only, and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.
Signs and Symptoms of fluid volume deficit
- Weakness and fatigue, especially in the joints.
- Abdominal cramps (as a result of the kidneys releasing substances into the urine)
- Chills (due to loss of blood volume)
- Cold and clammy skin
- Headaches
- Confusion, disorientation, or difficulty concentrating
- Constipation (due to a decrease in peristalsis)
- Irritability and personality changes (from decreased blood flow through the brain)
Associated symptoms: hunger, thirst, fever, vomiting/nausea (due to the patient’s failure to take in adequate fluids)
Causes of fluid volume deficit include
1) Sepsis – It is the most common cause of hypovolemia and occurs when bacteria in the blood overwhelms the body’s ability to fight it. Blood sepsis, also known as infective endocarditis (IE), can occur when bacteria enter the bloodstream through implanted devices with an open valve or catheter tip.
2.) Burns – a severe type of trauma where the patient loses more than 20% of their total body fluid. Fluid loss may be caused by inhalation of hot air and smoke. The condition is usually life-threatening because it can lead to multiple organ failures and death within 2-3 days from the time of the event.
3.) Hyperthyroidism – a condition where there is an overproduction of thyroid hormone, usually caused by an overactive thyroid gland (Graves’ disease). There are 2 types: exophthalmic and non-exophthalmic
4.) Pneumonia – acute inflammation of the lung tissue that causes breathlessness and coughing. Bacteria, fungi, or viruses can cause it. In the worst cases, it can cause hypoxemia (low oxygen level in the blood) which may lead to death.
5.) Hernia – a protrusion of an organ or tissue through a defect in the surrounding tissues or muscle layers. In this case, the intestines can protrude through a weak section of the abdominal muscle and subsequently leads to the accumulation of fluid within the abdomen
6.) Gastrointestinal bleeding – The most common cause of gastrointestinal bleeding is peptic ulcer disease. It occurs when there is continuous exposure of the stomach lining to certain medications (such as aspirin), alcohol, stress, and other medical conditions.
7.) Inadequate intake of fluids – the patient can lose a significant amount of fluids if their intake is inadequate. This is common in patients undergoing chemotherapy for cancer.
8.) Diuresis – the sudden loss of water from the body, which can also cause hypovolemia. This uncomfortable condition needs immediate attention, usually caused by severe dehydration due to the unavailability of sufficient drinking water or other fluid intakes.
9.) Vomiting – forceful emptying of the stomach’s contents through the mouth. In this case, there is a loss of gastric secretions (such as hydrochloric acid), digestive enzymes, and mucus which can further damage the esophagus.
10.) Diarrhea – a condition where the frequency of bowel movement is greater than normal. It can be caused by bacterial, viral, or parasitic infection, stress, certain medications (such as aspirin), and other medical conditions.
Nursing Diagnosis for Fluid Volume Deficit
Impaired skin integrity: Skin Integrity is a nursing diagnosis that refers to the physical condition of the patient’s skin. It may refer to problems related to pressure sores, infection, irritation, or other impairments that may be caused by pressure, shearing forces (such as friction), or exposure to chemicals.
Impaired gas exchange: Gas Exchange refers to the ability of tissues in various parts of the body (such as the lungs, intestines, and brain) to receive adequate amounts of oxygen. If this condition persists, it can lead to hypoxia (a decreased amount of oxygen in the organs), inducing other problems such as respiratory distress.
Impaired oral mucous membrane: Oral Mucous Membranes include the lips, tongue, mouth lining (oropharynx), and esophagus. It is a sensitive tissue where problems in swallowing can lead to vomiting, dental abscesses due to infection or trauma from eating abrasive food, and other complications that can compromise the health of the patient.
Impaired renal function: Renal Function refers to the ability of the kidneys to regulate electrolyte and water balance in the body and excrete waste products and by-products of metabolism such as urea and creatinine from the bloodstream. If these kidneys fail, it can lead to edema or accumulation of fluid in the lungs and other organs.
Impaired tissue perfusion: Tissue Perfusion refers to the delivery of oxygen and nutrients (such as glucose) to the cells in various parts of the body. Hypoxia will occur when this process fails, resulting in symptoms such as altered mental status, weakness, and tachycardia (rapid heart rate).
Impaired elimination: Elimination refers to removing waste products, such as carbon dioxide and urea, from the body via excretory pathways in the kidneys. When these fail, it may lead to fluid accumulation or electrolyte imbalance such as hyponatremia.
Nursing Assessment for Fluid Volume Deficit
1. Skin – inspect and auscultate the abdomen for fluid accumulation; also, assess for edema in lower extremities and other areas of the body where conditions are conducive to swelling such as feet, ankles, legs, hands, arms
2. Cardiovascular system – listen to the heart sounds with a stethoscope to check for rate and rhythm. Check for signs of edema in the ankles and feet.
3. Respiratory system – auscultate lungs for wheezing, crackles, or decreased breath sounds; check oxygen saturation using an oximeter
4. Gastrointestinal tract – assess for abdominal pain, nausea, vomiting, or diarrhea (leading to dehydration).
5. Central nervous system (CNS) – assess mental status, skin turgor, and capillary refill time
6. Renal/urinary system – assess for dysuria, frequency, and nocturia. Check for the patient’s hydration status through lab tests (i.e., serum sodium concentration).
7. Musculoskeletal system – assess the range of motion and muscle strength in the extremities. Check for deep tissue edema.
8. Oral cavity – assess for any oral lesions, ulcers, or other problems that may cause difficulty with eating or drinking (such as dysphagia)
9. Elimination – check for signs and symptoms of urinary retention, urinary frequency, and incontinence
10. Cardiovascular system – check for arterial blood pressure readings; ensure that the patient is taking any prescribed antihypertensive agents to reduce their high blood pressure
11. Clinical manifestations of fluid volume deficit include: oliguria, orthostatic hypotension (systolic BP <90 mmHg upon standing up), tachycardia, hypotension (SBP < 90 mmHg), fatigue, general malaise, and dizziness
12. If the patient is conscious and able to follow commands: ask them if they are experiencing nausea or vomiting; evaluate for joint pain, increased thirst, decreased appetite, or changes in heart rate and vital signs.
13. If the patient is unconscious: check for the respiratory effort by auscultating lung sounds, and feel for chest rise and fall; check capillary refill time (CRT) in the extremities (which should be less than 2 seconds), skin turgor by pinching up the skin and releasing it; check for muffled heart sounds, absent bowel sounds (by auscultation), or decreased peripheral pulses.
Check the patient’s urine output at least 8 times per day with a sterile catheter to ensure that they adequately eliminate waste products from their body.
Assessment: continuously monitor blood pressure, respiratory rate, pulse, skin turgor, and temperature
Nursing Interventions and Care Plans for Fluid Volume Deficit
Macro goals and outcomes
The primary goal of nursing care is to prevent further loss of fluids, maintain fluid levels in the body, restore lost fluid volume through adequate intake of fluids, and maintain hydration. Specific treatment plans depend on the cause or risk factors involved for the patient. It also aims to promote healing, symptom relief, and prevent complications.
Interventions plan include:
1. Establish a plan of care, including goals and anticipated outcomes for the patient’s status; check electrolyte levels (i.e., potassium, sodium) at least daily using laboratory results to ensure that there is no imbalance in the body fluids.
2. Monitor vital signs every 4 hours or more frequently if changes occur: blood pressure, heart rate, respiratory rate
3. Monitor intake and output to check for signs of fluid imbalances
4. Maintain the patient’s proper body alignment using a special bed or chair that provides foot support when standing; reposition the patient every 2 hours; monitor them for orthostatic hypotension by checking blood pressure upon standing.
5. Maintain the patient’s hydration at all times: prevent dehydration through adequate fluid intake; promote a gradual increase in oral fluids using bland liquids or ice chips to facilitate the swallowing reflex, which may be temporarily decreased in the unconscious patient as a result of stroke, seizure activity, or drug administration; administer intravenous (IV) fluids if the patient is unable to consume sufficient oral fluids; ensure that IV fluids are being administered at the correct rate and proper site to prevent infection.
6. Encourage the patient to eat small, frequent meals if they are conscious (patients should take in at least 250 mL of food or liquids per shift). Recommend clear liquids if they cannot eat solids for a few days; increase fluids by 25-100 mL every hour if they tolerate them (depending on the severity of fluid deficit).
7. Encourage the patient to maintain physical activity as tolerated, and offer assistance with mobility if needed; give gentle range-of-motion exercises every 2 hours or more frequently if there is movement impairment.
8. Assist patients who are at risk for dehydration or fluid imbalance to maintain an adequate intake of fluids by providing increased fluids if they have difficulty. Encourage them to consume high-protein food, such as eggs and peanuts, instead of diet beverages (as advised by a physician); offer small amounts of high-carbohydrate food such as bread, cereal, or crackers every 2 hours.
9. Encourage patients to rest; help them maintain their usual routines as much as possible. Encourage them to follow a well-balanced diet after discharge from the hospital if they can gain weight normally (if patients have had electrolyte imbalances and renal impairments, they may require a high-protein diet after discharge).
Patient responsibilities include:
1. Drink at least 240 mL of fluid every 2 hours if conscious to prevent dehydration; oral intake may be decreased with difficulty swallowing or nausea (take in small amounts such as ice chips).
2. Seek medical attention immediately if unable to urinate, observe abnormal bleeding (blood in urine or stools), experience confusion, feel dizzy upon standing, or experience lightheadedness.
3. Report pain, nausea, vomiting, and unintended weight loss to a medical professional; report any changes in vision and sensation to the nurse
4. Ensure proper breathing and avoid exertion if at risk for fluid imbalance; if there is shortness of breath, shallow breathing, or difficulty speaking, check for signs of fluid imbalance and notify the nurse.
5. Follow up with a medical professional for any recommendations regarding diet and medications.
6. Inform nurses if they have an underlying condition that is causing fluid imbalance: chronic heart, kidney, or liver disease; ulcers; diabetes mellitus, Hyperthyroidism, high blood pressure (i.e., stage 2 hypertension), asthma, cancer/chemotherapy; pregnancy.
7. Follow up with their doctor if they have a condition that may require fluid restriction (e.g., congestive heart failure, cirrhosis).
8. Avoid alcohol or ingestion of caffeine-containing beverages for at least 24 hours after surgery and while taking diuretics; avoid smoking because it reduces blood volume and disturbs the fluid balance.
9. Report any change in their urine color, including pink, brown (signifying a possible blood disorder), yellow, or red tinges (indicating infection or kidney disease).
The above article gives a brief overview of the nursing diagnosis, care plan, and interventions for fluid volume deficit. The prevention of this disorder is primarily associated with interventions that promote adequate fluid intake and restrictions for those in need of fluid restriction.
The nursing care for this client will primarily be focused on maintaining or restoring fluid balance, promoting comfort and mobility, preventing complications, providing education to the patient related to the use of medications or dietary restrictions and follow up with the physician for any recommendations related to fluid intake.
In cases where a patient is at high risk for fluid imbalance, such as when there are underlying medical conditions, the nurse will need to frequently monitor fluid intake and output as well as changes in respiration or weight. Other interventions that promote comfort and mobility include providing gentle range-of-motion exercises every 2 hours or more frequently if there is movement impairment.
Lastly, in case you prefer that our top writers handle your nursing assignment, press the green button below!
