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VOLUME (DEHYDRATION) NURSING CARE PLAN

Deficient Fluid
Volume
(Dehydration)
Nursing Care Plan
UPDATED ON OCTOBER 3, 2021 BY GIL WAYNE, BSN, R.N.

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Use this guide to help you formulate nursing care plans
for deficient fluid volume (dehydration).

Care Plans Exams Study Notes Career

Deficient Fluid Volume (also known as Fluid Volume ADVERTISEMENTS

Deficit (FVD), hypovolemia) is a state or condition

NurseLife
where the fluid outputNews
exceeds the fluid intake. It
occurs when the body loses both water and
electrolytes from the ECF in similar proportions.
Common sources of fluid loss are the gastrointestinal
tract, polyuria, and increased perspiration. Risk factors
for deficient fluid volume are as follows: vomiting,
diarrhea, GI suctioning, sweating, decreased intake,
nausea, inability to gain access to fluids, adrenal
insufficiency, osmotic diuresis, hemorrhage, coma,
third-space fluid shifts, burns, ascites, and liver
dysfunction. Fluid volume deficit may be an acute or
chronic condition managed in the hospital, outpatient
center, or home setting.

SEE ALSO: Nursing Diagnosis Complete

List and Guide »

Appropriate management is vital to prevent potentially

life-threatening hypovolemic shock. Older patients are
more likely to develop fluid imbalances. The
management goals are to treat the underlying disorder
and return the extracellular fluid compartment to
normal, restore fluid volume, and correct any
electrolyte imbalances.

1. Causes
2. Signs and Symptoms
3. Goals and Outcomes
4. Nursing Assessment and Rationales for Fluid
Volume Deficit
5. Nursing Interventions for Fluid Volume Deficit
6. References and Sources

Causes
Here are the common factors or etiology for fluid
volume deficit:

Abnormal losses through the skin, GI tract, or

kidneys.
Decrease in intake of fluid (e.g., inability to
intake fluid due to oral trauma)
Bleeding
Movement of fluid into third space.
Diarrhea
Diuresis
Abnormal drainage
Inadequate fluid intake
Increased metabolic rate (e.g., fever, infection)

Signs and Symptoms

The following are the common signs and symptoms
presented for dehydrated patients presenting fluid
volume deficit that can help guide your nursing
assessment:
 Alterations in mental state
Patient complaints of weakness and thirst that
may or may not be accompanied by tachycardia
or weak pulse
Weight loss (depending on the severity of fluid
volume deficit)
Concentrated urine, decreased urine output
Dry mucous membranes, sunken eyeballs
Weak pulse, tachycardia
Decreased skin turgor
Decreased blood pressure, hemoconcentration
Postural hypotension

Goals and Outcomes

Here are some example goals and outcomes for fluid
volume deficit:

Patient is 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.
Patient demonstrates lifestyle changes to avoid
progression of dehydration.
Patient verbalizes awareness of causative
factors and behaviors essential to correct fluid
deficit.
Patient explains measures that can be taken to
treat or prevent fluid volume loss.
Patient describes symptoms that indicate the
need to consult with health care provider.

Nursing Assessment and

Rationales for Fluid
Volume Deficit
Assessment is necessary to identify potential problems
that may have led to fluid volume deficit and name any
episode that may occur during nursing care.

1. Monitor and document vital signs, especially BP

and HR.
A 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 irregular if electrolyte
imbalance also occurs. Hypotension is evident in
hypovolemia.

2. Assess skin turgor and oral mucous membranes

for signs of dehydration.
Signs of dehydration are also detected through the
skin. The 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 around the tongue.

3. Monitor BP for orthostatic changes (changes

seen when changing from supine to standing
position). Monitor HR for orthostatic changes.
A common manifestation of fluid loss is postural
hypotension. It is manifested by a 20-mm Hg drop in
systolic BP and a 10 mm Hg drop in diastolic BP. The
incidence increases with age.
4. Assess alteration in mentation/sensorium
(confusion, agitation, slowed responses).
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 a patient to aspiration regardless of the
cause.

5. Assess color and amount of urine. Report urine

output less than 30 ml/hr for two (2) consecutive
hours.
Normal urine output is considered normal, not less than
30ml/hour. Concentrated urine denotes fluid deficit.

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6. Monitor and document temperature.

Febrile states decrease body fluids by perspiration and
increased respiration. This is known as insensible water
loss.
7. Monitor fluid status in relation to dietary intake.
Most fluid comes into the body through drinking, water
in food, and water formed by the oxidation of foods.
Verifying if the patient is on a fluid restraint is
necessary.

8. Note the presence of nausea, vomiting, and

fever.
These factors influence intake, fluid needs, and route
of replacement.

9. Auscultate and document heart sounds; note

rate, rhythm, or other abnormal findings.
Cardiac alterations like dysrhythmias may reflect
hypovolemia or electrolyte imbalance, commonly
hypocalcemia. MI, pericarditis, and pericardial effusion
with/ without tamponade are common cardiovascular
complications.

10. Monitor serum electrolytes and urine osmolality,

and report abnormal values.
Elevated blood urea nitrogen suggests fluid deficit.
Urine-specific gravity is likewise increased.

11. Ascertain whether the patient has any related

heart problem before initiating parenteral therapy.
Cardiac and older patients are often susceptible to fluid
volume deficit and dehydration due to minor changes
in fluid volume. They also are susceptible to the
development of pulmonary edema.

12. Weigh daily with the same scale, and preferably

at the same time of day.
Weight is the best assessment data for possible fluid
volume imbalance. An increase in 2 lbs a week is
considered normal.

13. Identify the possible cause of the fluid

disturbance or imbalance.
Establishing a database of history aids accurate and
individualized care for each patient.

14. Monitor active fluid loss from wound drainage,

tubes, diarrhea, bleeding, and vomiting; maintain
accurate input and output record.
Fluid loss from wound drainage, diarrhea, bleeding, and
vomiting cause decreased fluid volume and can lead to
dehydration.

15. 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).
Close monitoring for responses during therapy reduces
complications associated with fluid replacement.

16. Monitor and document hemodynamic status,

including CVP, pulmonary artery pressure (PAP),
and pulmonary capillary wedge pressure (PCWP) if
available in the hospital setting.
These direct measurements serve as an optimal guide
for therapy.

17. Monitor 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).
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.

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Nursing Interventions for

Fluid Volume Deficit
The following are the therapeutic nursing interventions
for fluid volume deficit:

1. Urge the patient to drink the prescribed amount

of fluid.
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.,
Rehydralyte) can be considered as needed.

2. Aid the patient if they cannot eat without

assistance, and encourage the family or SO to
assist with feedings as necessary.
Dehydrated patients may be weak and unable to meet
prescribed intake independently.

3. If the patient can tolerate oral fluids, give what

oral fluids the patient prefers. Provide fluid and
straw at bedside within easy reach. Provide fresh
water and a straw.
Most elderly patients may have a reduced sense of
thirst and may require continuing reminders to drink.

4. Emphasize the importance of oral hygiene.

A fluid deficit can cause a dry, sticky mouth. Attention
to mouth care promotes interest in drinking and
reduces the discomfort of dry mucous membranes.

5. Provide a comfortable environment by covering

the patient with light sheets.
Drop situations where patients can experience
overheating to prevent further fluid loss.

6. Plan daily activities.

Planning conserves the patient’s energy.

Interventions for severe hypovolemia:

7. Insert an IV catheter to have IV access.

Parenteral fluid replacement is indicated to prevent or
treat hypovolemic complications.

8. Administer parenteral fluids as prescribed.

Consider the need for an IV fluid challenge with an
immediate infusion of fluids for patients with
abnormal vital signs.
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.

9. Administer blood products as prescribed.

Blood transfusions may be required to correct fluid loss
from active gastrointestinal bleeding.

10. Maintain IV flow rate. Stop or delay the infusion

if signs of fluid overload transpire, refer to
physician respectively.
Most susceptible to fluid overload are elderly patients
and require immediate attention.

11. Assist the physician with inserting the central

venous line and arterial line, as indicated.
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.

12. Provide measures to prevent excessive

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

13. Begin to advance the diet in volume and

composition once ongoing fluid losses have
stopped.
The addition of fluid-rich foods can enhance continued
interest in eating.

14. Encourage to drink bountiful amounts of fluid as

tolerated or based on individual needs.
A patient may have restricted oral intake in an attempt
to control urinary symptoms, reducing homeostatic
reserves and increasing the risk of dehydration or
hypovolemia.

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15. Enumerate interventions to prevent or minimize

future episodes of dehydration.
A patient needs to understand the value of drinking
extra fluid during bouts of diarrhea, fever, and other
conditions causing fluid deficits.

16. Educate patient about possible causes and

effects of fluid loss or decreased fluid intake.
Enough knowledge aids the patient in taking part in
their plan of care.

17. Emphasize the relevance of maintaining proper

nutrition and hydration.
Increasing the patient’s knowledge level will assist in
preventing and managing the problem.

18. Teach family members how to monitor output in

the home. Instruct them to monitor both intake and
output.
An accurate measure of fluid intake and output is an
important indicator of a patient’s fluid status.

19. Refer patient to home health nurse or private

nurse to assist patient, as appropriate.
Continuity of care is facilitated through the use of
community resources.

20. Identify an emergency plan, including when to

ask for help.
Some complications of deficient fluid volume cannot be
reversed in the home and are life-threatening. Patients
progressing toward hypovolemic shock will need
emergency care.

References and Sources

Additional references and recommended readings for
this Deficient Fluid Volume care plan guide:

1. Ackley, B. J., Ladwig, G. B., Msn, R. N., Makic, M.

B. F., Martinez-Kratz, M., & Zanotti, M.
(2019). Nursing Diagnosis Handbook E-Book: An
Evidence-Based Guide to Planning Care. Mosby.
2. Carpenito-Moyet, L. J. (2006). Handbook of
nursing diagnosis. Lippincott Williams & Wilkins.
3. Corrigan, A., Gorski, L., Hankins, J., Perucca, R.,
& Alexander, M. (2009). Infusion nursing: An
evidence-based approach. Elsevier Health
Sciences.
4. Docherty, B., & McIntyre, L. (2002). Nursing
considerations for fluid management in
hypovolaemia. Professional nurse (London,
England), 17(9), 545-549.
5. Marik, P. E., Monnet, X., & Teboul, J. L. (2011).
Hemodynamic parameters to guide fluid
 therapy. Annals of intensive care, 1(1), 1.
6. McGee, S., Abernethy III, W. B., & Simel, D. L.
(1999). Is this patient
hypovolemic?. Jama, 281(11), 1022-1029.
7. Meyers, K. A. (1988). Nursing management of
hypovolemic shock. Critical care nursing
quarterly, 11(1), 57-67.
8. Pellico, L. H., Bautista, C., & Esposito, C.
(2012). Focus on adult health medical-surgical
nursing.
9. Saavedra, J. M., Harris, G. D., Li, S., & Finberg, L.
(1991). Capillary refilling (skin turgor) in the
assessment of dehydration. American journal of
diseases of children, 145(3), 296-298.
10. Scales, K. (2014). NICE CG 174: intravenous fluid
therapy in adults in hospital. British journal of
nursing (Mark Allen Publishing), 23(8), S6-S8.
11. Shimizu, M., Kinoshita, K., Hattori, K., Ota, Y.,
Kanai, T., Kobayashi, H., & Tokuda, Y. (2012).
Physical signs of dehydration in the
elderly. Internal medicine, 51(10), 1207-1210.
12. Shires, T., COLN, D., Carrico, J., & LIGHTFOOT,
S. (1964). Fluid therapy in hemorrhagic
shock. Archives of surgery, 88(4), 688-693.
13. Sinert, R., & Spektor, M. (2005). Clinical
assessment of hypovolemia. Annals of
emergency medicine, 45(3), 327-329.

Nursing Diagnosis
deficient fluid volume, Fluid Volume Deficit, Nursing
Diagnosis
Cellulitis
zDoggMD’s Low: A Parody of the ER That Will Get You
Crazy!

Gil Wayne, BSN, R.N.

Gil Wayne graduated in 2008 with a bachelor of science in
nursing. He earned his license to practice as a registered
nurse during the same year. His drive for educating people
 stemmed from working as a community health nurse. He
conducted first aid training and health seminars and
workshops for teachers, community members, and local
groups. Wanting to reach a bigger audience in teaching, he is
now a writer and contributor for Nurseslabs since 2012 while
working part-time as a nurse instructor. His goal is to expand
his horizon in nursing-related topics. He wants to guide the
next generation of nurses to achieve their goals and empower
the nursing profession.

4 thoughts on “Deficient Fluid

Volume (Dehydration) Nursing
Care Plan”

GLORIA
July 12, 2019 at 3:07 AM

AMAZING……..GOD BLESS YOU

YOU ARE DOING A GREAT JOB

Reply

Jonathan Marcel
April 12, 2020 at 2:53 PM

Great article but complications related to

dehydration should be added.

Reply
Paulina
November 6, 2020 at 6:15 AM

Thank you very much

Reply

Krista
March 10, 2021 at 2:24 AM

This is the best website to ever exist ever

Reply

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