Nursing Care Plan (NCP) for Fluid Volume Deficit

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Outline

Pathophysiology

Fluid Volume deficit (dehydration) is a state or condition where the fluid output exceeds the fluid intake. The body loses both water and electrolytes from the ECF in similar proportions. Common sources are the gastrointestinal tract, polyuria, and increased perspiration.

Etiology

Common causes are decreased fluid intake, bleeding, diarrhea, diuresis, abnormal drainage, increased metabolic rate, movement of fluid into third space, and abnormal losses through the skin, GI tract, or kidneys.

Desired Outcome

Patient has normal vital signs. Demonstrates adequate lifestyle changes to avoid dehydration. Patient has normal urine output

Subjective Data

  • Weakness 
  • Extreme thirst 
  • Dizziness

Objective Data

  • Alterations in mental state 
  • Weight loss
  • Concentrated urine/decreased urine output 
  • Dry mucous membranes 
  • Weak pulse/tachycardia
  • Decreased skin turgor 
  • Hypotension 
  • Postural hypotension 
  • Sunken eyes/cheeks

Nursing Interventions and Rationales

 

Nursing Intervention (ADPIE) Rationale
Monitor and document VS (BP & HR, orthostatic BP) 20 mm drop in systolic, and 10 mm drop in diastolic) decrease in blood volume can cause hypotension and tachycardia
Assess skin turgor and mucous membranes  dehydration can be detected through the skin. (Dry membranes and decreased skin turgor)
Monitor I&O’s (encourage fluid intake and monitor urine output) Noting urine color, amount, clear/cloudy, etc) Make sure patient is taking in an adequate amount of fluid. Concentrated or decreased urine can indicate dehydration 
Monitor lab values  dysrhythmias can reflect hypovolemia or electrolyte imbalances such as K, Mg. Elevated BUN, Creatinine, and urine specific gravity can reflect dehydration.

Also, elevated hematocrit with no change in hemoglobin also reflects fluid volume deficit 

Give IV fluids (isotonic solutions) such as normal saline, lactated ringers, 5% dextrose in water) giving isotonic solutions will help aid in rehydrating the patient 
Daily weights (usually same time each day) best way of showing any fluid volume imbalance.
Get proper health history from patient  such factors as GI losses, uncontrolled DM II, or diuretic therapy can cause fluid volume deficit)
Educate the patient/family on prevention/treatment/S&S/when to call physician  patient should know how to prevent dehydration and know when they should be concerned and contact physician if needed 

Writing a Nursing Care Plan (NCP) for Fluid Volume Deficit

A Nursing Care Plan (NCP) for Fluid Volume Deficit starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.

References

https://www.mayoclinic.org/diseases-conditions/dehydration/symptoms-causes/syc-203540

https://my.clevelandclinic.org/health/treatments/9013-dehydration

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Transcript

Hi everyone. Today, we’re going to be creating a nursing care plan for fluid volume deficit. So let’s get started. First, we’re going to be going over the pathophysiology. So fluid volume deficit or dehydration is a state or condition where the fluid output exceeds the fluid intake. Nursing considerations: we’re going to monitor vital signs, full head to toe assessment, monitor I&Os, lab values, administer IV fluids, and educate the patient on prevention. Desired outcomes: the patient will have normal vital signs, demonstrate adequate lifestyle changes to avoid dehydration, and the patient will have normal urine output. 

So if we’re going to go ahead and dive into the care plan, we’re going to be writing out some subjective data and some objective data. So, what are we going to see with these patients? Some subjective data could be weakness and dizziness. Some objective data that we’ll see: maybe some weight loss, hypotension, maybe concentrated urine. Some other things you’ll see are extreme thirst in these patients and alteration in their mental status. There’ll be a decreased urine output, dry mucous membranes, and sunken in eyes and cheeks. 

So interventions: we want to make sure that we’re going to monitor and document vital signs. So we’re always going to be checking those vital signs. We’re going to be looking for their blood pressure and their heart rate. And orthostatics. So, for orthostatic blood pressure, 20 millimeter drop in systolic and 10 millimeter drop in diastolic is what you’re looking for. Decrease in blood volume can cause hyper or hypotension and tachycardia. Another thing we want to do is we want to make sure we’re getting proper health history from the patient. So we want to make sure we’re getting a history. Do they have such factors as GI losses? Are they diabetic? Are they on any sort of diuretic therapies that would cause them to be losing so much fluid? We want to make sure we’re going to be monitoring their I&Os. We’re going to make sure that we’re encouraging fluid intake and making sure we’re monitoring their urine output, noting the urine characteristics and the amount. Is it clear? Is it cloudy? We want to make sure patients are taking in an adequate amount of fluids – concentrated or decreased urine can indicate dehydration. We want to make sure we’re going to monitor lab values. So we want to see such things as elevated BUN or Creatinine. So these are further kidney functions. There are a lot of others such as potassium and magnesium going to be looking for. We’re also going to be looking for hematocrit. With hematocrit, if there is no change in the hemoglobin, this can also reflect fluid volume deficit. We want to make sure that we’re giving IV fluids or isotonic solutions such as normal saline or lactated ringers or 5% dextrose in water. We want to make sure that we’re giving these solutions and able to help rehydrate these patients and make sure we’re getting daily weights. We want to make sure we’re doing this at the same time as this is the best way of showing any sort of fluid volume and balance. And we want to make sure that we’re educating the patient and the family on prevention and any signs and symptoms that they need to be reporting to the physician. The patient should know how to prevent dehydration and know when they should be concerned and contact the physician as needed. 

Okay, we’re going to go over some key points here. So fluid volume deficit is a condition where the fluid output exceeds the intake. Decreased fluid intake, bleeding, diarrhea, increased metabolic rate, and third spacing are common causes. Some subjective and objective data we’re looking at the patient could be complaining of weakness, extreme thirst, dizziness, any sort of alterations in their mental status. They’ve got weight loss, concentrated urine, decreased urine output, and dry mucous membranes. We’re going to monitor their vital signs, do a full assessment, make sure we’re monitoring their I&Os, their lab values, and administering those fluids. Make sure we’re doing daily weights and educating the patient on preventing dehydration. And there we have a completed care plan. 

Awesome job guys. We love ya. Go out and be your best self today and as always happy nursing.

 

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