What are the top three priority nursing interventions for a patient with fluid volume deficit?
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Looking for information about fluid volume deficit? We’ve got you covered! In this article, we’ll explain the fluid volume deficit nursing diagnosis (AKA deficient fluid volume) and describe the causes, symptoms, and signs. We’ll also provide guidance on creating a fluid volume deficit care plan. What Is Fluid Volume Deficit?Fluid volume deficit (also known as deficient fluid volume or hypovolemia) describes the loss of extracellular fluid from the body. Extracellular fluid is the body fluid not contained within individual cells. It constitutes about 20% of our body weight and includes blood plasma, lymph, spinal cord fluid, and the fluid between cells. Importantly, this fluid isn’t just water—it also contains electrolytes and other essential solutes. Fluid volume deficit is often used interchangeably with the term “dehydration,” but they aren’t exactly the same thing. Dehydration refers specifically to the loss of body water as opposed to body fluid. What’s the difference? Electrolytes. If a patient has just lost water but no electrolytes, they’ll have slightly different issues—and require slightly different treatment—than a patient who has lost wholesale body fluids, which contains water and electrolytes. Well, some of these things are electrolytes. What Causes Fluid Volume Deficit?There are a number ways the body can lose fluid. Here are some major causes of deficient fluid volume:
The fluids in the body also constantly need to be replenished. Patients can experience deficient fluid volume if they aren’t taking in enough fluid. This is particularly an issue with infant and elderly patients. Patients can also experience fluid volume deficit if they are losing body fluids to a place inside the body where the fluid is not easily accessed by other organs and body systems; e.g. from edema or internal bleeding caused by trauma or as a complication of surgery. This is known as third spacing. Types of Fluid Volume DeficitWhile fluid volume deficit refers to the loss of both water and solutes from the body, there are three major types of fluid volume deficit:
The type of fluid volume deficit (as determined through lab work) may inform care, especially what fluids are offered to the patient to replace the lost fluid/solutes. She doesn't look very happy to be getting IV therapy. Signs and Symptoms of Fluid Volume DeficitThere are a variety of fluid volume deficit signs and symptoms to check for. First we’ll discuss what major symptoms the patient may experience, and then address some ways to determine it the fluid volume deficit nursing diagnosis applies. Major Fluid Volume Deficit Signs
If fluid volume deficit is severe (more than 20% of body fluid volume is lost), the patient may go into hypovolemic shock. The more fluids that are lost, the more severe the symptoms will become. The following shock symptoms may manifest:
Get this tired dog some fluids, stat! How to Diagnose Fluid Volume DeficitThere are a variety of indicators you can use to diagnose deficient fluid volume. (Well before the patient reaches coma stage!) Vital Signs
Other Fluid Volume Deficit Signs and Symptoms
Lab Results
Depending on the cause of the deficient fluid volume, you may also see:
The other kind of lab! Potential Complications of Fluid Volume DeficitWhen left untreated, severe fluid volume deficit can lead to:
Even if patient’s life is saved through fluid infusion, if they reach the point of organ failure they may experience irreversible damage to some body systems. A nursing care plan is a written document that tracks what you have done and will do to take care of a particular patient’s individual needs. Nursing students generally need to create fairly detailed care plans fully from scratch at part of their training in order to learn nursing best practices and to practice the analytical skills critical for good nursing. However, if you are a working nurse, your place of work probably has a computer system that partially generates a care plan based on the input of the relevant nursing diagnoses. We'll go through the four parts of a nursing care plan (the diagnosis, goals for patient recovery, nursing orders or interventions, and evaluation) tailored to fluid volume deficit. We also have links to useful examples of completed fluid volume deficit care plans. DiagnosisFirst, you'll identify the relevant nursing diagnosis or diagnoses. Unlike medical diagnoses, which typically identify the specific medical condition at issue (i.e. diabetes, bronchitis, celiac disease), nursing diagnoses describe the more immediate and ongoing physical and psychological needs of the patient. According to the standards set by NANDA International, a nursing diagnosis is typically written in a three-part manner: first the diagnosis, then what the diagnosis is related to (its direct cause), and finally the evidence for that diagnosis. You can reference the common direct causes and diagnostic signs and symptoms of fluid volume deficit as noted above for help creating your diagnostic statement. An example fluid volume deficit nursing diagnosis statement might look something like this: “Fluid volume deficit related to diarrhea and vomiting secondary to gastroenteritis as evidenced by decreased skin turgor, low blood pressure, and decreased urine output.” “Risk for fluid volume deficit” or “risk for deficient fluid volume” is a slightly different nursing diagnosis that can be used to describe patients who, while not yet exhibiting serious signs of fluid volume deficit, are at particular risk of developing the issue. A risk nursing diagnosis only has two parts: the diagnosis (“risk for fluid volume deficit”) is related to whatever the cause of the potential future issue is (“diarrhea and vomiting”). So the risk diagnosis would be “risk for fluid volume deficit related to diarrhea and vomiting.” The patient may also have other nursing diagnoses in addition to fluid volume deficit. These should be included in the care plan. Any other diagnoses you made would be specific to the patient and based on a head-to-toe assessment. I diagnose this owl with incredible cuteness. GoalsThe overall goal of a nursing care plan for a stable patient with deficient fluid volume is to safely restore fluids and necessary electrolytes to the body, but you’ll want to be more specific than that. Good goals for your care plan should be specific to the patient and measurable (so you can definitively assess whether the goal has been met). Depending on the patient, here are some example goals that might be appropriate for treating fluid volume deficit. Patient is no longer deficient in fluid volume as evidenced by:
Orders/InterventionsWhile the particular interventions you choose in your care plan should be tailored to the patient and the severity of their condition, here are some potentially appropriate nursing interventions for fluid volume deficit. Note that some of these deficient fluid volume interventions are not highly specific because they would need to be tailored to the individual patient. If you do use these interventions in a care plan, be sure to select appropriate benchmarks for the patient and add more information.
EvaluationIn your fluid volume deficit care plan, you’ll use this section to track what interventions and orders were successfully implemented, assess patient progress towards the goals, and evaluate whether each of the fluid volume deficit interventions (and interventions for any other diagnoses you made) described in the plan should be ceased, continued, or revised. Well, this dog seems pretty happy with how everything is going. Example Fluid Volume Deficit Care PlansThere are several sources of example care fluid volume deficit care plans. Here are some you may find useful: Prenhall Nursing Care Plan—Deficient Fluid VolumeThis example nursing plan is free supplemental material from a Prentice Hall nursing textbook. It offers a detailed case study with a nursing care plan for fluid volume deficit tailored to the particular patient. Nursing Concept Blogspot—Deficient Fluid Volume This care plan is quite detailed and offers explanations and rationale for lots of different potential nursing interventions for fluid volume deficit. Additionally, it segments out which interventions might be appropriate for different patient populations. Nurses Labs Deficient Fluid Volume Care Plan This is a very detailed care plan with detailed suggestions for nursing assessment and nursing interventions, along with rationales. It could be a helpful resource for students who need to write rationales for their care plans. Nurses Labs—Hypovolemic Shock Care Plan This care plan is specifically for addressing hypovolemic shock caused by fluid volume deficit, with specific interventions. RN Speak Hypovolemia Nursing Management This isn’t a complete care plan, but it does offer lots of specific assessment and interventions that could be incorporated into a fluid volume deficit nursing care plan. RN Central Fluid Volume Deficit Care Plan This care plan is laid out similarly to the computer care plans generated in hospitals, where the nurse simply selects the relevant components of the diagnosis, outcome, and interventions. It’s not very detailed but it gives a good idea of how quick care plans are generated in the field. Delmar Learning Fluid Volume Concept Map This isn’t laid out like a traditional care plan. However, nursing students may find it helpful as it lays out how all of the different parts of the fluid volume deficit care plan are conceptually related to each other. Plans are very important! Key Takeaways: Fluid Volume Deficit“Fluid volume deficit” (which is the same as “deficient fluid volume” or hypovolemia) is a nursing diagnosis that describes a loss of extracellular fluid from the body. Gastrointestinal issues, blood loss (internal or external), inadequate fluid intake, and renal disorder are all things that can place a patient at risk for fluid volume deficit. There are a variety of signs and symptoms of fluid volume deficit you can look for, including dizziness, dry mouth and skin, thirst and/or nausea, low blood pressure, and an increased heart rate. If the fluid loss is very serious, the patient will go into hypovolemic shock and you might see the following severe fluid volume deficit symptoms: Pallor, confusion, cool/clammy extremities, fainting, and even coma. Deficient fluid volume can be diagnosed through a combination of observation and assessment of patient body systems, vital signs, and lab work. Finally, we also discussed how to make a fluid volume deficit care plan and listed potential goals, outcomes, and nursing intervention. The main deficient fluid volume interventions are to monitor the patient’s fluid levels and safely restore the lost fluid. What's Next?Looking for a blood pressure chart? We've got you covered. If you're looking for ICD-10 codes, we have the codes for abdominal pain and diabetes. Got a patient with shingles? We have pictures of the infamous rash, common shingles treatments, and some methods of transmission to avoid. Need help converting fluid measurements? Find out how many cups four quarts is here. Have friends who also need help with test prep? Share this article!About the Author Ellen has extensive education mentorship experience and is deeply committed to helping students succeed in all areas of life. She received a BA from Harvard in Folklore and Mythology and is currently pursuing graduate studies at Columbia University. What are the nursing interventions for fluid volume deficit?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.
What nursing intervention will you provide for a patient with fluid imbalance?Restriction of sodium or water decreases extracellular fluid retention. Administer diuretics as indicated: Loop diuretics such as furosemide (Lasix). Potassium-sparing diuretics such as spironolactone (Aldactone).
What are the priority nursing actions for fluid volume overload?Nursing Interventions for Excess Fluid Volume. Enforce fluid restrictions and educate on the importance. ... . Record accurate intake and output. ... . Record daily weights. ... . Educate the patient and family on signs of fluid gain. ... . Administer diuretics. ... . Review dietary restrictions. ... . Consult with a dietician. ... . Provide mouth care.. What would your goal of care be for a patient experiencing a fluid volume deficit?Deficient Fluid Volume
Encourage oral fluid intake, as tolerated. Provide fluids the patient prefers within easy reach.
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