Nursing Care Plan: Risk for fluid volume deficit related to inadequate fluid intake, active fluid loss (perspiration), and old age.

Scientific Basis:

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 tract, polyuria, and increased perspiration. Fluid volume deficit may be an acute or chronic condition managed in the hospital out patient 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 paramount to prevent potentially life-threatening hypovolemic shock. Older clients are more like to develop fluid imbalances.

Gulanick, 2007

Intervention and Rationale

I: Obtain client’s history to ascertain the probable cause of the fluid disturbance.
R: This can help guide interventions. Causes may include acute trauma and bleeding, reduced fluid intake from changes in cognition.

I: Assess or instruct the client to monitor weight daily and consistently, with the same scale and preferably at the same time of day.
R: This facilitates accurate measurement and follows trends.

I: Evaluate fluid status in relation to dietary intake. Determine whether the client on fluid restriction.
R: Most fluid enters the body through drinking, water in foods, and water formed by oxidation of foods.

I: Measure and record intake and output.
R: Accurate documentation helps identify fluid losses/replacement needs and influences choice of interventions. Note: Ability to concentrate urine declines with age, increasing renal losses despite general fluid deficit.

I: Monitor vital signs noting changes in blood pressure, heart rate and rhythm, and respirations. Calculate pulse
pressure.
R: Hypotension, tachycardia, increased respirations may indicate fluid deficit, e.g., dehydration/hypovolemia. Although a drop in blood pressure is generally a late sign of fluid deficit (hemorrhagic loss), widening of the pulse pressure may occur early, followed by narrowing as bleeding continues and systolic BP begins to fall.

I: Monitor skin temperature, palpate peripheral pulses.
R: Cool/clammy skin, weak pulses indicate decreased peripheral circulation and need for additional fluid replacement.

I: Monitor blood pressure for orthostatic changes (from lying supine to high-Fowler’s).
R: Postural hypotension is a common manifestation in fluid loss. Note the following orthostatic hypotension significance: (Greater than 10 mmHg drop: circulating blood volume is decreased by 20%. ; Greater than 20 to 30 mmHg drop: circulating blood volume is decreased by 40%.)

I: Assess skin turgor and mucous membrane for signs of dehydration.
R: The skin in older clients 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: May serum electrolytes and urine osmolality, and report abnormal values.
R: Elevated hemoglobin and elevated blood urea nitrogen suggest fluid deficit. Urine specific gravity is likewise increased.

I: Monitor mental status changes.
R: Dehydration may alter mental status, especially among older adults. Manifestations may include restlessness, anxiety, lethargy, and confusion.

I: Determine the client’s fluid preferences: type, temperature (cold or hot).
R: Selecting those fluids that the client enjoys drinking cam facilitate replacement therapy.

I: Encourage the client to drink prescribed fluid amounts.
R: Oral fluid replacement is indicated for mild fluid deficit and is a cost-effective method for replacement treatment. Older clients have a decreased sense of thirst and may need ongoing reminders to drink.

I: Plan daily activities.
R: Planning prevents client from being too tired at mealtimes.

I: Provide oral hygiene.
R: Attention to mouth care promotes interest for drinking.

I: Describe or teach causes of fluid losses or decreased fluid intake.
R: Information is key to managing the problem.

I: Explain or reinforce rationale and intended effect of treatment program. Information the client or caregiver of importance of maintaining prescribed fluid intake and special diet.
R: Follow-up care will be the client’s and/or caregiver’s responsibility. Information is needed for making correct choices.

I: Teach interventions to prevent future episodes of inadequate intake.
R: Client’s need to understand the importance of drinking extra fluid during bouts of diarrhea, fever, and other conditions causing fluid deficits.

Gulanick, 2007; Kruse, et al, 2003

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Nursing care plan: risk for fluid volume deficit related to inadequate fluid intake, active fluid loss (perspiration), and old age. 1

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