Nursing Diagnosis: Application to Clinical Practice
11th Edition

Deficient Fluid Volume
DEFINITION
Deficient Fluid Volume: State in which a person who can take fluids (not NPO) experiences or is at risk of experiencing dehydration
DEFINING CHARACTERISTICS
Major (Must Be Present, One or More)
  • Insufficient oral fluid intake
  • Negative balance of intake and output
  • Dry skin/mucous membranes
  • Weight loss
Minor (May Be Present)
  • Increased serum sodium
  • Concentrated urine or urinary frequency
  • Thirst/nausea/anorexia
  • Decreased urine output or excessive urine output
RELATED FACTORS
Pathophysiologic
Related to excessive urinary output
Uncontrolled diabetes
Diabetes insipidus (inadequate antidiuretic hormone)
Related to increased capillary permeability and evaporative loss from burn wound (nonacute)
Related to losses secondary to:
  • Fever or increased metabolic rate
  • Abnormal drainage
  • Wound
  • Excessive menses
  • Peritonitis
  • Diarrhea
Situational (Personal, Environmental)
Related to vomiting/nausea
Related to decreased motivation to drink liquids secondary to:
  • Depression
  • Fatigue
Related to fad diets/fasting
Related to high-solute tube feedings
Related to difficulty swallowing or feeding self secondary to:
  • Oral or throat pain
  • Fatigue
Related to extreme heat/sun/dryness
Related to excessive loss through:
  • Indwelling catheters
  • Drains
Related to insufficient fluids for exercise effort or weather conditions
Related to excessive use of:
  • Laxatives or enemas
  • Diuretics, alcohol, or caffeine
P.322

Maturational
Infant/Child
Related to increased vulnerability secondary to:
Decreased fluid reserve and decreased ability to concentrate urine
Older Adult
Related to increased vulnerability secondary to:
Decreased fluid reserve and decreased sensation of thirst
P.324

Focus Assessment Criteria
Subjective Data
Assess for Defining Characteristics.
  • Fluid intake (amounts, type)
  • Thirst
  • Urine output (decreased, increased)
  • Skin (dry, turgor)
  • Weight loss (How much? Since when?)
Assess for Related Factors.
Refer to Related Factors.
Objective Data
Assess for Defining Characteristics.
Present weight/usual weight
Intake (last 2 to 48 h)
Output (last 24 to 48 h)
Skin
  • Mucosa (lips, gums) (dry)
  • Tongue (furrowed/dry)
  • Turgor (decreased)
  • Color (pale or flushed)
  • Moisture (dry or diaphoretic)
  • Fontanelles of infants (depressed)
  • Eyeballs (sunken)
  • Tachycardia
Urine output
  • Amount (varied; very large or minimal amount)
  • Color (amber; very dark or very light; clear?; cloudy?)
  • Specific gravity (increased or decreased)
  • Odor?
Assess for Related Factors.
Abnormal or excessive fluid loss
  • Liquid stools
  • Diuresis or polyuria
  • Abnormal or excessive drainage
  • Fever
  • Vomiting or gastric suction (eg, fistulas, drains)
  • Diaphoresis
  • Loss of skin surfaces (eg, healing burns)
P.325

Decreased fluid intake related to
  • Fatigue
  • Depression/disorientation
  • Physical limitations (eg, cannot hold glass)
  • Decreased level of consciousness
  • Nausea or anorexia
For more information on Focus Assessment Criteria, visit http://connection.lww.com.
Goal
The person will maintain urine specific gravity within normal range.
Indicators
  • Increase fluid intake to a specified amount according to age and metabolic needs.
  • Identify risk factors for fluid deficit and relate need for increased fluid intake as indicated.
  • Demonstrate no signs and symptoms of dehydration.
General Interventions
Assess Causative Factors.
Inability to feed self
Dislike of available liquids
Sore throat/mouth
Extreme fatigue or weakness
Lack of knowledge (of the need for increased fluid and electrolyte intake)
Difficulty swallowing (see Impaired Swallowing)
Inadequate fluid intake before and during exercise (usually in athletes)
Reduce or Eliminate Causative Factors.
Inability to Feed Self (See Deficient Self-Care)
Dislike of Available Liquids
Assess likes and dislikes; provide favorite fluids within dietary restrictions.
Plan an intake goal for each shift (eg, 1000 mL during day; 800 mL during afternoon; 300 mL at night).
Set a schedule for supplementary liquids.
Sore Throat/Mouth
Offer warm or cold fluids; consider ices.
Consider warm saline gargle or anesthetic lozenges before fluids.
Extreme Fatigue or Weakness
Give small amounts of fluids frequently.
Provide for rest periods before meals.
Lack of Knowledge
Assess client’s understanding of reasons to maintain adequate hydration and methods to reach fluid intake goal.
Include significant others.
Proceed with teaching.
See Key Concepts, Health-Seeking Behaviors.
Have Person Maintain a Record (Log).
Fluid intake
Urinary output
Daily weight
Prevent Dehydration in High-Risk Clients (see Key Concepts)
Monitor intake; ensure at least 2000 mL of oral fluids every 24 h.
Monitor output; ensure at least 1000 to 1500 mL every 24 h.
P.326

Monitor serum electrolyte studies as needed.
Offer fluids in large glasses, 120 or 240 mL.
Weigh daily in same clothes, at same time. A 2% to 4% weight loss indicates mild dehydration; 5% to 9% weight loss indicates moderate dehydration.
Monitor urine and serum electrolytes, blood urea nitrogen, osmolality, creatinine, hematocrit, and hemoglobin.
For people scheduled to fast before diagnostic studies, advise them to increase fluid intake 8 h before fasting.
Review client’s medications. Do they contribute to dehydration (eg, diuretics)? Do they require increased fluid intake (eg, lithium)?
Teach that coffee, tea, and grapefruit juice are diuretics and can contribute to fluid loss.
Consider the additional fluid losses associated with vomiting, diarrhea, fever.
Initiate Health Teaching, as Indicated.
Give verbal and written directions for desired fluids and amounts.
Include the person/family in keeping a written record of fluid intake, output, daily weights.
Provide a list of alternative fluids (eg, ice cream, pudding).
Explain the need to increase fluids during exercise, fever, infection, and hot weather.
Teach how to observe for dehydration (especially in infants) and to intervene by increasing fluid intake (see Subjective and Objective Data for signs of dehydration).
Seek medical consultation for continued dehydration.
For Athletes, Stress the Need to Hydrate Before and During Exercise, Preferably with a High-Sodium-Content Beverage (Refer to Hyperthermia for Additional Interventions).
For Dehydration in the Terminally Ill (Parkash & Burge, 1997):
Help caregivers and families to discover client’s wishes and attitudes concerning procedures for hydration (eg, intravenous [IV]).
Provide as accurate information as available about advantages and disadvantages of hydration.
Recognize and explore caregiver’s concerns (eg, who will manage IV administration).
Rationales
  • Output may exceed intake, which already may be inadequate to compensate for insensible losses.
  • Dehydration may increase glomerular filtration rate, making output inadequate to clear wastes properly and leading to elevated BUN and electrolyte levels.
  • Accurate daily weights can detect fluid loss.
  • To monitor weight effectively, weights should be measured at the same time on the same scale with the same clothes.
  • Large amounts of sugar, alcohol, and caffeine act as diuretics that increase urine production and may cause dehydration.
  • People receiving tube feedings are at high risk for dehydration, because the high solute concentration of the tube feeding may cause diarrhea and diuresis. Tube feedings must be supplemented with specific amounts of water to maintain adequate hydration.
  • Adequate protein intake is necessary to maintain normal osmotic pressures. Foods with high protein content are meats, fish, fowl, soybeans, eggs, legumes, and cheese.
Rationales
  • Older children usually respond to the challenge of meeting a specific intake goal (Wong, 2003).
  • Rewards and contracts are also effective (eg, sticker for drinking a certain amount).
  • Young children usually respond to games that integrate drinking fluids.
Footnote
*May require a primary care professional’s order. Do not give aspirin or products containing aspirin to children younger than 18 years with flu symptoms because of risk of potentially fatal Reye’s syndrome.
RELATED TO ABNORMAL FLUID LOSS
Abnormal fluid loss describes fluid loss by vomiting, diarrhea, excessive diaphoresis, or drains, not by hemorrhage or acute burns.
Goal
The person will maintain urine specific gravity within normal range.
Indicators
  • Maintain adequate intake of fluid and electrolytes, as evidenced by (specify):
  • Identify abnormal fluid loss, relate methods of decreasing (if possible), and replace fluids as needed.
P.328

Interventions
Assess Causative Factors.
  • Vomiting
  • Fever
  • Gastric suction
  • Diarrhea/loose stools
  • Impaired swallowing (see Impaired Swallowing)
Remove or Reduce Causative Factors.
Vomiting
Encourage small, frequent ice chips or clear liquids such as weak tea or apple juice (adults 30 mL, children 15 mL); see Diarrhea for replacement therapy.
Fever (See Also Hyperthermia)
Maintain temperature lower than 101°F (38.4°C) with medication (eg, ibuprofen or acetaminophen).*
  • Eliminate excessive clothing and bed covers.
  • Keep room temperature cool.
  • Encourage cool, clear liquids when medication is at peak effectiveness and temperature is lowest.
  • Substitute frozen ices or popsicles if necessary (be resourceful). If the temperature is extremely high (above 103°F [39.5°C]), sponge with tepid water.
Gastric Suction (Nasogastric or Other)
Use only normal saline for irrigation of gastric tubes to minimize electrolyte imbalance.
Do not allow swallowing of water or ice chips; a “few small sips” can readily add up over time.
For the thirsty person with gastric suction, unless contraindicated by surgery or renal failure, consult with physician concerning ingestion of measured sips of Gatorade (1 oz/h).
Always subtract all fluid ingested (by either tube or mouth) from any total gastric drainage to attain net drainage.
Keep a careful, clear record of intake and output: amount, character, and color.
Offer frequent mouth care.
Diarrhea/Loose Stools
See Diarrhea.
Wound Drainage
Keep careful records of amount and type of drainage.
Weigh dressings, if necessary, to estimate fluid loss (weigh the wet dressing; weigh a dry dressing of the same type; compare the difference).
Weigh client daily if drainage is excessive and difficult to measure (eg, soaked sheets).
Replace fluid loss (may be contraindicated in cardiac failure, renal failure, or head trauma).
Initiate Health Teaching, as Indicated.
Assess client’s understanding of the type of fluid loss he or she is experiencing (what electrolytes are lost) and the fluids that provide replacement (see Key Concepts).
Give verbal and written instructions for fluid replacement (eg, “Drink at least 3 quarts of liquid a day, including 1 quart of Gatorade.”).
Teach client to:
  • Avoid sudden exposure and overexposure to heat, sun, and exercise.
  • Gradually increase exposure and activity in hot weather.
  • Eat three balanced meals a day.
  • Increase fluid intake during hot days.
  • Decrease activity during extreme weather.
Rationales
  • The focus of treatment is replacing both water and electrolytes lost (Porth, 2002).
  • Fluids high in sugar (eg, soda, Jell-O) can cause osmotic diarrhea (Porth, 2002).
  • Refer to Rationales in Diarrhea.
  • For child, refer to Rationales under Pediatric Interventions in Diarrhea.
Footnotes
*May require a primary care professional’s order. Do not give aspirin or products containing aspirin to children younger than 18 years with flu symptoms because of risk of potentially fatal Reye’s syndrome.
†May require a primary care professional’s order.