Which assessment findings would alert the nurse that patient could have fluid volume deficit?

Fluid volume deficit also known as dehydration can be a common occurrence and nursing diagnosis for many patients. Dehydration is when there is a loss of too much fluid from the body. This leads to a lack of water in the body’s cells and blood vessels. It is due to more fluids being expelled from the body than the body takes in.

Causes 

There are several reasons an individual may become dehydrated. Below is a brief list of some potential causes: 

• Vomiting  
• Diarrhea
• Excessive sweating  
• Fever 
• Frequent urination  
• Lack of oral fluid intake  
• Medications (i.e. diuretics)  
• Other medical conditions (i.e. diabetes) 
• Pregnancy and breastfeeding

Symptoms

There are several signs and symptoms that may be present for an individual suffering from dehydration. Some symptoms can be vague and a sign for other conditions as well so it is important the nurse is completing a full assessment and brining all the pieces of the assessment together in making clinical decisions. A brief list of signs and symptoms includes: 

• Headache  
• Confusion
• Fatigue  
• Dizziness/light-headedness 
• Weakness  
• Dry mouth/dry cough  
• Tachycardia with hypotension
• Decreased appetite  
• Muscle cramps 
• Constipation 
• Concentrated urine  
• Dry skin
• Feeling of thirst

For very young children or infants who are unable to verbalize, additional signs and symptoms may be present that include: 

• Crying without tears 
• No wet diapers for 3 hours or longer 
• High fevers  
• Irritability  
• Sunken eyes  
• Unusually drowsy

At risk population

Some individuals and populations are more at risk of developing dehydration than others. These populations include: 

• Elderly patient  
• Infants and children  
• Individuals with chronic conditions
• Individuals with complex medication regimens (especially those including the use of diuretics) 
• Active individuals who may not be rehydrating after exercising 

Expected Outcomes

• Patient’s vital signs will remain stable and/or return to patient’s baseline
• Patient’s intake and output will stabilize
• Patient’s lab values will return to baseline
• Patient will verbalize measures to take at home to maintain hydration/prevent dehydration

Nursing Assessment for Fluid Volume Deficit

1. Complete a thorough head-to-toe assessment.
This will allow the nurse to assess the entire person and put all data together when making clinical decisions and assist in identifying the cause of dehydration.

2. Assess intake and output.
This will allow the nurse objective data in determining the patient’s net loss of fluid.

3. Assess vital signs.
Vital signs may be abnormal if dehydrated (i.e. tachycardia and/or hypotension).

4. Assess laboratory values.
Patients may have abnormal blood work levels due to dehydration (i.e. abnormal electrolyte levels or renal function).

5. Assess skin turgor.
Loss of skin elasticity can be a sign of dehydration.

6. Assess urine color and concentration.
Dark and concentrated urine can be a sign of dehydration; patients should produce at least 30mL of urine/hour.

7. Auscultate cardiac sounds.
Abnormal cardiac sounds may be heard with severe dehydration and dysrhythmias can develop.

8. Assess cardiac rhythm.
Dysrhythmias may develop if severely dehydrated and if electrolyte abnormalities are present.

9. Assess mental status.
Severe dehydration may cause alteration in mentation.

Nursing Interventions for Fluid Volume Deficit

1. Encourage/remind patient of the need for oral intake.
As individuals age sometimes there is a loss of thirst, reminding and encouraging individuals may help them to remember the need to continue drinking fluids even if they do not feel they are thirsty.

2. Administer intravenous hydration if needed.
Severely dehydrated patients or patients unable to take oral hydration may require IV hydration to maintain appropriate hydration level.

3. Educate patient and family on possible causes of dehydration.
Education will help allow the patient and family to have a better understanding of the diagnosis and preventative measures they can take in the future to avoid dehydration.

4. Administer electrolyte replacements as needed/as ordered.
Dehydration can lead to electrolyte abnormalities, it is important the nurse monitors for this and provides supplemental replacements when needed.

5. Educate patient and family on how to monitor intake and output.
Patients and family members will need to know how to monitor intake and output once discharged home to ensure they are maintaining appropriate hydration level.

6. Weigh patient daily.
Daily weight measurements will allow the nurse to easily monitor for potential fluid overload when rehydrating patients.

7. Educate patient on the importance of maintaining a proper hydration and nutrition status regularly.
Education will help the patient to become more independent upon discharge and will help them to understand what they can do to prevent further episodes of dehydration.

References and Sources

1. Celeveland Clinic. (2021). Dehydration https://my.clevelandclinic.org/health/treatments/9013-dehydration
2. Mayo Clinic. (2021). Dehydration https://www.mayoclinic.org/diseases-conditions/dehydration/symptoms-causes/syc-20354086
3. Thorek Memorial Hospital. (2014). 14 Surprising causes of dehydration https://www.thorek.org/news/14-surprising-causes-of-dehydration

Published on November 21, 2021

Tabitha Cumpian, MSN, RN

Tabitha Cumpian is a registered nurse with a passion for education. She completed her BSN at Edgewood College Nursing School and her MSN with an emphasis in Nursing Education at Herzing University. She has a vast clinical background from years of traveling the United States providing nursing care. The majority of her time has been spent in cardiovascular care. She loves educating others in her field, as well as, patients and their family members through healthcare writing.