Sie sind auf Seite 1von 12

Fluid Volume Deficit (Hypovolemia)

I. Description of the disease/condition:

 Occurs when loss of extracellular fluid volume exceeds the intake of fluid. It
occurs when water and electrolytes are lost in the same proportion as they
exist in normal body fluids, so that the ratio of serum electrolytes to water
remains the same. ( Med. Surg. Nsg. By Smeltzer)
 Is a state of decreased blood volume; more specifically, decrease in volume
of blood plasma. (
 Means low blood volume. "Hypo" means low, "vol" is for volume, and "emia"
refers to blood.

II. Risk Factors

 Severe bleeding (from internal or external injuries)

 Severe vomiting
 Dehydration
 Severe burns
 Blood donation
 Excessive sweating
 Severe diarrhea
 Surgery

III. Assessment Findings/Clinical Manifestations

 Tachycardia
 Decreased blood pressure
 Oliguria
 Tachypnea
 Dizziness
 Poor skin turgor
 Hyperthermia
 Cool clammy skin
 Delayed capillary refill
 Confusion
 Thirst
 Fatigue
 Muscle weakness
 Cramps

IV. Diagnostic Test results

 BUN to Creatinine ratio

Normal value: 10:1-15:1
Hypovolemia: 20:1
Renal failure or decreased renal perfusion

 Blood urea nitrogen (BUN)

Normal value: 5-20 mg/dl
Hypovolemia: elavated

Dehydration, Renal failure or decreased renal perfusion

 Hematocrit
Normal value: Males: 42-52% Females: 35-47%
Hypovolemia: elevated

RBCs become suspended in a decreased plasma volume

 Urine specific gravity

Normal value: 1.016-1.022
Hypovolemia: elevated

In attempt to conserve water

 Urine osmolality
Normal values: 250-900 mOsm/kg H2O
Hypovolemia: elevated

Kidneys try to compensate by conserving water

 Serum Sodium
Normal Value: 135-145 mEq/L
Hypovolemia: reduced or elevated

Hyponatremia: occurs with increased thirst and ADH release. Low total body water
and sodium levels may be due to dehydration, vomiting, diarrhea, over diuresis, or

 If the amount of fluid in your body is low, you may have fluid loss due to
excessive sweating, diarrhea, use of diuretics, or burns.
 If your total body water is normal, high sodium levels may be due diabetes
insipidus (too little of the hormone vasopressin).

 Serum potassium
Normal value: 3.5-5.3 mEq/L
Hypovolemia: reduced or elevated

Hypokalemia: GI and renal losses; Chronic diarrhea, vomiting

Hyperkalemia: occurs with adrenal insufficiency, metabolic or respiratory acidosis

V. Nursing Diagnoses:
1. Ineffective Cardiopulmonary, Cerebral, or Renal tissue perfusion r/t
reduced cardiac output caused by blood loss and hypotension.
• Desired Outcome:
o Patient would not develop chest pain, cardiac arrhythmias,
or shortness of breath
o Skin warm and dry
o Hematocrit – 32%
o Stay alert and oriented to time, place, and person
o Maintain urine output of at least 30 ml hourly or 0.5 to 1
o Regain or maintain normal GI function
o Regain normal peripheral pulses, color, and temperature.
o Systolic blood pressure 90 to 120 mm Hg
o Mean arterial pressure 70 to 105 mm Hg
o Cardiac index 2.5 to 4 l/min/m2
o O2 sat - 95 %

2. Decreased Cardiac Output r/t diminished venous return caused by

blood loss.
• Desired Outcome:
o Regain normal cardiac output as evidenced by normal
blood, central venous, right atrial, pulmonary artery, and
pulmonary artery wedge pressure (PAWP) readings.
o Identify early signs and symptoms of decreased cardiac
output (such as dizziness, syncope, cool or clammy skin,
fatigue, and dyspnea), and express the importance of
seeking immediate medical attention if they occur.
3. Fluid Volume Deficit that may be r/t active fluid/blood loss e.g., hemorrhage,
prolonged vomiting/gastric intubation, diarrhea, burns [may be severe],
profuse sweating, water deprivation, diuretic abuse, wounds, fistulas.

• Desired Outcome:
o Recover and maintain normal fluid volume at a functional
level as evidenced by individually adequate urine output
with normal specific gravity, stable vital signs, moist
mucous membranes, good skin turgor, and prompt
capillary refill.
o Recover normal hemoglobin levels, hematocrit, red
blood cell and platelet counts, arterial blood gas (ABG)
and electrolyte levels
o Identify causes of fluid volume deficit, and express the
rationale for following a prescribed diet, taking
medications, maintaining his activity level, and obtaining
follow–up medical care.
VI. Nursing interventions:

A. Patient Monitoring:

• Monitor the patient’s vital signs, CVP, Right atrial pressure,

pulmonary artery pressure, PAWP, and CO at least hourly or as
ordered. Note presence/degree of postural BP changes. Observe
for temperature elevation/fever.

o Tachycardia is present along with a verifying degree of

hypotension, depending on degree of FVD. CVP
measurements are useful in determining degree of FV and
response to replacement therapy. Fever increases
metabolism and exacerbates fluid loss.

• Monitor blood pressure for orthostatic changes (from patient lying supine
to high-Fowler). Note the following orthostatic hypotension significance:

o Greater than 10 mm Hg drop: circulating blood volume is decreased

by 20%.
o Greater than 20 to 30 mm Hg drop: circulating blood volume is
decreased by 40%.

• Record pulses and respiratory rates, and peripheral pulse rates

every 15 minutes until stable. Monitor cardiac rhythm
continuously. Note capillary refill, skin color/temperature, and
note any changes. Cold, clammy skin may signal continuing
peripheral vascular constriction, indicating progressive shock.

o Conditions that contribute to ECF deficit can result in

inadequate organ perfusion to all areas and may cause
circulatory collapse/shock.

• Continuously monitor ECG to detect life-threatening dysrythmias of HR >

140 beats/min, which can adversely affect SV.
• Measure the patient’s urine output hourly. Measure/estimate fluid
losses from all sources e.g., gastric losses, wound drainage,

o Fluid replacement needs are based on correction of current

deficits and ongoing losses. Note: A diaphoretic episode
requiring a full linen change may represent a fluid loss of
as much as 1 L. Decreased urinary output may indicate
sufficient renal perfusion/hypovolemia, or polyuria can be
present, requiring more aggressive fluid replacement.

• Monitor the patient’s ABG and electrolyte levels frequently as


• Watch for signs of impending coagulopathy (such as petechiae,

bruising, bleeding or oozing from gums or venipuncture sites).

B. Patient Assessment

• Obtain patient history to ascertain the probable cause of the fluid

disturbance. This can help to guide interventions. Causes may include
acute trauma and bleeding, reduced fluid intake from changes in cognition,
large amount of drainage post-surgery, or persistent diarrhea.

• Assess or instruct pt to Weigh daily and consistently; and

compare with same scale, and preferably at the same time of day with
24-hr fluid balance. Mark/measure edematous areas; e.g.,
abdomen, limbs

o Although weight gain and fluid intake greater than output

may not accurately reflect IV volume (e.g., third-space fluid
accumulation cannot be used by the body for tissue
perfusion), these measurements provide useful date for
comparison and facilitates accurate measurement and follows

• Assess skin turgor and mucous membranes for signs of dehydration. The
skin in elderly patients 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.

• Assess color and amount of urine. Report urine output less than 30 ml/hr
for 2 consecutive hours. Concentrated urine denotes fluid deficit.
• Assess LOC, mentation and for pressure ulcer development.

• Evaluate client’s ability to swallow.

o Impaired gag/swallow reflexes, anorexia/nausea, oral

discomfort, and changes in LOC/ cognition are among the
factors that affect client’s ability to replace fluids orally.

C. Diagnostic Assessment

• Review Hgb and Hct levels and note trends. Decreased RBCs can
adversely affect oxygen carrying capacity.

• Review lactate levels, an indicator of reduced tissue perfusion and

anaerobic metabolism.

• Review ABGs for hypoxemia and respiratory or metabolic acidosis.

• Review BUN, creatinine, and electrolytes and more trends to evaluate

renal function.

D. Patient Management

• Independent:

o Ascertain client’s beverage preferences, and set up a 24-hr

schedule for fluid intake. Encourage foods with high fluid

 Relieves thirst and discomfort of dry mucous

membranes and augments parenteral replacement.
Note: Sense of thirst is often diminished in the older

o Turn frequently, gently massage skin and protect bony


 Tissues are susceptible to breakdown because of

vasoconstriction and increased cellular fragility.

o Provide skin and mouth care. Bathe every other day using
mild soap. Apply lotion as indicated.
 Skin and mucous membranes are dry with decreased
elasticity because of vasoconstriction and reduced
intracellular water. Daily bathing may increase
o Provide safety precautions as indicated; e.g., use of side
rails where appropriate, bed in low position, frequent
observation, soft restraints (if required).

 Decreased cerebral perfusion frequently results in

changes in mentation /altered thought process,
requiring protective measures to prevent client injury.
Note: The use of restraints may increase agitation
and can pose a safety risk.

o Investigate reports of sudden/sharp chest pain, dyspnea,

cyanosis, increased anxiety, and restlessness.

 Hemoconcentration (sludging) and increased platelet

aggregation may result in systemic emboli formation.

o Monitor for sudden/marked elevation of BP, restlessness,

moist cough, dyspnea, basilar crackles, and frothy sputum.

 Too rapid a correction of fluid deficit may compromise

the cardiopulmonary system, esp. if colloids are used
in general fluid replacement (increased osmotic
pressure potentiates fluid shifts).

E. Patient Teaching:

• Explain all procedures and their purposes to ease the patient’s


• Discuss the risks associated with blood transfusions to the

patient and his family.

• Describe or teach causes of fluid losses or decreased fluid intake.

• Explain or reinforce rationale and intended effect of treatment program.

• Explain importance of maintaining proper nutrition and hydration.

• Teach interventions to prevent future episodes of inadequate intake.
Patients need to understand the importance of drinking extra fluid during
bouts of diarrhea, fever, and other conditions causing fluid deficits.

• Inform patient or caregiver of importance of maintaining prescribed fluid

intake and special diet considerations involved.

• If patients are to receive IV fluids at home, instruct caregiver in managing

IV equipment. Allow sufficient time for return demonstration. Responsibility
for maintaining venous access sites and IV supplies may be overwhelming
for caregiver. In addition, elderly caregivers may not have the cognitive
ability and manual dexterity required for this therapy.

Refer to home health nurse as appropriate.

VII. Collaborative / Medical:

a. Assist with identification/treatment of underlying cause.

i. Refer to listing of predisposing/contributing factors to

determine treatment needs.

b. Monitor laboratory studies as indicated; e.g., electrolytes,

glucose, pH/PCO2, coagulation studies.

i. Depending on the avenue of fluid loss, differing

electrolyte/metabolic imbalances may be present/require

c. Use a large bore (16 to 18 gauge) cannula for intravenous lines to

replace volume rapidly.

d. Administer IV solutions as indicated:

i. Isotonic solutions; e.g., 0.9% NaCl (normal saline), 5%


1. Crystalloids provide prompt circulatory

improvement, although the benefit may be
transient (increased renal clearance)
ii. 0.45% NaCl (half-normal saline), lactated Ringer’s (LR)

1. This may be used to provide both electrolytes and

free water for renal excretion of metabolic wastes.

iii. Colloids; e.g., dextran, Plasmanate/albumin,hetastarch

(Hespan); and crytalloids in addition to blood products as

1. Corrects plasma protein concentration deficits,

thereby increasing IV osmotic pressure and
facilitating return of fluid into vascular

iv. Whole blood/packed RBC transfusion, or autologous

collection of blood.

1. Indicated when hypovolemia is r/t blood loss.

o Administer sodium bicarbonate if indicated.

o May be given to correct severe acidosis while

correcting fluid balance.

o Provide tube feedings, including free water as appropriate.

o Enteral replacement can provide proteins and other

needed elements in addition to meeting general fluid
requirements when swallowing is impaired.

o Pharmacologic agents may be used to improve hemodynamic

parameters if intravascular volume is replaced.

o Provide oxygen as ordered.

o Prepare the patient for surgical intervention is required.

o Institute pressure ulcer prevention strategies.

VIII. Dietary Management:

• High Fiber, Low Carbohydrate, Low Fat, Low Salt Diet. Also, Iron-rich
foods are recommended for hypovolemic patients.
IX. Surgical Management:
• Intraosseous Infusion
Intraosseous (IO) infusion is the placement of a rigid needle through
the bone cortex into the medullary cavity. This method can be used to
administer blood products and fluids when a patient is in need of fluid
replacement and IV access cannot be obtained. 9 The site of choice for the
placement of an IO in the anterior aspect of the tibia 1 to 3 cm below the
proximal tibial tuberosity. 9 This site is ideal because it is broad and flat and is
easily accessible through a thin layer of skin covering the bone. 9 The site is
also preferred because it is free of blood vessels, nerves, or major muscle
groups. The distal medial tibia is a site that can be used in either children or
adults, and is a flat, easily accessible area. Other sites that can be used are:
distal femur, iliac crest, humerus, and sternum in children over age
3. 9 Nursing care for a patient with IO infusion is aimed toward immobilization
of the catheter and the extremity so as not to jeopardize the site.

• Surgical Intervention Aimed at Repairing the Source of Bleeding

In order for fluid volume status to stabilize and to ensure patient

recovery of shock, the source of bleeding must be found and repaired early in
the treatment of the patient. Early repair will significantly improve the patient's
chances for a meaningful recovery.