Nursing Care Plan
"Fluid volume deficit"
Patient
Problem
( Actual )
Nursing diagnosis \ Fluid volume deficit related to (contributing factor
according to the patient’s condition)
Subjective
Data
According to the nurse’s observation.
Objective
Data
According to the patient description.
Objectives
Short term
In 2 days, the patient will…
Verbalize awareness of causative factors and behaviors essential to
correct fluid deficit.
Explain measures that can be taken to treat or prevent fluid volume loss
Describe symptoms that indicate the need to consult with health care
provider.
Long term
In 2 weeks, the patient will…
Be normovolemic as evidenced by systolic BP greater than or equal to 90
mm HG (or patient’s baseline), absence of orthostasis, HR 60 to 100
beats/min, urine output greater than 30 mL/hr. and normal skin turgor.
Demonstrate lifestyle changes to avoid progression of dehydration.
Nursing intervention
Assessment
Assess and document vital signs especially BP and HR.
- Rationale: Decrease in circulating blood volume can cause hypotension
and tachycardia. Alteration in HR is a compensatory mechanism to
maintain cardiac output. Usually, the pulse is weak and may be irregular if
electrolyte imbalance also occurs. Hypotension is evident in hypovolemia.
Assess skin turgor and oral mucous membranes for signs of dehydration.
- Rationale: Signs of dehydration are also detected through the skin. Skin
of elderly patients’ losses elasticity, hence skin turgor should be assessed
over the sternum or on the inner thighs. Longitudinal furrows may be
noted along the tongue.
