Dehydration Nursing Diagnosis and Nursing Care Plan

Dehydration Nursing Care Plans Diagnosis and Interventions

Dehydration NCLEX Review and Nursing Care Plans

Dehydration refers to the deficit of fluids in the body to carry out normal bodily functions. Fluid balance is an important aspect of the body’s overall health. It is responsible for maintaining renal and cardiac functions as well as electrolyte balance.

A shortfall in the body’s fluid level, such as in cases of dehydration, can lead to serious health conditions.

Dehydration can occur in both children and adults. However, babies, children, and the elderly are likely to get more serious symptoms and complications from severe dehydration.

Dehydration can easily be prevented by regular fluid intake. It can also be easily treated upon early detection and management.

Signs and Symptoms of Dehydration

The signs and symptoms of dehydration are related to how much water is lost. They can be mild, moderate, to severe and usually start with thirst and dark-colored urine.

The signs and symptoms of dehydration can also differ in children and adults.

Dehydration in Infants and Children

• Dry mouth, lips, and tongue
• Absence of tears when crying
• Dry diapers for three hours or more
• Sunken eyes and cheeks
• Sinking of the soft spot on top of the skull
• Irritability

Dehydration in Adults

• Extreme thirst
• Infrequent urination
• Dark-colored urine
• String-smelling urine
• Fatigue
• Dizziness or light-headedness
• Confusion

Causes and Risk Factors of Dehydration

• Illness – most illnesses can cause increased fluid loss due to the increased metabolic demands. However, some illnesses have a higher rate of fluid loss such as diarrhea and vomiting. These two conditions are the most common causes of dehydration in infants and children.
• Sweating – extensive sweating after an episode of fever, exercise, or manual labor especially in hot weather can cause dehydration. Children and teens are more prone to dehydration from sweating as they are likely to ignore the symptoms such as thirst.
• Alcohol – Alcohol is a diuretic and therefore can increase the frequency of urination. The headache that comes after a hangover is a symptom of dehydration.
• Increased urination – several conditions and medications can cause increased urinary frequency. One of the most common medical conditions that can cause dehydration is diabetes. The body compensates for the high blood sugar level by producing more urine to excrete the excess sugar in the bloodstream. on the other hand, certain drugs can also cause dehydration such as diuretics and antihypertensive drugs.

Complications of Dehydration

1. Heat injury. One of the functions of fluids in the body is thermoregulation. Dehydration can cause mild to severe heat injuries including life-threatening heatstroke.
2. Urinary and renal problems. Dehydration predisposes the body to kidney stones, urinary tract infections, and kidney failure.
3. Seizures. Seizures can occur because of electrolyte imbalances caused by dehydration.
4. Hypovolemic shock. This condition is one of the most serious complications of dehydration. It occurs when there is severely low blood volume resulting in low blood pressure leading to a drop in oxygen delivery.

Diagnosis of Dehydration

The diagnosis of dehydration is often reliant on the presence of the signs and symptoms and the results of physical examination. Other procedures such as blood tests and urine tests can also be performed to confirm the diagnosis.

• Physical Examination –this will include the assessment of the presence of signs and symptoms and basic vitals signs measurement. Having low blood pressure is highly associated with dehydration and it is taken after standing up from a lying or sitting position. Also, a higher than normal heart rate may be noted in dehydration which is part of the body’s compensatory mechanism.
• Blood tests – electrolyte levels and kidney functions test may be performed to confirm the diagnosis. Higher electrolytes level may be expected as they may be diluted due to low blood volume secondary to dehydration.
• Urinalysis – a simple urine test may help check for the presence of dehydration. It is also a helpful way to check for infections that are likely in dehydrated individuals.

Treatment for Dehydration

Dehydration can easily be corrected through the replacement of the lost fluid. However, several factors need to be taken into accounts such as the severity of dehydration, age of the patient, and the cause of the fluid loss. The treatment may also be slightly different for children and adults.

In Babies:

• Seeking the help of a healthcare provider is strongly recommended when dehydration is suspected in an infant. If the dehydration is due to diarrhea, increasing the frequency of feeding and giving extra fluids are recommended. However, it is discouraged to give fruit juices as it may make diarrhea worse.
• Hospitalization may be necessary in cases of moderate to severe dehydration.

• It is recommended that dehydrated children be given fluids with electrolytes because pure water can dilute the little electrolytes left in their system.
• Offer fluids more frequently.
• Hospital management may be necessary in severe cases of dehydration. Treatment may include intravenous fluid infusion.

• Most adults can reverse dehydration through increasing oral fluid intake.
• Working in cooler places can help reduce water loss.
• Sports drinks containing electrolytes and carbohydrates are often helpful.
• Hospital management of dehydration may be required in severe cases or if the individual is not responding to earlier treatments.

Nursing Diagnosis for Dehydration

Nursing Care Plan for Dehydration 1

Nursing Diagnosis: Fluid Volume Deficit related to dehydration due to fever as evidenced by temperature of 39.0 degrees Celsius, skin turgidity, dark yellow urine output, profuse sweating, and blood pressure of 89/58.

Desired Outcome: Within 48 hours of nursing interventions, the patient will have a stabilized temperature within the normal range and will verbalize feeling more comfortable.

Nursing Care Plan for Dehydration 2

Nursing Diagnosis: Fluid Volume Deficit related to blood volume loss secondary to gastrointestinal bleeding as evidenced by hematemesis, HB of 70, skin pallor, blood pressure level of 85/58, and lightheadedness

Desired Outcome: The patient will have an absence of GI bleeding, a hemoglobin (HB) level of over 100, blood pressure level within normal range, full level of consciousness, and normal skin color.

Nursing Care Plan for Dehydration 3

Nursing Diagnosis: Risk for Fluid Volume Deficit due to osmotic diuresis secondary to diabetes

Desired Outcome: The patient will demonstrate adequate hydration and balanced fluid volume

Nursing Care Plan for Dehydration 4

Risk for Deficient Volume (Dehydration)

Nursing Diagnosis: Risk for Deficient Volume (Dehydration) related to fluid loss via normal channels, contractions with force, and premature placental separation secondary to precipitous labor.

As a risk nursing diagnosis, the Risk for Deficient Volume is entirely unrelated to any signs and symptoms since it has not yet developed in the patient, and safety precautions will be initiated instead.

• The patient will determine personal risk factors and suitable actions.
• To avoid the development of a fluid volume deficit, the patient will display behaviors or make lifestyle modifications.
• The patient will verbalize her awareness of the reasons causing the fluid deficit and the activities required to correct it.

Nursing Care Plan for Dehydration 5

Risk for Deficient Fluid Volume (Dehydration)

Nursing Diagnosis: Risk for Deficient Fluid Volume (Dehydration) related to low serum protein level, augmented blood sugar levels, and incapacity to respond to thirst mechanisms due to NPO (nothing by mouth) status.

• The patient will be normovolemic if systolic blood pressure is 90 mm Hg or above, there is no orthostasis, the heart rate is 60 to 90 beats per minute, the urine output should be at least 30 ml per hour, and skin turgor is acceptable.
• The patient will describe the procedures that can be used to treat and prevent fluid volume loss.
• The patient will recount symptoms that point to the need for a visit with a health care practitioner.

Nursing Care Plan for Dehydration 6

Risk for Deficient Fluid Volume (Dehydration)

Nursing Diagnosis: Risk for Deficient Fluid Volume (Dehydration) related to the vascular nature of the surgical region, difficulties in limiting hemorrhage, restricted intake preoperatively and post-obstructive diuresis secondary to prostatectomy.

• The patient will maintain adequate hydration as demonstrated by stabilized vital signs, palpable peripheral pulses, excellent capillary refill, hydrated mucosal membranes, and sufficient urine output.
• There should be no active bleeding.
• The client will verbalize individual dietary and fluid limits.
• The client will exhibit actions to maintain fluid status and avoid or restrict relapse.
• The client will demonstrate the balanced fluid volume as demonstrated by stable vital signs and controlled intake and output.

More Dehydration Nursing Diagnosis

• Fatigue
• Risk for Seizures
• Risk for Shock
• Acute Confusion
• Failure to Thrive (Infants)

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

Anna Curran. RN-BC, BSN, PHN, CMSRN I am a Critical Care ER nurse. I have been in this field for over 30 years. I also began teaching BSN and LVN students and found that by writing additional study guides helped their knowledge base, especially when it was time to take the NCLEX examinations.