DEFICIENT FLUID VOLUME
Decreased intravascular, interstitial, or intracellular ﬂuid; water loss
alone without change in sodium
• Changes in mental status
• Decreased pulse volume and pressure, urine output, and venous
• Dry skin and mucous membranes
• Increased body temperature, HCT, pulse rate, and urine concen-
• Low blood pressure
• Poor turgor of skin or tongue
• Sudden weight loss
• Active ﬂuid volume loss
• Failure of regulatory mechanisms
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Fluid and electrolytes
• Physical regulation
The patient will
• Maintain stable vital signs.
• Have normal skin color.
• Have electrolyte levels within normal range.
• Maintain an adequate ﬂuid volume.
• Maintain an adequate urine volume.
• Have normal skin turgor and moist mucous membranes.
• Have a urine speciﬁc gravity between 1.005 and 1.010.
• Have normal ﬂuid and blood volume.
• Express understanding of factors that caused ﬂuid volume deﬁcit.
SUGGESTED NOC OUTCOMES
Electrolyte & Acid–Base Balance; Fluid Balance; Hydration; Nutri-
tional Status: Food & Fluid Intake
INTERVENTIONS AND RATIONALES
Determine: Monitor and record vital signs every 2 hr or as often as
necessary until stable. Then monitor and record vital signs every
4 hr. Tachycardia, dyspnea, or hypotension may indicate ﬂuid
volume deﬁcit or electrolyte imbalance.
Measure intake and output every 1–4 hr. Record and report sig-
niﬁcant changes. Include urine, stools, vomitus, wound drainage,
nasogastric drainage, chest tube drainage, and any other output.
Low urine output and high speciﬁc gravity indicate hypovolemia.
Weigh patient daily at same time to give more accurate and con-
sistent data. Weight is a good indicator of ﬂuid status.
Assess skin turgor and oral mucous membranes every 8 hr to
check for dehydration. Give meticulous mouth care every 4 hr to
avoid dehydrating mucous membranes.
Test urine speciﬁc gravity every 8 hr. Elevated speciﬁc gravity may
Measure abdominal girth every shift to monitor for ascites and
third-space shift. Report changes.
Perform: Cover patient lightly. Avoid overheating to prevent vasodi-
lation, blood pooling in extremities, and reduced circulating blood
Administer ﬂuids, blood or blood products, or plasma expanders
to replace ﬂuids and whole blood loss and facilitate ﬂuid movement
into intravascular space. Monitor and record effectiveness and any
Don’t allow patient to sit or stand up quickly as long as circula-
tion is compromised to avoid orthostatic hypotension and possible
Administer and monitor medications to prevent further ﬂuid loss.
Inform: Explain reasons for ﬂuid loss, and teach patient how to
monitor ﬂuid volume; for example, by recording daily weight and
measuring intake and output. This encourages patient involvement
in personal care.
SUGGESTED NIC INTERVENTIONS
Acid–Base Management; Electrolyte Monitoring; Fluid Management;
Kelley, D. M. (2005, January–March). Hypovolemic shock: An overview. Crit-
ical Care Nursing Quarterly, 28(1), 2–19.