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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. (http://en.wikipedia.org/wiki/Hypovolemia)
Means low blood volume. "Hypo" means low, "vol" is for volume, and "emia"
refers to blood.
http://coloncancer.about.com/od/glossaries/g/Hypovolemia.htm)
Tachycardia
Decreased blood pressure
Oliguria
Tachypnea
Dizziness
Poor skin turgor
Hyperthermia
Cool clammy skin
Delayed capillary refill
Confusion
Thirst
Fatigue
Muscle weakness
Cramps
Hematocrit
Normal value: Males: 42-52% Females: 35-47%
Hypovolemia: elevated
Urine osmolality
Normal values: 250-900 mOsm/kg H2O
Hypovolemia: elevated
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
ketonuria.
Hypernatremia:
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
• 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 blood pressure for orthostatic changes (from patient lying supine
to high-Fowler). Note the following orthostatic hypotension significance:
B. Patient Assessment
• 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.
C. Diagnostic Assessment
• Review Hgb and Hct levels and note trends. Decreased RBCs can
adversely affect oxygen carrying capacity.
D. Patient Management
• Independent:
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
dryness.
o Provide safety precautions as indicated; e.g., use of side
rails where appropriate, bed in low position, frequent
observation, soft restraints (if required).
E. Patient Teaching: