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Fluid Volume Deficit/Dehydration

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Fluid volume deficit (FVD) or hypovolemia is a state or condition where the fluid output exceeds the fluid intake. It occurs when the body loses both water and electrolytes from the ECF in similar proportions. Common sources of fluid loss are the gastrointestinal tract, polyuria, and increased perspiration

Risk factors for FVD are as follows: vomiting, diarrhea, GI suctioning, sweating, decreased intake, nausea, inability to gain access to fluids, adrenal insufficiency, osmotic diuresis, hemorrhage, coma, third-space fluid shifts, burns, ascites, and liver dysfunction. Fluid volume deficit may be an acute or chronic condition managed in the hospital, outpatient center, or home setting.

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Fluid volume deficit (also known as deficient fluid volume or hypovolemia) describes the loss of extracellular fluid from the body. Extracellular fluid is the body fluid not contained within individual cells. It constitutes about 20% of our body weight and includes blood plasma, lymph, spinal cord fluid, and the fluid between cells. Importantly, this fluid isn’t just water—it also contains electrolytes and other essential solutes. Fluid volume deficit is often used interchangeably with the term “dehydration,” but they aren’t exactly the same thing. Dehydration refers specifically to the loss of body water as opposed to body fluid

What’s the difference? Electrolytes. If a patient has just lost water but no electrolytes, they’ll have slightly different issues—and require slightly different treatment—than a patient who has lost wholesale body fluids, which contains water and electrolytes. First, you'll identify the relevant nursing diagnosis or diagnoses. Unlike medical diagnoses, which typically identify the specific medical condition at issue (i.e. diabetes, bronchitis, celiac disease), nursing diagnoses describe the more immediate and ongoing physical and psychological needs of the patient. According to the standards set by NANDA International, a nursing diagnosis is typically written in a three-part manner: first the diagnosis, then what the diagnosis is related to (its direct cause), and finally the evidence for that diagnosis. You can reference the common direct causes and diagnostic signs and symptoms of fluid volume deficit as noted above for help creating your diagnostic statement. An example fluid volume deficit nursing diagnosis statement might look something like this: “Fluid volume deficit related to diarrhea and vomiting secondary to gastroenteritis as evidenced by decreased skin turgor, low blood pressure, and decreased urine output.” “Risk for fluid volume deficit” or “risk for deficient fluid volume” is a slightly different nursing diagnosis that can be used to describe patients who, while not yet exhibiting serious signs of fluid volume deficit, are at particular risk of developing the issue. A risk nursing diagnosis only has two parts: the diagnosis (“risk for fluid volume deficit”) is related to whatever the cause of the potential future issue is (“diarrhea and vomiting”). So the risk diagnosis would be “risk for fluid volume deficit related to diarrhea and vomiting.”

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Though uncommon, some physicians have insufficient knowledge of body fluids due to a lack of factual information about body fluid compartments and differences in their composition. Most are aware that a patient with haemorrhagic shock has a depleted intravascular compartment, but only a few recognize which compartment suffers the most in a dehydrated patient with a serum sodium of 170 µmol/L. Suppose an elderly patient is admitted with community-acquired pneumonia. He has been rather drowsy for two days before admission with poor oral intake. He is tachypneic and pyrexial, but his blood pressure is normal with no postural change. Initial laboratory tests reveal a serum sodium of 170 µmol/L. He is receiving antibiotics and D5W infusion (Feig PU, 1977). When asked “What condition are you treating with D5W infusion?”, most students reply “hypernatremia” rather than “dehydration”, i.e., they mention the biochemical derangement rather than the condition that produced it. Further probing reveals that some students do not recognize that hypernatremia in most instances represents loss of water in relation to Na+ (not an excess of sodium) and is a manifestation of dehydration (hence we calculate the free water deficit to assess the amount of water replacement needed to correct hypernatremia)

In other words, it is the water intake/excretion (rather than Na+ handling) that regulates the ECF sodium concentration. It also appears that although some students have knowledge of the different fluid compartments, they fail to apply their knowledge to real life cases. A number of students have a skewed understanding of body fluid compartments and harbour various misconceptions, the most common of which is erroneously referring to “ECF volume depletion” or “intravascular volume depletion” as “dehydration”. The vast majority of doctors appreciate that patients who present with profuse diarrhoea and vomiting and are consequently hypotensive and tachycardic are intravascularly depleted. They also very appropriately resuscitate these patients with 0.9% NS rather than D5W infusion. However, when presenting such a case during the ward round, they say “this patient was severely dehydrated and resuscitated with 0.9% NS”. So, although they correctly identify and treat the clinical syndrome of intravascular volume depletion, they use imprecise terminology (Freda BJ, Davidson MB, 2004).

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After all, health professionals should be aware of the utility of alternative routes, such as percutaneous gastrostomy, that may be preferred in older adults with co-existing anorexia or dysphagia. Subcutaneous fluid infusion (hypodermoclysis) is a convenient, simple, relatively safe, and cost-effective method that is particularly effective in older patients in subacute or long-term care. Effective management of dehydration in the older adult mandates meticulous attention to pathophysiological stressors in the context of pre-existing hypodipsia. Ultimately, the ideal therapeutic goal is the development of an individualized fluid maintenance and hydration intervention strategy for all older adults, healthy or otherwise.

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Freda BJ, Davidson MB, Hall PM. Evaluation of hyponatremia: a little physiology goes a long way. Cleve Clin J Med. 2004;71:639–650. [PubMed]

Ritz P Source Study. Bioelectrical impedance analysis estimation of water compartments in elderly diseased patients: the source study. J Gerontol A Biol Sci Med Sci. 2001;56:M344–M348.

O'Brien C, Baker-Fulco CJ, Young AJ, Sawka MN. Bioimpedance assessment of hypohydration. Med Sci Sports Exerc. 1999;31:1466–1471.

Olde Rikkert MG, Deurenberg P, Jansen RW, van't Hof MA, Hoefnagels WH. Validation of multi-frequency bioelectrical impedance analysis in detecting changes in fluid balance of geriatric patients. J Am Geriatr Soc. 1997;45:1345–1351.

Feig PU, McCurdy DK. The hypertonic state. N Engl J Med. 1977

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