- Actual
- Risk for (Potential)
Related To: [Check those that apply]
- Excessive fluid intake
- Excessive sodium intake
- Renal insufficiency or failure
- Low protein intake or malnutrition
- Decreased cardiac output; chronic or acute heart disease
- Steroid therapy
- Head injury
- Liver disease
- Severe stress
- Hormonal disturbances
As evidenced by: [Check those that apply]
- Weight gain
- Edema
- Bounding pulses
- Shortness of breath; orthopnea
- Pulmonary congestion on x-ray
- Abnormal breath sounds: crackles (rales)
- Change in respiratory pattern
- Third heart sound S3
- Intake greater than output
- Decreased hemoglobin or hematocrit
- Increased blood pressure
- Increased central venous pressure (CVP)
- Increased pulmonary artery pressure (PAP)
- Jugular vein distention
- Change in mental status (lethargy or confusion)
- Oliguria
- Specific gravity changes
- Azotemia
- Change in electrolytes
- Restlessness and anxiety
Patient’s Diagnosis: –
Date:-
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- maintains adequate fluid volume and electrolyte balance as evidenced by: vital signs within normal limits, clear lung sounds, pulmonary congestion absent on x-ray, resolution of edema.
- Others
Note: you need to indicate time frame/target as objective must be measurable.
| Nursing Interventions | Scientific Rationale |
|---|---|
| Obtain patient history to ascertain the probable cause of the fluid disturbance. | This will help to guide interventions. |
| Assess or instruct patient to monitor weight daily and consistently, with same scale and preferably at the same time of day. | To facilitate accurate measurement and to follow trends. |
| Monitor and document vital signs. | Sinus tachycardia and increased blood pressure are seen in early stages. Elderly patients have reduced response to catecholamines; thus their response to fluid overload may be blunted, with less rise in heart rate. |
| Auscultate for a third sound, and assess for bounding peripheral pulses. | These are signs of fluid overload |
| Assess for crackles in lungs, changes in respiratory pattern, shortness of breath, and orthopnea. | For early recognition of pulmonary congestion. |
| Monitor chest x-ray reports. | As interstitial edema accumulates, the x-rays show cloudy white lung fields. |
| Monitor input and output closely. | To monitor fluid balance. |
| Evaluate urine output in response to diuretic therapy. | Focus is on monitoring the response to the diuretics, rather than the actual amount voided. |
| Assess the need for an indwelling urinary catheter. | Treatment focuses on diuresis of excess fluid. |
| Institute/instruct patient regarding fluid restrictions as appropriate. | To help reduce extracellular volume. For some patients, fluids may need to be restricted to 100 ml per day. |
| Restrict sodium intake as prescribed. | Sodium diets of 2 to 3 gm. are usually prescribed. |
| Administer or instruct patient to take diuretics as prescribed. | Diuretic therapy may include several different types of agents for optimal therapy, depending on the acuteness or chronicity of the problem. |
| Elevate edematous extremities. | To increase venous return and, in turn, decrease edema. |
| Reduce constriction of vessels (use appropriate garments, avoid crossing of legs or ankles). | To prevent venous pooling. |
| Instruct in need for antiembolic stockings or bandages as ordered. | To help promote venous return and to minimize fluid accumulation in the extremities |
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