Excess Fluid Volume

NURSING DIAGNOSIS:
Excess Fluid Volume
  • 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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Objective/Expected Outcome;The patient will:
  • 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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