Nursing diagnosis – EXCESS FLUID VOLUME

EXCESS  FLUID  VOLUME

DEFINITION

Increased isotonic fluid retention

DEFINING CHARACTERISTICS

• Altered mental status or respiratory pattern

• Anasarca

• Azotemia

• Changes in blood pressure, pulmonary artery pressure, urine

specific gravity, and electrolyte levels

• Crackles

• Decreased Hb and HCT levels

• Dyspnea

• Edema

• Increased central venous pressure (CVP)

• Intake greater than output

• Jugular vein distention

• Oliguria

• Orthopnea

• Pleural effusion

• Positive hepatojugular reflex

• Pulmonary congestion

• Rapid weight gain

• Restlessness and anxiety

• S3 heart sound

RELATED FACTORS

• Compromised regulatory mechanism

• Excess fluid intake

• Excess sodium intake

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac function

• Neurocognition

• Elimination

• Nutrition

• Fluid and electrolytes

• Respiratory function

EXPECTED OUTCOMES

The patient will

• State ability to breathe comfortably.

• Maintain fluid intake at ___ ml/day.

• Return to baseline weight.

• Maintain vital signs within normal limits (specify).

• Exhibit urine specific gravity of 1.005–1.010.

• Have normal skin turgor.

• Show electrolyte level within normal range (specify).

• Avoid complications of excess fluid.

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SUGGESTED NOC OUTCOMES

Electrolyte Balance; Fluid Balance; Fluid Overload Severity; Kidney

Function; Nutritional Status: Food & Fluid Intake

INTERVENTIONS AND RATIONALES

Determine: Monitor and record vital signs at least every 4 hr.

Changes may indicate fluid or electrolyte imbalances. Measure and

record intake and output. Intake greater than output may indicate

fluid retention and possible overload.

Weigh patient at same time each day to obtain consistent

readings. Test urine specific gravity every 8 hr and record results.

Monitor laboratory values and report significant changes to

physician. High specific gravity indicates fluid retention. Fluid over-

load may alter electrolyte levels.

Assess patient daily for edema, including ascites and dependent or

sacral edema. Fluid overload or decreased osmotic pressure may

result in edema, especially in dependent areas.

Perform: Help patient into a position that aids breathing, such as

Fowler’s or semi-Fowler’s, to increase chest expansion and improve

ventilation.

Administer oxygen, as ordered, to enhance arterial blood oxygena-

tion. Restrict fluids to ____ ml per shift. Excessive fluids will worsen

patient’s condition.

Administer diuretics to promote fluid excretion. Record effects.

Maintain patient on sodium-restricted diet, as ordered, to reduce

excess fluid and prevent reaccumulation.

Reposition patient every 2 hr, inspect skin for redness with each

turn, and institute measures as needed to prevent skin breakdown.

Apply antiembolism stockings or intermittent pneumatic compres-

sion stockings to increase venous return. Remove for 1 hr every

8 hr or according to facility policy.

Inform: Educate patient regarding maintenance of daily weight

record, daily measuring and recording of intake and output, diuretic

therapy, and dietary restrictions, especially sodium. These measures

encourage patient and caregivers to participate more fully.

Attend: Encourage patient to cough and deep breathe every 2–4 hr

to prevent pulmonary complications.

SUGGESTED NIC INTERVENTIONS

Electrolyte Management; Fluid Management; Fluid Monitoring;

Nutrition Management

Reference

Bennett, S. J., et al. (2005, December). Medication and dietary compliance

beliefs in heart failure. Western Journal of Nursing Research, 27(8),
977–993.

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