EXCESS FLUID VOLUME
Increased isotonic ﬂuid retention
• Altered mental status or respiratory pattern
• Changes in blood pressure, pulmonary artery pressure, urine
speciﬁc gravity, and electrolyte levels
• Decreased Hb and HCT levels
• Increased central venous pressure (CVP)
• Intake greater than output
• Jugular vein distention
• Pleural effusion
• Positive hepatojugular reﬂex
• Pulmonary congestion
• Rapid weight gain
• Restlessness and anxiety
• S3 heart sound
• Compromised regulatory mechanism
• Excess ﬂuid intake
• Excess sodium intake
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac function
• Fluid and electrolytes
• Respiratory function
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.
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
Administer oxygen, as ordered, to enhance arterial blood oxygena-
tion. Restrict ﬂuids to ____ ml per shift. Excessive ﬂuids will worsen
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;
Bennett, S. J., et al. (2005, December). Medication and dietary compliance
beliefs in heart failure. Western Journal of Nursing Research, 27(8),