Excess fluid volume
Retention of water and sodium because of increased Aldosterone level.
- Rate of respiration is increased.
- Swelling of body parts.
- Hemoglobin level will be decreased.
- Changes in heart sounds.
- Imbalance of electrolytes.
- State of confusion.
- Shortness of breath.
- Disorders of liver.
- Dysfunction of kidneys.
- High intake of sodium diet.
- Excessive fluid intake.
- Blood pressure within normal limits.
- Pulse must be in normal limits.
- S3 heart sound should be absent.
- Level of sodium towards normal limits.
- Shortness of breath should be decreased.
- Normal mental condition.
Nursing Interventions and Rationale:
1. Assessment of patient’s health and general condition.
Rationale: For basic knowledge of disease.
2. Monitoring of vital signs of patient.
Rationale: Provide information about treatment plan.
3. Inhibition of fluid intake by the patient.
Rationale: Prevent further retention of fluid in patient’s body.
4. Position of patient must be change after time interval.
Rationale: To prevent pressure sores.
5. Evaluation of patient mental status.
Rationale: To assess cerebral edema.
6. Observe any edema on patient’s body.
Rationale: Indicates retention of fluid in patient’s body.
7. Administer drugs to excrete excessive fluid.
Rationale: To excrete excess of fluids in patient’s body.