Excess Fluid Volume – Nursing Diagnosis & Care Plan

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Excess-fluid-volume

Excess fluid volume

Excess fluid volume is an imbalance in the normal range of fluids. Having an excessive fluid volume means there is an excessive amount of fluids in the body that needs a treatment.

Some of the causes of Excess fluid volume nursing diagnosis are increase in the water and sodium in the body which permits fluid shifting from interstitial to extracellular regions. Thereby pulling excessive amount of water outside the cells in the body. Diseases such as heart failure, liver diseases and kidney failure can result to this fluid overload. However, to much intake of sodium rich foods can contribute to its development.

Read Also: Deficient fluid volume Nursing Diagnosis & Nursing Care Plan
Read also : Example of a Nursing Care plan for deficient fluid volume.

NANDA-I Definition for Excess fluid Volume:

Surplus intake and/or retention of fluid.

Defining Characteristics:

  • Tachypnea: Rate of respiration is increased.
  • Edema: Swelling of body parts.
  • Decreased level Hemoglobin or hematocrit.
  • Changes in heart sounds.
  • Imbalance of electrolytes.
  • State of confusion: Alteration in the mental status of the patient
  • Shortness of breath.
  • BP changes
  • Oliguria
  • Restlessness
  • Tachycardia

Related factors:

  • Heart disease
  • Decreased cardiac output
  • Excessive oral fluid intake
  • Excessive intake of sodium-rich food
  • Hormonal imbalances
  • Liver disorders
  • Poor nutrition (Read Also: Imbalanced Nutrition less than body requirements)
  • Kidney disease
  • Stress

Nursing Outcomes:

  • Patient maintains the normal fluid and electrolyte balance
  • Patient has equal in the intake and output
  • Patient reported no difficulty of breathing and shortness of breath
  • Patient has clear lung sounds.
  • Patient verbalizes increase in knowledge on the prevention of fluid volume excess and its treatment

Nursing Assessment/Rationale

Assessment Rationales
1. Assess and determine the causes of the fluid imbalance. ·       it will determine the most appropriate nursing interventions to be done and treatment to be given
2. Monitor weight regularly using the same standard weighing scale ·       Weight gain indicates fluid overload
3. Monitor input and output closely. ·       It will determine presence of fluid imbalance
4. Check the vital signs ·       It gives signs of fluid retention by increased in BP, increase in HR and RR and presence of difficulty of breathing
5. Review chest x-ray reports and refer accordingly ·       This is to check if there are fluids present in the lungs
6. Check and record for any presence of edema ·       It will determine the most appropriate treatment to prevent worsening of the symptoms
7. Assess for lungs sounds and record abnormalities ·       This is to detect accumulation of fluids in the lungs

Nursing Interventions and Rationale:

Interventions Rationale
1. Instruct patient to restrict fluid intake as necessary and inform its purpose of such restrictions ·       It will permit compliance to such intervention
2. Limit sodium-rich foods intake as prescribed. ·       Sodium attracts water so there is a need to limit it to prevent fluid retention
3. administer diuretics as prescribed by the physician. ·       It helps in eliminating excessive fluids in the body through urination
4. Elevate the extremities with edema ·       increases venous return to the heart
5. Position the  patient in a semi-Fowler’s or high-Fowler’s if there if difficulty of breathing. ·       It will let the patient to breath in easily
6. Educate patient and family members the importance of proper nutrition, hydration, and diet modification. ·       This provides motivation and compliance of the patient and significant others in maintaining fluid balance.
7. Put anti-embolic stockings on the edematous extremities as prescribed ·       It will prevent further accumulation of fluids on the area

 

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