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Nursing Diagnosis Fluid Excess

Nursing Diagnosis Fluid Excess

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Published by: Luthfiy Irfanasruddin on Jun 20, 2012
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Nursing Diagnosis: Excess Fluid volume
Betty J. Ackley and Martha A. Spies
NANDA Definition:
Increased isotonic fluid retention
Defining Characteristics:
Jugular vein distention; decreased hemoglobin and hematocrit;weight gain over short period; changes in respiratory pattern, dyspnea or shortness of breath; orthopnea; abnormal breath sounds (rales or crackles); pulmonary congestion;pleural effusion; intake exceeds output; S
3
heart sound; change in mental status;restlessness; anxiety; blood pressure changes; pulmonary artery pressure changes;increased central venous pressure; oliguria; azotemia; specific gravity changes; alteredelectrolytes; edema, may progress to anascara; positive hepatojugular reflex
Related Factors:
Compromised regulatory mechanism; excess fluid intake; excess sodiumintake
NOC Outcomes (Nursing Outcomes Classification)Suggested NOC Labels
 
 
Electrolyte and Acid-Base Balance
 
Fluid Balance
 
Hydration
Client Outcomes
 
Remains free of edema, effusion, anascara; weight appropriate for client
 
Maintains clear lung sounds; no evidence of dyspnea or orthopnea
 
Remains free of jugular vein distention, positive hepatojugular reflex, and gallop heartrhythm
 
Maintains normal central venous pressure, pulmonary capillary wedge pressure, cardiacoutput, and vital signs
 
Maintains urine output within 500 ml of intake and normal urine osmolality and specificgravity
 
Remains free of restlessness, anxiety, or confusion
 
Explains measures that can be taken to treat or prevent excess fluid volume, especiallyfluid and dietary restrictions and medications
 
Describes symptoms that indicate the need to consult with health care provider
NIC Interventions (Nursing Interventions Classification)Suggested NIC Labels
 
 
Fluid Management
 
Fluid Monitoring
Nursing Interventions and Rationales
 
Monitor location and extent of edema; use a millimeter tape in the same area at thesame time each day to measure edema in extremities.
Heart failure and renal failure areusually associated with dependent edema because of increased hydrostatic pressure;dependent edema will cause swelling in the legs and feet of ambulatory clients and the presacral region of clients on bed rest. Dependent edema was found to demonstrate thegreatest sensitivity as a defining characteristic for excess fluid volume (Rios et al, 1991).Generalized edema (e.g., in the upper extremities and eyelids) is associated with decreased oncotic pressure as a result of nephrotic syndrome. Measuring the extremity with amillimeter tape is more accurate than using the 1 to 4 scale (Metheny, 2000).
 
 
Monitor daily weight for sudden increases; use same scale and type of clothing at sametime each day, preferably before breakfast.
Body weight changes reflect changes in body 
 
fluid volume. Clinically it is extremely important to get an accurate body weight of a client with fluid imbalance (Metheny, 2000).
 
 
Monitor lung sounds for crackles, monitor respirations for effort, and determine thepresence and severity of orthopnea.
Pulmonary edema results from excessive shifting of fluid from the vascular space into the pulmonary interstitial space and alveoli. Pulmonary edema can interfere with the oxygen-carbon dioxide exchange at the alveolar-capillary membrane (Metheny, 2000), resulting in dyspnea and orthopnea.
 
 
With head of bed elevated 30 to 45 degrees, monitor jugular veins for distention in theupright position; assess for positive hepatojugular reflex.
Increased intravascular volumeresults in jugular vein distention, even in a client in the upright position, and also a positivehepatojugular reflex.
 
 
Monitor central venous pressure, mean arterial pressure, pulmonary artery pressure,pulmonary capillary wedge pressure, and cardiac output; note and report trends indicatingincreasing pressures over time.
Increased vascular volume with decreased cardiac contractility increases intravascular pressures, which are reflected in hemodynamic  parameters. Over time, this increased pressure can result in uncompensated heart failure.
 
 
Monitor vital signs; note decreasing blood pressure, tachycardia, and tachypnea.Monitor for gallop rhythms. If signs of heart failure are present, see nursing care plan for
Decreased Cardiac output
.
Heart failure results in decreased cardiac output andecreased blood pressure. Tissue hypoxia stimulates increased heart and respiratory rates.
 
 
Monitor serum osmolality, serum sodium, blood urea nitrogen (BUN)/creatinine ratio,and hematocrit for decreases.
These are all measures of concentration and will decrease(except in the presence of renal failure) with increased intravascular volume. In clients withrenal failure the BUN will increase because of decreased renal excretion.
 
 
Monitor intake and output; note trends reflecting decreasing urine output in relation tofluid intake.
 Accurately measuring intake and output is very important for the client withfluid volume overload.
 
 
Monitor client's behavior for restlessness, anxiety, or confusion; use safety precautionsif symptoms are present.
When excess fluid volume compromises cardiac output, the client will experience tissue hypoxia. Cerebral tissue is extremely sensitive to hypoxia, and theclient may demonstrate restlessness and anxiety before any physiological alterations occur.When the excess fluid volume results in hyponatremia, the cerebral function will also bealtered because of cerebral edema (Fauci et al, 1998).
 
 
Monitor for the development of conditions that increase the client's risk for excess fluidvolume.
Common causes are heart failure, renal failure, and liver failure, all of which result in decreased glomerular filtration rate and fluid retention. Other causes are increased intakeof oral or IV fluids in excess of the client's cardiac and renal reserve levels, increased levelsof antidiuretic hormone, or movement of fluid from the interstitial space to the intravascular space (Fauci et al, 1998). Early detection allows the institution of specific treatment measures before the client develops pulmonary edema.
 
 
Provide a restricted-sodium diet as appropriate if ordered.
Restricting the sodium in thediet will favor the renal excretion of excess fluid. Take care to avoid hyponatremia.Decreasing sodium can be more important that restricting fluid intake (Fauci et al, 1998).
 
 
Monitor serum albumin level and provide protein intake as appropriate.
Serum albuminis the main contributor to serum oncotic pressure, which favors the movement of fluid fromthe interstitial space into the intravascular space. When serum albumin is low, peripheral edema may be severe.
 
 
Administer prescribed loop, thiazide, and/or potassium-sparing diuretics as appropriate;these may be given intravenously or orally.
Therapeutic responses to diuretic therapinclude natriuresis, diuresis, elimination of edema, vasodilation, reduction of cardiac filling pressures, decreased renal vasculature resistance, and increased renal blood flow (Cody,Kubo, Pickworth, 1994; DePriest, 1997).
 
 
Monitor for side effects of diuretic therapy: orthostatic hypotension (especially if client
 
is also receiving angiotensin-converting enzyme [ACE] inhibitors) and electrolyte andmetabolic imbalances (hyponatremia, hypocalcemia, hypomagnesemia, hyperuricemia, andmetabolic alkalosis). In clients receiving loop or thiazide diuretics, observe for hypokalemia.Observe for hyperkalemia in clients receiving a potassium-sparing diuretic, especially withthe concurrent administration of an ACE inhibitor.
The blood pressure reduction in responseto ACE inhibitors is greater in the presence of sodium depletion and diuretic therapy. Theincidence of electrolyte and metabolic imbalances ranges from 14% to 60%; the most common is hypokalemia (Cody, Kubo, Pickworth, 1994).
 
 
Implement fluid restriction as ordered, especially when serum sodium is low; include allroutes of intake. Schedule fluids around the clock, and include the type of fluids preferred bythe client.
Fluid restriction may decrease intravascular volume and myocardial workload.Overzealous fluid restriction should not be used because hypovolemia can worsen heart failure. In one study, instituting fluid restriction, distributing fluids over a 24-hour period,and using a fluid restriction when the client had hyponatremia all had high interventioncontent validity scores for the fluid management intervention label (Cullen, 1992). Client involvement in planning will enhance participation in the necessary fluid restriction.
 
 
Maintain the rate of all IV infusions carefully.
This is done to prevent inadvertant exacerbation of excess fluid volume.
 
 
Turn clients with dependent edema frequently (i.e., at least every 2 hours).
Edematoustissue is vulnerable to ischemia and pressure ulcers (Cullen, 1992).
 
 
Provide for scheduled rest periods.
Bed rest can induce diuresis related to diminished  peripheral venous pooling, resulting in increased intravascular volume and glomerular filtration rate (Metheny, 2000).
 
 
Promote a positive body image and good self-esteem.
Visible edema may alter theclient's body image (Cullen, 1992). See the care plan for 
Disturbed Body image
.
 
 
Consult with physician if signs and symptoms of excess fluid volume persist or worsen.
Because excess fluid volume can result in pulmonary edema, it must be treated promptly and aggressively (Fauci et al, 1998).
 
Geriatric 
 
 
Recognize that the presence of risk factors for excess fluid volume is particularly seriousin the elderly.
Decreased cardiac output and stroke volume are normal aging changes that increase the risk for excess fluid volume (Metheny, 2000).
 
Home Care Interventions
 
Assess client and family knowledge of disease process causing excess fluid volume.Teach about disease process and complications of excess fluid volume, including when tocontact physician.
Knowledge of disease and complications promotes early detection of and intervention for pending problems.
 
 
Assess client and family knowledge and compliance with medical regimen, includingmedications, diet, rest, and exercise. Assist family with integrating restrictions into dailyliving.
Knowledge promotes compliance. Assistance with integration of cultural values,especially those related to foods, with medical regimen promotes compliance and decreased risk of complications.
 
 
If client is confined to bed rest or has difficulty reclining, follow previously mentionedpositioning recommendations.
 
Teach and reinforce knowledge of medications. Instruct client not to use over-the-counter medications (e.g., diet medications) without first consulting the physician. Instructclient to make primary physician aware of medications ordered by other physicians.
There is potential for undesirable interaction among multiple medications, especially when use of over-the-counter and other prescribed medications is not monitored.
 
 
Identify emergency plan for rapidly developing or critical levels of excess fluid volumewhen diuresing is not safe at home.
When out of control, excess fluid volume can be lifethreatening.
 

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