Body fluids have a variety of important functions in the human body: the facilitate transport of nutrients,

hormones, proteins, and other molecules into cells; aid in the removal of metabolic waste products;
regulate body temperature; lubricates musculoskeletal joints; provide a medium for which cellular
metabolism could take place; and act as a component in body cavities.

Hypervolemia refers to an isotonic volume expansion of the extracellular fluid (ECF) caused by the
abnormal retention of water and sodium in approximately the same proportions in which they normally
exist in the ECF.

Hypovolemia occurs when loss of extracellular fluid exceeds the intake of fluid.

Excess Fluid Volume (Hypervolemia)

Excess Fluid Volume: Increased isotonic fluid retention

May be related to

Excess fluid or sodium intake.

Compromised regulatory mechanism.

Possibly evidenced by

Ascites.

Aphasia, muscle twitching, tremors, seizures.

Bounding pulses.

Changes in the level of consciousness (lethargy, disorientation, confusion to coma).

Crackles.

Distended neck and peripheral veins.

Edema variable from dependent

Elevated central venous pressure.

Extra heart sounds S3.

Hypertension.

Productive cough.
Shortness of breath.

Sudden weight gain, often in excess of 5% of total body weight.

Tachypnea with or without dyspnea, orthopnea.

Tachycardia usually present; bradycardia-late sign of cardiac decompensation.

Desired Outcomes

Client will verbalize understanding of individual dietary and fluid restrictions.

Client will demonstrate behaviors to monitor fluid status and prevent or limit recurrence.

Client will demonstrate stable fluid volume as evidenced by stable vital signs, balanced intake and
output, stable weight, and absence of signs of edema.

Deficient Fluid Volume (Hypovolemia)

Deficient Fluid Volume: Decreased intravascular, interstitial, and intracellular fluid.

May be related to

Active fluid loss-burns, diarrhea, fistulas, gastric intubation, hemorrhage, wounds.

Regulatory failure- diabetes insipidus, diabetic ketoacidosis (DKA), adrenal disease, systemic infections,
recovery phase of acute renal failure.

Possibly evidenced by

Abdominal distention.

Confusion, restlessness.

Dark concentrated urine.

Decreased urine volume.

Decreased central venous pressure.

Flattened neck veins.

Hypotension.

Pale, moist, clammy skin.

Tachycardia.

Tachypnea.

Weak pulses.

Desired Outcomes

Client will verbalize understanding of causative factors and purpose of therapeutic interventions.

Client will demonstrate behaviors to monitor and correct deficit, as appropriate.

Client will maintain fluid volume at a functional level as evidenced by stable vital signs, good skin turgor,
good capillary refill, moist mucous membranes and adequate urinary output with normal specific gravity.

https://nurseslabs.com/fluid-electrolyte-imbalances-nursing-care-plans/

https://www.cancerresearchuk.org/about-cancer/breast-cancer/advanced/symptoms