Student Nurses’ Community

NURSING CARE PLAN – Hypervolemia ASSESSMENT SUBJECTIVE: “Namamanas ang paa ko”(My feet are swelling) as verbalized by the patient. DIAGNOSIS Excess fluid volume related to compromised regulatory mechanism INFERENCE Excessive fluid volume in the blood. This fluid excess usually results from compromised regulatory mechanisms for sodium and water as seen in congestive heart failure (CHF), kidney failure, and liver failure. It can also be caused by too much intake of sodium from foods, intravenous (IV) solutions, medications, or diagnostic contrast dyes. The excess fluid, mainly salt and water, builds up in different body locations and can lead to swelling in the legs and arms (peripheral edema), and/or fluid in the abdomen (ascites). PLANNING After 4 hours of nursing interventions, the Patient will demonstrate stabilized fluid volume as evidenced by balanced intake and output (I&O) and vital signs within client’s normal range. INTERVENTION INDEPENDENT • Monitor vital signs as well as central venous pressure. • Auscultate lung and heart sounds. RATIONALE • Tachycardia and hypertension are common manifestations. • Crackle sounds and extra heart sounds are indicative of fluid excess, possibly resulting in rapid development of pulmonary edema. • Decreased renal perfusion, cardiac insufficiency, and fluid shifts may cause decrease urinary output and edema formation. • One liter of fluid retention equals a weight gain of 1 kilogram. • Pulmonary fluid shifts potentate respiratory complications. • Gravity improves lung expansion. • Reduce pressure and friction on EVALUATION After 4 hours of nursing interventions, the Patient was able to demonstrate stabilized fluid volume as evidenced by balanced intake and output (I&O) and vital signs within client’s normal range.

OBJECTIVE: • • • Restlessness Fatigue Edema on lower extremities V/S taken as follows T: 36.9˚C P: 102 R: 20 BP: 110/ 80

Maintain adequate I&O. Note decreased urinary output and positive fluid balance on 24hour calculations.

Weigh as indicated. Be alert for sudden weight gain. Encourage coughing and deep breathing exercises. Maintain semifowler’s position. Turn or reposition,

• •

• Limited cardiac reserves results in fatigue and activity intolerance. .Student Nurses’ Community and provide skin care at regular intervals. edematous tissue. • Encourage bed rest.

Sign up to vote on this title
UsefulNot useful