Anasarca is a severe and generalized edema characterized by widespread swelling of the skin and subcutaneous tissues throughout the body. This nursing diagnosis focuses on identifying and managing massive fluid accumulation, preventing complications, and improving patient outcomes.
Causes (Related to)
Anasarca can develop due to various underlying conditions and factors that affect fluid balance and distribution:
- Severe kidney disease (nephrotic syndrome)
- Liver cirrhosis or severe liver dysfunction
- Congestive heart failure
- Severe protein deficiency (hypoalbuminemia)
- Severe malnutrition
- Chronic conditions such as:
- Uncontrolled diabetes
- Advanced cancer
- Severe thyroid disorders
- Chronic venous insufficiency
- Contributing factors include:
- Prolonged immobility
- Medication side effects
- Lymphatic system disorders
- Severe allergic reactions
Signs and Symptoms (As evidenced by)
Anasarca presents distinctive signs and symptoms that nurses must recognize for proper diagnosis and treatment.
Subjective: (Patient reports)
- The feeling of tightness in the skin
- Difficulty moving limbs
- Shortness of breath
- Decreased exercise tolerance
- Feeling of heaviness
- Discomfort in affected areas
- Clothing and jewelry feel tight
Objective: (Nurse assesses)
- Generalized pitting edema (+4)
- Significant weight gain
- Increased abdominal girth
- Stretched, shiny skin
- Decreased urine output
- Respiratory distress
- Decreased mobility
- Skin breakdown risk
- Altered vital signs
Expected Outcomes
The following outcomes indicate the successful management of anasarca:
- The patient will demonstrate decreased edema
- The patient will maintain a stable weight
- The patient will show improved mobility
- The patient will maintain skin integrity
- The patient will demonstrate effective breathing patterns
- The patient will comply with prescribed treatments
- The patient will verbalize understanding of condition management
Nursing Assessment
Monitor Fluid Status
- Assess the extent and degree of edema
- Track daily weights
- Measure intake and output
- Monitor vital signs
- Document abdominal girth
Evaluate Respiratory Function
- Monitor breathing patterns
- Assess oxygen saturation
- Note the use of accessory muscles
- Check for respiratory distress
- Document activity tolerance
Assess Skin Integrity
- Check for breakdown
- Monitor color and temperature
- Assess for tension or shininess
- Document any lesions
- Note areas of concern
Monitor Complications
- Check for signs of infection
- Assess for deep vein thrombosis
- Monitor for respiratory compromise
- Evaluate cardiac status
- Check renal function
Review Contributing Factors
- Assess underlying conditions
- Review medication history
- Check dietary intake
- Monitor activity levels
- Evaluate support systems
Nursing Care Plans
Nursing Care Plan 1: Excess Fluid Volume
Nursing Diagnosis Statement:
Excess Fluid Volume related to compromised regulatory mechanisms as evidenced by generalized edema, weight gain, and decreased urine output.
Related Factors:
- Compromised cardiac function
- Impaired kidney function
- Decreased plasma protein levels
- Fluid retention mechanisms
Nursing Interventions and Rationales:
- Monitor daily weights
Rationale: Tracks fluid status and treatment effectiveness - Maintain accurate I&O records
Rationale: Assesses fluid balance and guides interventions - Administer diuretics as ordered
Rationale: Promotes fluid elimination - Position patient to reduce edema
Rationale: Enhances fluid redistribution
Desired Outcomes:
- The patient will demonstrate decreased edema
- The patient will maintain a stable weight
- The patient will show improved urine output
Nursing Care Plan 2: Impaired Physical Mobility
Nursing Diagnosis Statement:
Impaired Physical Mobility related to severe edema and heaviness of extremities as evidenced by difficulty moving and decreased activity tolerance.
Related Factors:
- Severe edema
- Joint stiffness
- Pain with movement
- Decreased muscle strength
Nursing Interventions and Rationales:
- Assist with positioning
Rationale: Prevents pressure injury and promotes comfort - Implement a progressive mobility plan
Rationale: Maintains function and prevents complications - Provide assistive devices
Rationale: Supports safe movement and independence
Desired Outcomes:
- The patient will demonstrate improved mobility
- The patient will maintain skin integrity
- The patient will participate in an activity as tolerated
Nursing Care Plan 3: Risk for Impaired Skin Integrity
Nursing Diagnosis Statement:
Risk for Impaired Skin Integrity related to severe edema and pressure on tissues as evidenced by stretched, shiny skin and decreased tissue perfusion.
Related Factors:
- Severe fluid accumulation
- Decreased circulation
- Pressure on tissues
- Limited mobility
Nursing Interventions and Rationales:
- Perform regular skin assessments
Rationale: Early detection of breakdown - Implement pressure relief measures
Rationale: Prevents tissue damage - Maintain proper skincare
Rationale: Promotes skin integrity
Desired Outcomes:
- The patient will maintain intact skin
- The patient will demonstrate improved tissue perfusion
- The patient will verbalize understanding of skincare
Nursing Care Plan 4: Ineffective Breathing Pattern
Nursing Diagnosis Statement:
Ineffective Breathing Pattern related to fluid accumulation and chest wall edema as evidenced by dyspnea and decreased oxygen saturation.
Related Factors:
- Fluid accumulation
- Chest wall edema
- Decreased lung expansion
- Increased work of breathing
Nursing Interventions and Rationales:
- Position for optimal breathing
Rationale: Maximizes respiratory function - Monitor oxygen saturation
Rationale: Ensures adequate oxygenation - Teach breathing exercises
Rationale: Improves ventilation
Desired Outcomes:
- The patient will maintain adequate oxygenation
- The patient will demonstrate an improved breathing pattern
- The patient will report decreased dyspnea
Nursing Care Plan 5: Knowledge Deficit
Nursing Diagnosis Statement:
Knowledge Deficit related to complex medical condition and treatment regimen as evidenced by questions about self-care and verbalized confusion.
Related Factors:
- Complex condition
- Multiple treatments
- New medication regimen
- Lifestyle modifications
Nursing Interventions and Rationales:
- Provide disease education
Rationale: Improves understanding and compliance - Teach medication management
Rationale: Ensures proper treatment - Demonstrate self-monitoring techniques
Rationale: Promotes early detection of problems
Desired Outcomes:
- The patient will verbalize understanding of the condition
- The patient will demonstrate proper self-care
- The patient will identify warning signs
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Kattula SRST, Avula A, Baradhi KM. Anasarca. [Updated 2023 Oct 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519013/
- King M. Management of Edema. J Clin Aesthet Dermatol. 2017 Jan;10(1):E1-E4. Epub 2017 Jan 1. PMID: 28210383; PMCID: PMC5300735.
- Khong LAM, Buckley A, Johnson W, Cavalheri V. Lower limb chronic edema management program: Perspectives of disengaged patients on challenges, enablers and barriers to program attendance and adherence. PLoS One. 2019 Nov 25;14(11):e0219875. doi: 10.1371/journal.pone.0219875. PMID: 31765379; PMCID: PMC6876834.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
