Anasarca Nursing Diagnosis and Care Plan

Definition:

Anasarca is a condition characterized by generalized severe edema throughout the body, leading to significant swelling in the subcutaneous tissues and body cavities.

Defining Characteristics of Anasarca:

1. Pitting edema: Presence of marked indentation after applying pressure to the skin.
2. Rapid weight gain: Sudden and significant increase in body weight due to fluid retention.
3. Swollen extremities: Edema affecting the arms, legs, hands, and feet.
4. Abdominal distension: Enlargement of the abdomen due to fluid accumulation.
5. Facial puffiness: Swelling in the face, particularly around the eyes and cheeks.
6. Dyspnea: Difficulty in breathing due to fluid accumulation in the lungs.
7. Reduced urine output: Decreased frequency and volume of urine due to impaired kidney function.
8. Hypertension: Elevated blood pressure due to fluid overload.
9. Fatigue and weakness: A feeling of tiredness and reduced strength.

Subjective (Client’s report): Patients may report:

• Feeling of tightness or fullness in the affected body parts.
• Difficulty in breathing or shortness of breath.
• Rapid weight gain or sudden increase in clothing or shoe size.

Objective (Observable signs): Nurses may observe:

• Generalized edema affecting the body.
• Indentation or pitting upon pressure over the skin.
• Distended abdomen.
• Swollen extremities.
• Facial puffiness.
• Increased blood pressure.
• Decreased urine output.
• Dyspnea or increased respiratory rate.
• Fatigue and weakness.

Related Factors:

The following factors may contribute to the development of anasarca:

• Cardiac disorders (e.g., congestive heart failure)
• Renal disorders (e.g., nephrotic syndrome, acute kidney injury)
• Liver cirrhosis
• Malnutrition
• Protein deficiency
• Venous insufficiency
• Medications (e.g., corticosteroids, calcium channel blockers)

Risk Population:

Individuals with the following conditions are at a higher risk of developing anasarca:

• Heart failure
• Kidney disease
• Liver disease
• Malnutrition
• Cancer
• Certain medications

Associated Problems: The presence of anasarca may lead to the following problems:

• Impaired mobility
• Risk of skin breakdown
• Impaired gas exchange
• Risk of infection
• Impaired self-image
• Pain and discomfort
• Impaired urinary elimination
• Disturbed body image

Suggestions for Use:

1. Assess the client’s history, symptoms, and physical examination findings to identify the presence of anasarca.
2. Monitor vital signs, intake and output, weight, and extent of edema regularly.
3. Collaborate with the healthcare team to determine and address the underlying cause of anasarca.
4. Provide appropriate nursing interventions to manage edema, improve fluid balance, and promote comfort.
5. Educate the client and their family about self-care measures, including dietary modifications and medication adherence.

Suggested Alternative NANDA Diagnoses:

1. Impaired Gas Exchange
2. Impaired Skin Integrity
3. Impaired Physical Mobility
4. Risk for Infection
5. Disturbed Body Image

Usage Tips:

• Use the NANDA nursing diagnosis Anasarca when there is evidence of severe generalized edema in a client.
• Ensure thorough assessment and monitoring to gather relevant subjective and objective data.
• Collaborate with the healthcare team to determine the underlying cause and tailor interventions accordingly.
• Regularly evaluate the client’s response to interventions and adjust the care plan as needed.

NOC Outcomes (Nursing Outcomes Classification):

1. Fluid Balance: Maintain fluid balance within normal limits.
2. Edema Control: Demonstrate reduction in edema.
3. Skin Integrity: Maintain intact skin without signs of breakdown.
4. Gas Exchange: Achieve and maintain adequate oxygenation and ventilation.
5. Mobility: Maintain or improve mobility and functional ability.
6. Self-Image: Express satisfaction with body image and acceptance of changes.

NOC Results:

1. Fluid Balance: Client’s fluid balance remains within normal limits.
2. Edema Control: Client demonstrates a reduction in edema.
3. Skin Integrity: Client’s skin remains intact without signs of breakdown.
4. Gas Exchange: Client achieves and maintains adequate oxygenation and ventilation.
5. Mobility: Client maintains or improves mobility and functional ability.
6. Self-Image: Client expresses satisfaction with body image and acceptance of changes.

NIC Interventions (Nursing Interventions Classification):

1. Edema Management:
   • Assess and document the extent and location of edema.
   • Elevate the affected body parts to promote fluid reabsorption.
   • Apply compression stockings or bandages as prescribed.
   • Monitor urine output and report any significant changes.
   • Administer diuretics as prescribed.
   • Teach the client and family about dietary sodium restrictions.
2. Skin Care:
   • Assess the skin regularly for signs of breakdown.
   • Cleanse and moisturize the skin to prevent dryness and cracking.
   • Apply barrier creams or ointments to protect the skin.
   • Reposition the client frequently to relieve pressure on vulnerable areas.
   • Use specialized support surfaces, such as pressure-reducing mattresses or cushions.
   • Educate the client and family about proper skin care techniques.
3. Respiratory Management:
   • Assess respiratory status regularly, including respiratory rate and effort.
   • Administer oxygen therapy as prescribed to maintain adequate oxygenation.
   • Position the client in an upright or semi-Fowler’s position to facilitate breathing.
   • Encourage deep breathing and coughing exercises.
   • Monitor arterial blood gases and pulse oximetry results.
   • Collaborate with the healthcare team to address underlying respiratory conditions.
4. Mobility Enhancement:
   • Assess the client’s mobility level and functional ability.
   • Encourage and assist with range of motion exercises.
   • Provide appropriate assistive devices to support mobility.
   • Teach energy conservation techniques to optimize activity tolerance.
   • Collaborate with physical therapy for rehabilitation, if needed.
   • Monitor for signs of impaired mobility and implement fall prevention strategies.
5. Psychological Support:
   • Assess the client’s emotional well-being and body image concerns.
   • Provide a supportive and empathetic environment.
   • Encourage the expression of feelings and concerns.
   • Refer to appropriate counseling or support services, if necessary.
   • Promote self-care activities and positive coping mechanisms.
   • Involve the client in decision-making and goal-setting.
6. Health Education:
   • Educate the client and family about the underlying cause of anasarca.
   • Provide information on medication management and potential side effects.
   • Teach the client about dietary modifications, including fluid and sodium restrictions.
   • Instruct on the importance of regular follow-up appointments and monitoring.
   • Discuss signs and symptoms of worsening condition and when to seek medical attention.
   • Promote adherence to the prescribed treatment plan.

Nursing Care Plan for Anasarca using Impaired Gas Exchange Nursing Diagnosis:

Nursing Diagnosis: Impaired Gas Exchange

Related Factors/Causes:

1. Accumulation of fluid in the lungs due to anasarca.
2. Decreased lung compliance and impaired ventilation.
3. Altered oxygen-carrying capacity of the blood.
4. Increased metabolic demands or oxygen consumption.
5. Presence of comorbid conditions affecting respiratory function (e.g., congestive heart failure, renal dysfunction).

Desired Outcomes:

1. Client will maintain adequate oxygenation and ventilation.
2. Client will have improved respiratory status with clear breath sounds.
3. Client will demonstrate improved arterial blood gas values within normal range.
4. Client will report decreased dyspnea and improved ability to perform activities of daily living.

Interventions:

1. Monitor Respiratory Status:
   • Assess respiratory rate, depth, and effort.
   • Auscultate breath sounds to identify abnormal findings.
   • Monitor oxygen saturation levels using pulse oximetry.
   • Measure arterial blood gases as ordered to evaluate oxygenation and ventilation.
   • Observe for signs of respiratory distress or decreased oxygen saturation.
2. Positioning and Mobilization:
   • Position the client in an upright or semi-Fowler’s position to optimize lung expansion.
   • Encourage frequent position changes and mobility exercises to promote ventilation and prevent complications.
   • Assist the client with turning, coughing, and deep breathing exercises to promote airway clearance.
3. Oxygen Therapy:
   • Administer supplemental oxygen as prescribed to maintain adequate oxygenation.
   • Monitor the client’s response to oxygen therapy and adjust the flow rate or delivery method as needed.
   • Educate the client and family on the proper use of oxygen equipment and safety precautions.
4. Airway Clearance:
   • Encourage and assist with effective coughing and deep breathing exercises.
   • Teach the client and family members how to perform and assist with chest physiotherapy techniques.
   • Administer respiratory treatments, such as nebulization or inhalation therapy, as prescribed.
   • Provide adequate hydration to promote thinning of respiratory secretions.
5. Education and Support:
   • Educate the client and family about the importance of medication adherence and management of underlying conditions contributing to impaired gas exchange.
   • Teach energy conservation techniques to minimize dyspnea during activities of daily living.
   • Provide information on the importance of maintaining a smoke-free environment and avoiding respiratory irritants.
   • Encourage the client to seek regular follow-up care and appointments with healthcare providers.
   • Offer emotional support and provide resources for coping with anxiety related to respiratory difficulties.

Evaluation:

1. Assess the client’s respiratory status regularly to determine the effectiveness of interventions.
2. Monitor arterial blood gas values and oxygen saturation levels for improvement.
3. Evaluate the client’s ability to perform activities of daily living without experiencing significant dyspnea.
4. Evaluate breath sounds and lung auscultation for improved ventilation and airway clearance.

Nursing Care Plan for Anasarca using Impaired Skin Integrity Nursing Diagnosis:

Nursing Diagnosis: Impaired Skin Integrity

Related Factors/Causes:

1. Prolonged edema and fluid accumulation in the subcutaneous tissues.
2. Impaired circulation and compromised lymphatic drainage.
3. Increased pressure on vulnerable areas due to swelling.
4. Nutritional deficiencies and compromised tissue healing.
5. Limited mobility and inability to change positions frequently.
6. Presence of comorbid conditions affecting skin integrity (e.g., cardiovascular disease, malnutrition).

Desired Outcomes:

1. Client will maintain intact skin without signs of breakdown.
2. Client will exhibit improved skin turgor and decreased edema.
3. Client will report relief from pain and discomfort associated with skin changes.
4. Client will demonstrate understanding and implementation of preventive measures for skin integrity.

Interventions:

1. Skin Assessment:
   • Perform a thorough assessment of the client’s skin, paying attention to areas prone to breakdown.
   • Document the location, characteristics, and severity of any skin changes, such as erythema, edema, or breakdown.
   • Use a validated assessment tool, such as the Braden Scale, to assess the client’s risk for developing pressure ulcers.
2. Moisture Management:
   • Keep the skin clean and dry by gently cleansing with mild, pH-balanced cleansers and patting dry.
   • Apply emollients or moisturizers to prevent dryness and maintain skin integrity.
   • Utilize moisture-barrier creams or ointments in areas prone to maceration, such as skin folds.
   • Implement appropriate management for incontinence to minimize exposure to moisture.
3. Pressure Redistribution:
   • Assist the client with frequent position changes, ensuring adequate pressure redistribution.
   • Utilize supportive devices, such as pressure-reducing mattresses, cushions, or specialty beds.
   • Encourage the use of pressure-reducing surfaces during sitting or lying activities.
   • Educate the client and caregivers on the importance of regular repositioning and offloading pressure points.
4. Skin Protection:
   • Apply protective dressings or barrier creams to areas at risk for friction, shearing, or pressure.
   • Utilize appropriate wound dressings for existing skin breakdown, following healthcare provider’s orders.
   • Encourage the use of soft, non-restrictive clothing and footwear to prevent further skin damage.
   • Educate the client and caregivers about proper techniques for donning and doffing garments to minimize skin trauma.
5. Nutrition and Hydration:
   • Collaborate with the dietitian to ensure the client’s nutritional needs are met, including adequate protein intake for tissue repair.
   • Encourage the client to consume a well-balanced diet and offer nutritional supplements as needed.
   • Monitor the client’s fluid intake and hydration status to promote tissue healing and skin integrity.
6. Education and Support:
   • Educate the client and caregivers about the importance of skin hygiene and preventive measures.
   • Teach proper techniques for skin inspection and early detection of skin changes.
   • Instruct on the use of assistive devices and techniques for safe transfers and mobility.
   • Provide resources and support for managing comorbid conditions that impact skin integrity.
   • Promote self-care and encourage the client’s active involvement in their own skin health.

Evaluation:

1. Assess the client’s skin regularly for signs of breakdown, such as redness, swelling, or open wounds.
2. Monitor the client’s skin turgor and edema levels for improvement.
3. Evaluate the client’s pain and discomfort levels associated with skin changes.
4. Assess the client’s understanding and implementation of preventive measures for skin integrity.

Anasarca Practice Nursing Questions

Question 1: A nursing student is caring for a client with anasarca. Which nursing intervention is essential to promote skin integrity in this client?

a) Administering diuretic medications as prescribed

b) Applying moisturizing creams to the skin regularly

c) Encouraging the client to increase fluid intake

d) Assisting with range of motion exercises

Answer: b) Applying moisturizing creams to the skin regularly

Rationale: Anasarca can lead to significant edema and fluid accumulation in the subcutaneous tissues, increasing the risk of skin breakdown. Regularly applying moisturizing creams helps maintain skin hydration and integrity, reducing the risk of skin breakdown.

Question 2: When planning care for a client with anasarca, the nurse recognizes the need to prioritize which intervention?

a) Monitoring daily weights

b) Assisting with ambulation

c) Administering diuretic medications

d) Assessing skin turgor

Answer: c) Administering diuretic medications

Rationale: Anasarca is characterized by generalized severe edema. Administering diuretic medications as prescribed is crucial to promote fluid removal and reduce edema in the client.

Question 3: A client with anasarca reports shortness of breath and difficulty breathing. Which action should the nurse take first?

a) Administering supplemental oxygen

b) Assessing vital signs

c) Elevating the client’s head

d) Auscultating lung sounds

Answer: b) Assessing vital signs

Rationale: Assessing vital signs is the priority action to determine the client’s overall condition and identify any immediate concerns. It helps the nurse gather essential data before proceeding with interventions.

Question 4: The nurse is planning care for a client with anasarca. Which dietary modification should the nurse anticipate for this client?

a) Low-sodium diet

b) High-protein diet

c) Low-potassium diet

d) High-calorie diet

Answer: a) Low-sodium diet

Rationale: Anasarca can result from fluid overload, and reducing sodium intake is essential to manage fluid balance. A low-sodium diet helps decrease fluid retention and edema in clients with anasarca.

Question 5: The nurse is assessing a client with anasarca and notes pitting edema on both lower extremities. Which nursing intervention should be implemented to reduce the edema?

a) Elevating the legs

b) Massaging the legs

c) Applying a heating pad to the legs

d) Applying cold compresses to the legs

Answer: a) Elevating the legs

Rationale: Elevating the legs above the level of the heart helps promote venous return and reduces dependent edema. It facilitates fluid reabsorption and can help decrease the severity of pitting edema in the lower extremities.

References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. 

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier.

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. 

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. 

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