excess fluid volume nursing diagnosis

Excess Fluid Volume Nursing Diagnosis & Care Plan

Nursing Diagnosis for Excess Fluid Volume:

Definition:

Excess Fluid Volume is a condition characterized by an increase in intravascular, interstitial, and/or intracellular fluid that may compromise health.

Defining Characteristics of Excess Fluid Volume:

Subjective (reported by the patient):

  1. Weight gain
  2. Feeling of fullness or bloating
  3. Swelling or edema in extremities or other body parts
  4. Shortness of breath
  5. Decreased urine output

Objective (observable signs):

  1. Edema or swelling in dependent body areas (e.g., ankles, hands, sacrum)
  2. Rapid weight gain
  3. Distended neck veins
  4. Ascites (accumulation of fluid in the abdominal cavity)
  5. Increased blood pressure
  6. Crackles or rales in lung fields
  7. Decreased oxygen saturation
  8. Changes in laboratory values (e.g., decreased hematocrit, decreased serum sodium levels)
  1. Impaired cardiac function (e.g., heart failure, myocardial infarction)
  2. Renal dysfunction (e.g., acute kidney injury, chronic kidney disease)
  3. Excessive sodium or fluid intake
  4. Medications that cause fluid retention (e.g., corticosteroids, nonsteroidal anti-inflammatory drugs)
  5. Liver disease (e.g., cirrhosis, hepatitis)
  6. Hormonal imbalances (e.g., increased antidiuretic hormone secretion)
  7. Lymphatic obstruction (e.g., lymphedema)
  8. Excessive intravenous fluid administration

Risk Population:

Individuals with compromised cardiac, renal, or hepatic function; those receiving intravenous fluids; and individuals with conditions that predispose them to fluid retention.

Associated Problems:

  1. Impaired gas exchange
  2. Activity intolerance
  3. Disturbed body image
  4. Impaired skin integrity
  5. Risk of electrolyte imbalances

Suggestions for Use:

  • Assess the patient for subjective and objective signs of excess fluid volume.
  • Identify the underlying cause(s) of excess fluid volume.
  • Implement interventions to promote fluid balance and prevent complications.
  • Monitor and evaluate the patient’s response to interventions.

Suggested Alternative NANDA Diagnoses:

  1. Impaired Gas Exchange
  2. Decreased Cardiac Output
  3. Risk for Impaired Skin Integrity
  4. Ineffective Breathing Pattern
  5. Activity Intolerance

Usage Tips:

  • Accurately assess and document the patient’s fluid intake, output, and weight changes.
  • Collaborate with other healthcare professionals to address the underlying cause(s) of excess fluid volume.
  • Educate the patient and their family about dietary and fluid restrictions, medication management, and self-monitoring techniques.

NOC (Nursing Outcomes Classification) Outcomes:

  1. Fluid Balance
  2. Tissue Perfusion: Abdominal Organs
  3. Tissue Perfusion: Peripheral
  4. Cardiac Pump Effectiveness
  5. Electrolyte and Acid-Base Balance

NOC Results:

  1. Maintains fluid balance within normal limits.
  2. Demonstrates normal tissue perfusion in abdominal organs and peripheral areas.
  3. Exhibits adequate cardiac pump effectiveness.
  4. Maintains electrolyte and acid-base balance within normal ranges.

NIC (Nursing Interventions Classification) Interventions:

Nursing interventions for excess fluid volume.

  1. Fluid Management
  2. Electrolyte Management
  3. Medication Administration
  4. Edema Management
  5. Nutrition Management
  6. Patient Education and Counseling

Excess Fluid Volume Nursing Care Plans

Impaired Gas Exchange Nursing Care Plan for Excess Fluid Volume:

Nursing Diagnosis: Impaired Gas Exchange related to excess fluid volume as evidenced by decreased oxygen saturation, crackles in lung fields, and dyspnea.

Related Factors/Causes:

  1. Increased fluid volume in the lungs due to fluid overload or heart failure.
  2. Pulmonary edema caused by excessive fluid accumulation in the interstitial spaces of the lungs.
  3. Inadequate oxygen perfusion due to decreased lung compliance from fluid-filled alveoli.

Desired Outcomes:

  1. The patient will maintain oxygen saturation within an acceptable range (e.g., 95% or higher).
  2. The patient will exhibit clear lung sounds on auscultation.
  3. The patient will report improved ease of breathing and absence of dyspnea.

Interventions:

  1. Monitor vital signs, including oxygen saturation levels, respiratory rate, and depth.
  2. Auscultate lung sounds regularly to assess for crackles, wheezes, or diminished breath sounds.
  3. Position the patient in an upright or semi-Fowler’s position to promote lung expansion.
  4. Administer supplemental oxygen as prescribed to improve oxygenation.
  5. Encourage deep breathing and coughing exercises to mobilize secretions and improve lung ventilation.
  6. Administer diuretic medications as prescribed to reduce excess fluid volume.
  7. Collaborate with the healthcare team to address the underlying cause of fluid overload (e.g., adjusting medication dosages, implementing fluid restrictions).
  8. Provide education to the patient and their family on the importance of maintaining fluid balance, adhering to prescribed medications, and recognizing signs of worsening respiratory distress.
  9. Monitor intake and output, including urine output, to assess fluid balance.
  10. Implement measures to promote comfort and reduce anxiety, such as providing a calm and quiet environment, administering prescribed analgesics, and using relaxation techniques.

Evaluation:

  1. The patient’s oxygen saturation remains within an acceptable range (e.g., 95% or higher).
  2. Lung auscultation reveals clear breath sounds without crackles or wheezes.
  3. The patient reports improved ease of breathing and absence of dyspnea.
  4. The patient demonstrates understanding of self-care measures to manage excess fluid volume and prevent impaired gas exchange.

Decreased Cardiac Output Nursing Diagnosis for Excess Fluid Volume:

Nursing Diagnosis: Decreased Cardiac Output related to excess fluid volume as evidenced by decreased cardiac output, edema, and increased blood pressure.

Related Factors/Causes:

  1. Impaired cardiac function due to conditions such as heart failure, myocardial infarction, or cardiomyopathy.
  2. Fluid overload resulting in increased preload and decreased contractility of the heart.
  3. Increased afterload due to vasoconstriction caused by excess fluid volume.
  4. Medications that can decrease cardiac output (e.g., beta-blockers, calcium channel blockers).

Desired Outcomes:

  1. The patient’s cardiac output will improve to a satisfactory level.
  2. The patient will demonstrate reduced edema and weight gain.
  3. The patient’s blood pressure will stabilize within a normal range.

Interventions:

  1. Monitor vital signs regularly, including blood pressure, heart rate, and rhythm.
  2. Assess for signs of fluid overload, such as edema, distended neck veins, and ascites.
  3. Administer prescribed medications to optimize cardiac function (e.g., angiotensin-converting enzyme inhibitors, beta-blockers).
  4. Implement measures to reduce fluid volume, such as monitoring fluid intake and output, and restricting sodium and fluid intake as prescribed.
  5. Elevate the head of the bed to decrease venous return and promote venous pooling.
  6. Encourage and assist with activities of daily living to promote circulation and reduce the workload on the heart.
  7. Provide education to the patient and their family regarding medication adherence, dietary modifications, and signs of worsening cardiac function.
  8. Collaborate with the healthcare team to address and manage underlying cardiac conditions.
  9. Monitor daily weights and assess for sudden weight gain, which may indicate fluid retention.
  10. Assist the patient with proper positioning, such as elevating legs, to facilitate venous return and reduce dependent edema.

Evaluation:

  1. The patient’s cardiac output shows improvement to a satisfactory level.
  2. Edema and weight gain decrease or stabilize.
  3. The patient’s blood pressure remains within a normal range.
  4. The patient demonstrates an understanding of self-care measures to manage excess fluid volume and improve cardiac output.

Note: This is a sample nursing care plan and should be individualized based on the patient’s specific condition, medical history, and healthcare provider’s orders.

Nursing Test Questions for Fluid Volume Excess:

Question 1: A patient with heart failure presents with signs and symptoms of excess fluid volume. The nurse suspects impaired gas exchange. Which assessment findings support this suspicion?

a) Decreased blood pressure and tachycardia.

b) Crackles in the lung fields and decreased oxygen saturation.

c) Edema in the lower extremities and weight loss.

d) Increased urine output and hyperventilation.

Answer: b) Crackles in the lung fields and decreased oxygen saturation. Rationale: Impaired gas exchange is characterized by inadequate oxygenation of the blood. Crackles in the lung fields indicate fluid accumulation in the alveoli, impairing gas exchange. Decreased oxygen saturation indicates inadequate oxygen transfer from the lungs to the bloodstream.

Question 2: A patient is admitted with renal dysfunction and is at risk for excess fluid volume. Which nursing intervention is appropriate for managing fluid balance?

a) Encouraging the patient to consume a low-sodium diet.

b) Administering diuretic medications as prescribed.

c) Limiting fluid intake to 500 mL per day.

d) Monitoring blood pressure every 4 hours.

Answer: b) Administering diuretic medications as prescribed. Rationale: Administering diuretic medications helps to increase urine output and promote fluid loss, thus managing fluid balance. Low-sodium diets and fluid restrictions may be implemented based on the patient’s condition, but diuretic medications directly address excess fluid volume.

Question 3: A patient with excess fluid volume is experiencing edema in the lower extremities. Which nursing intervention is appropriate for managing edema?

a) Applying compression stockings.

b) Elevating the affected extremities.

c) Encouraging ambulation.

d) Administering analgesic medication.

Answer: b) Elevating the affected extremities. Rationale: Elevating the affected extremities promotes venous return, reduces dependent edema, and improves fluid balance. Compression stockings can also assist in reducing edema. Encouraging ambulation and administering analgesic medication may have other benefits but are not directly related to managing edema.

Question 4: A patient is diagnosed with excess fluid volume related to impaired cardiac function. Which assessment finding is consistent with this diagnosis?

a) Weight loss of 2 kg over 24 hours.

b) Jugular vein distention.

c) Blood pressure of 90/60 mmHg.

d) Decreased urine output.

Answer: b) Jugular vein distention. Rationale: Jugular vein distention is a sign of increased central venous pressure, which can be seen in excess fluid volume related to impaired cardiac function. Weight loss, low blood pressure, and decreased urine output are not typical findings in excess fluid volume.

Question 5: A patient with excess fluid volume complains of shortness of breath and reports weight gain. Which nursing intervention is appropriate for this patient?

a) Encouraging deep breathing exercises.

b) Administering a bronchodilator medication.

c) Providing a sodium-restricted diet.

d) Assisting with daily weights.

Answer: d) Assisting with daily weights. Rationale: Assisting with daily weights is important to monitor fluid balance and detect changes in weight, which can indicate fluid retention or loss.

Encouraging deep breathing exercises may be helpful for other respiratory issues, but in this scenario, the focus is on fluid volume. Administering a bronchodilator may be appropriate for specific respiratory conditions but does not directly address excess fluid volume. Providing a sodium-restricted diet may be necessary, but it is not the most appropriate intervention based on the given patient complaint.

Nursing 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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