Excess Fluid Volume Nursing Diagnosis and Nursing Care Plan

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Excess Fluid Volume Nursing Care Plans Diagnosis and Interventions

Fluid Volume Excess NCLEX Review and Nursing Care Plans

Fluid volume excess also known as hypervolemia, refers to the excessive accumulation of fluid in the extracellular fluid compartment.

It may occur due to a variety of factors. Excess fluid volume is mainly associated with sodium regulation. A normal fluid volume is important in the balanced functioning of cells and sodium helps make this happen.

Sodium is a major extracellular electrolyte. It maintains fluid balance through the concept of tonicity. The tonicity of a solution is related to whether the fluid will influence the cells or not.

A solution that does not change the volume of the cell is called isotonic. While a hypotonic solution causes cells to swell, a hypertonic solution on the other hand makes cells shrink.

Sodium moves around intracellularly and extracellularly to keep body fluids isotonic and not affect cells and their function.

Restricting sodium and fluid intake is one of the effective treatment options to regain “normovolemia” or balanced fluid volume in the body.

If left untreated, fluid volume excess can put a strain on the major organs in the body such as the heart, liver, and kidneys.

Excess Fluid Volume Nursing Diagnosis

Excess Fluid Volume Nursing Care Plan 1

Heart Failure

Nursing Diagnosis: Fluid Volume Excess related to compromised regulatory mechanism secondary to heart failure as evidenced by the presence of crackles and shortness of breath

Desired Outcome: The patient will regain a balanced fluid volume as evidenced by ease of breathing and clear lung sounds.

Nursing Interventions Fluid Volume ExcessRationales
Commence fluid balance chart.Heart failure can compromise the fluid balance mechanism of the body. A record of the patient’s intake and output will help direct medical management by identifying how much fluid excess there is and where most of the fluid is coming from. 
Assess the patient’s vital signs regularly.The measurement of the patient’s vital signs will help evaluate the progress of management. It will also indicate if the patient’s breathing is improving.
Weigh the patient on a daily basis Use the same scale.
Use the same clothing.
Weigh patient at the same time each day
The patient’s weight is one clinical indicator of fluid volume and fluid retention.
Reposition the patient to an upright, sitting position if tolerated.Positioning the patient to an upright position will help straighten the airway and improve breathing.
Check with doctors for the need for fluid restriction.Fluid restriction may be necessary to prevent fluid excess. Educate the patient on what counts as fluid other than water and drinks, such as soup, frozen juice pops, and gelatin.
Administer diuretics as prescribed.Diuretics are effective in excreting excess fluid through the urine.
Encourage the use of anti-embolic stockings.Anti-embolic stockings prevent fluid accumulation in the extremities.
Refer to chest physiotherapy as needed.Chest physiotherapists can help control fluid build-up in the lungs through breathing techniques.

Excess Fluid Volume Nursing Care Plan 2

Chronic Kidney Disease (CKD)

Nursing Diagnosis: Fluid Volume Excess related to renal insufficiency secondary to CKD as evidenced by bilateral leg edema, as well as a positive balance in the fluid balance chart.

Desired Outcome: The patient will understand measures to maintain normovolemia in the presence of CKD.

Nursing Interventions Fluid Volume ExcessRationales
Place the patient on strict input and output monitoring.A record of the patient’s fluid intake and output can help direct medical management. It will also help identify the main sources of fluid excess.
Monitor the patient’s vital signs.The patient’s blood pressure and heart rate can signify fluid volume.
Limit fluid intake as advised.Fluid restriction is common to patients with CKD. The kidneys function is reduced that it cannot strain an excessive amount of fluids. Many patients are limited to a maximum of 1 liter of fluids per day.
Explain the importance of following fluid restriction.The patient’s cooperation is essential in achieving fluid intake below the allocated level.
Explain the other sources of fluids such as gelatin, soup, frozen popsicles, and sherbet.Water is not only sourced from drinks but can be gained from some foods as well.
Explain the symptoms of fluid volume excess such as edema, difficulty breathing, weight gain, and sometimes, low urine output.Early recognition of fluid volume excess can prevent the worsening of the condition and allows for early treatment.
Explain possible causes of fluid volume excess.Fluid balance can be affected by several factors such as high oral fluid intake, water-rich fruits and vegetables, and electrolyte imbalance.
Elevate the legs of the patient. Encourage the use of anti-embolic stockings. Encourage mobilization or short walks if tolerated.Elevating the legs promotes fluid return to the heart, reducing the swelling in the legs. Anti-embolic stockings prevent fluid accumulation in the extremities.

Excess Fluid Volume Nursing Care Plan 3

Hypertension

Nursing Diagnosis: Fluid Volume Excess related to high sodium intake and chronic hypertension as evidenced by a serum sodium level of 149 mEQ/L and blood pressure of 180/98 mmHg

Desired Outcome: The patient will restore normal fluid balance through interventions to normalize sodium level and blood pressure.

Nursing Interventions Fluid Volume ExcessRationales
Start patient on a strict fluid balance chart.A record of the patient’s fluid intake and output will help identify the main source of fluid excess. It will also help staff and the patient if the fluid output is enough in comparison to fluid intake.
Monitor vital signs.The patient’s blood pressure and heart rate may indicate fluid volume. It will also help in the evaluation of progress from the treatment.
Monitor patient’s electrolyte levels, particularly the serum sodium levels.Sodium is a major extracellular fluid electrolyte partly responsible for fluid balance.
Review intravenous fluid orders.Most intravenous fluids contain sodium which can affect fluid balance.
Limit sodium-rich food.Sodium can be found in food sources too. Adding sodium from other sources may worsen fluid excess.
Administer diuretics as prescribed.Diuretics help in the excretion of excess fluid build-up.

Excess Fluid Volume Nursing Care Plan 4

Acute Respiratory Distress Syndrome (ARDS)

Nursing Diagnosis: Fluid Volume Excess related to compromised respiratory mechanisms secondary to ARDS as evidenced by crackles upon auscultation, shortness of breath, restlessness, anxiety, and altered serum sodium levels

Desired Outcome: The patient will restore normal fluid balance through interventions to normalize sodium level, reduce fluid retention in the lungs, and prevent pulmonary edema.

Nursing Interventions Fluid Volume ExcessRationales
Place the patient on a strict fluid balance chart.A record of the patient’s intake and output will help direct medical management by identifying how much fluid excess there is and where most of the fluid is coming from. 
Assess the patient’s vital signs regularly. Auscultate the lungs at least once every shift or when there are changes to condition.The measurement of the patient’s vital signs will help evaluate the progress of management. Vital signs will also indicate if the patient’s breathing is improving.
Create a weight chart. Weigh the patient on a daily basis.
Use the same scale.
Use the same clothing.
Weigh patient at the same time each day.
The patient’s weight is one clinical indicator of fluid volume and fluid retention.
Reposition the patient every 2 hours or encourage mobilization if the patient is able to tolerate. Reposition the patient to an upright, sitting position if tolerated.Repositioning or mobilizing can help prevent the accumulation of fluids in the lobes of the lungs. Positioning the patient to an upright position will help straighten the airway and improve breathing.
Check with doctors for the need for fluid restriction.Fluid restriction may be necessary to prevent fluid excess. Educate the patient on what counts as fluid other than water and drinks, such as soup, frozen juice pops, and gelatin.
Administer diuretics as prescribed.ARDS can result in pulmonary edema if not treated at once. Diuretics are effective in excreting excess fluid through the urine.
Administer prescribed intravenous fluids through an infusion pump.Using an infusion pump facilitates precise administration and recording of intravenous fluids, making sure that only the required fluids are administered.
Refer to chest physiotherapy as needed.Chest physiotherapists can help decrease fluid build-up in the lungs through breathing techniques.

Excess Fluid Volume Nursing Care Plan 5

Lupus: Long-term Steroid Therapy

Nursing Diagnosis: Fluid Volume Excess related to long-term steroid therapy secondary to lupus as evidenced by bilateral leg edema, increased weight, and blood pressure of 160/100 mmHg

Desired Outcome: The patient will achieve optimal normal fluid balance.

Nursing Interventions Fluid Volume ExcessRationales
Commence patient on a strict fluid balance chart.A record of the patient’s fluid intake and output will help identify the main source of fluid excess. It will also help staff and the patient if the fluid output is enough in comparison to fluid intake.
Monitor vital signs, particularly the blood pressure.Lupus may cause hypertension, which can lead to FVE. The patient’s blood pressure and heart rate may indicate fluid volume. It will also help in the evaluation of progress from the treatment.
Monitor patient’s electrolyte levels, particularly the serum sodium levels.Sodium is a major extracellular fluid electrolyte partly responsible for fluid balance.
Administer diuretics as prescribed.Diuretics are effective in excreting excess fluid through the urine.
Limit sodium-rich food.Sodium can be found in food sources too. Adding sodium from other sources may worsen fluid excess.
Review the dose of steroids in the multi-disciplinary meeting (MDT).Lupus patients are usually on long-term steroid therapy. However, the therapeutic benefit of steroids should be weighed against the current side effects, such as hypervolemia. This can be effectively discussed during MDT.
Administer diuretics as prescribed.Diuretics help in the excretion of excess fluid build-up.
Elevate the legs of the patient. Encourage the use of anti-embolic stockings. Encourage mobilization or short walks if tolerated.Elevating the legs promotes fluid return to the heart, reducing the swelling in the legs.
Anti-embolic stockings prevent fluid accumulation in the extremities.

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.  Buy on Amazon

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

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.  Buy on Amazon

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

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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