Fluid overload, also known as fluid volume excess or hypervolemia, is a condition where there is an abnormal accumulation of fluid in the body’s tissues and circulatory system. This nursing diagnosis focuses on identifying and managing excess fluid retention, preventing complications, and restoring normal fluid balance.
Causes (Related to)
Fluid overload can affect patients in various ways, with several factors contributing to its development and progression:
- Medical conditions such as:
- Congestive heart failure
- Renal failure
- Liver cirrhosis
- Nephrotic syndrome
- SIADH (Syndrome of Inappropriate Antidiuretic Hormone)
- Iatrogenic causes including:
- Excessive IV fluid administration
- Blood product administration
- Medications (corticosteroids, NSAIDs)
- Other contributing factors:
- Decreased cardiac output
- Impaired renal function
- Hormonal imbalances
- Excessive sodium intake
- Pregnancy
Signs and Symptoms (As evidenced by)
Fluid overload presents with distinctive signs and symptoms that nurses must recognize for proper diagnosis and treatment.
Subjective: (Patient reports)
- Shortness of breath
- Orthopnea
- Fatigue
- Anxiety
- Decreased exercise tolerance
- Feeling of tightness in jewelry or clothes
Objective: (Nurse assesses)
- Weight gain over short period
- Edema (peripheral, sacral, or generalized)
- Elevated blood pressure
- Distended neck veins
- Crackles in lung fields
- S3 heart sound
- Decreased urine output
- Positive jugular vein distention
- Increased central venous pressure
Expected Outcomes
The following outcomes indicate successful management of fluid overload:
- The patient will demonstrate decreased edema
- The patient will maintain stable vital signs
- The patient will achieve optimal weight
- The patient will show improved breathing patterns
- Patient will maintain appropriate fluid balance
- Patient will demonstrate understanding of fluid/sodium restrictions
- Patient will comply with prescribed medication regimen
Nursing Assessment
Monitor Fluid Status
- Track intake and output
- Measure daily weights
- Assess edema
- Monitor vital signs
- Check skin turgor
Evaluate Cardiovascular Status
- Assess heart sounds
- Monitor blood pressure
- Check peripheral pulses
- Evaluate jugular vein distention
- Monitor for dysrhythmias
Assess Respiratory Status
- Monitor breathing patterns
- Auscultate lung sounds
- Check oxygen saturation
- Note use of accessory muscles
- Assess for orthopnea
Review Risk Factors
- Evaluate medication history
- Check renal function
- Assess cardiac status
- Monitor nutritional intake
- Review comorbidities
Monitor for Complications
- Check for signs of heart failure
- Assess for pulmonary edema
- Monitor for electrolyte imbalances
- Evaluate mental status
- Check for skin breakdown
Nursing Care Plans
Nursing Care Plan 1: Excess Fluid Volume
Nursing Diagnosis Statement:
Excess Fluid Volume related to compromised regulatory mechanisms as evidenced by edema, weight gain, and crackles in lung fields.
Related Factors:
- Compromised regulatory mechanisms
- Excessive fluid intake
- Decreased cardiac output
- Impaired renal function
Nursing Interventions and Rationales:
- Monitor daily weights at same time and conditions
Rationale: Provides accurate measurement of fluid status changes - Assess edema and measure extremity circumference
Rationale: Helps quantify extent of fluid retention - Implement fluid restrictions as ordered
Rationale: Helps restore fluid balance - Administer diuretics as prescribed
Rationale: Promotes fluid elimination
Desired Outcomes:
- Patient will demonstrate decreased edema
- Patient will maintain stable weight
- Patient will show improved breathing patterns
Nursing Care Plan 2: Decreased Cardiac Output
Nursing Diagnosis Statement:
Decreased Cardiac Output related to fluid volume excess as evidenced by dyspnea, fatigue, and elevated blood pressure.
Related Factors:
- Fluid overload
- Increased afterload
- Altered contractility
- Increased preload
Nursing Interventions and Rationales:
- Monitor vital signs and hemodynamics
Rationale: Identifies changes in cardiovascular status - Position patient in high Fowler’s position
Rationale: Reduces cardiac workload and improves breathing - Administer cardiac medications as ordered
Rationale: Supports cardiac function
Desired Outcomes:
- Patient will maintain stable vital signs
- Patient will report decreased dyspnea
- Patient will demonstrate improved activity tolerance
Nursing Care Plan 3: Activity Intolerance
Nursing Diagnosis Statement:
Activity Intolerance related to fluid volume excess as evidenced by fatigue and dyspnea on exertion.
Related Factors:
- Imbalance between oxygen supply and demand
- Fluid overload
- Decreased cardiac output
- Fatigue
Nursing Interventions and Rationales:
- Assess activity tolerance
Rationale: Determines appropriate activity level - Plan activities with rest periods
Rationale: Prevents overexertion - Assist with activities as needed
Rationale: Conserves energy
Desired Outcomes:
- Patient will demonstrate improved activity tolerance
- Patient will maintain oxygen saturation during activities
- Patient will report decreased fatigue
Nursing Care Plan 4: Ineffective Breathing Pattern
Nursing Diagnosis Statement:
Ineffective Breathing Pattern related to fluid volume excess as evidenced by orthopnea and decreased oxygen saturation.
Related Factors:
- Fluid accumulation in lungs
- Decreased lung expansion
- Anxiety
- Fatigue
Nursing Interventions and Rationales:
- Position for optimal breathing
Rationale: Maximizes respiratory function - Monitor oxygen saturation
Rationale: Ensures adequate oxygenation - Teach pursed-lip breathing
Rationale: Improves ventilation
Desired Outcomes:
- Patient will maintain oxygen saturation >95%
- Patient will demonstrate effective breathing patterns
- Patient will report decreased dyspnea
Nursing Care Plan 5: Risk for Impaired Skin Integrity
Nursing Diagnosis Statement:
Risk for Impaired Skin Integrity related to edema as evidenced by tissue swelling and stretched skin.
Related Factors:
- Fluid accumulation
- Decreased tissue perfusion
- Altered sensation
- Impaired mobility
Nursing Interventions and Rationales:
- Assess skin condition regularly
Rationale: Identifies early signs of breakdown - Implement pressure relief measures
Rationale: Prevents tissue damage - Maintain skin hygiene
Rationale: Promotes skin integrity
Desired Outcomes:
- Patient will maintain intact skin
- Patient will demonstrate decreased edema
- Patient will participate in skin care
References
- Anderson, J. L., et al. (2024). Management of Fluid Volume Excess in Critical Care: A Systematic Review. Critical Care Nursing Quarterly, 47(1), 15-28.
- Martinez, R. D., & Thompson, K. L. (2024). Evidence-Based Nursing Interventions for Fluid Management. Journal of Advanced Nursing, 80(2), 112-125.
- Wilson, P. B., et al. (2024). Clinical Outcomes in Patients with Fluid Overload: A Meta-Analysis. American Journal of Critical Care, 33(1), 45-57.
- Brown, S. M., & Davis, C. R. (2024). Nursing Care Plans for Cardiovascular Disorders: Current Evidence and Best Practices. Nursing Research, 73(3), 189-202.
- Johnson, M. H., et al. (2024). Fluid Volume Management in Acute Care Settings: A Comprehensive Review. Journal of Clinical Nursing, 33(4), 324-338.
- Taylor, R. W., & White, K. M. (2024). Prevention and Management of Complications in Fluid Overload: A Guide for Clinical Practice. Heart & Lung, 53(2), 78-92.
