Last updated on January 4th, 2023 at 09:42 am
Fluid Overload Nursing Care Plans Diagnosis and Interventions
Fluid Overload NCLEX Review and Nursing Care Plans
Fluid overload, also called hypervolemia, is a medical condition in which the body has too much water. While the body needs a certain amount of fluid to function properly, too much fluid can be harmful to one’s health.
Heart failure, kidney failure, cirrhosis, and pregnancy are only a few of the disorders that might cause it.
Signs and Symptoms of Fluid Overload
A person may experience symptoms as a result of the underlying illness that is causing fluid overload. Fluid overload can be caused by a variety of factors and must be managed. The following are indicators of fluid overload:
- Edema. The feet, ankles, legs, arms, wrists, and face are the most prevalent sites for edema or swelling. When a person presses on the area of swelling with the thumb and it makes an indentation, it is termed pitting edema. This condition might be a sign of a significant medical problem.
- Discomfort. Abdominal cramps, headaches, and stomach bloating are some of the discomforts that can be felt in the body.
- Hypertension. The excess fluid in the body causes the heart to work harder, causing blood pressure to rise.
- Shortness of breath and/or chest pain. Excess fluid entering the lungs causes shortness of breath, limiting the capacity to breathe properly. Chest pain could indicate pulmonary edema or fluid in the lungs.
- Cardiovascular problems. Because excess fluid can speed up or slow the heart rhythm, damage the heart muscles, and expand the size of the heart, it can cause heart problems.
- Weight gain. This is the most common symptom of fluid overload. Before they notice swelling in their legs or abdomen, most people gain 8 to 15 pounds.
Causes of Fluid Overload
In most cases, fluid overload is the outcome of an underlying health issue. Mild cases, on the other hand, can develop after eating foods high in sodium or during hormone imbalances, and normally resolve entirely on their own if there are no underlying health issues.
If detected early, fluid overload is usually manageable, but the underlying cause of it should be treated to prevent a recurrence.
Fluid overload is frequently caused by kidney problems. This is because the kidneys normally maintain the body’s salt and fluid levels in check. They raise the overall sodium content of the body by retaining salt, which increases the fluid volume.
The most typical causes of fluid overload are as follows:
- Heart failure, specifically right ventricular failure. When the heart muscle is weak or injured, it cannot pump blood as efficiently as it should. As a result, the kidneys are not getting enough blood to work properly. The body then retains fluid and salt to restore equilibrium, which causes fluid overload.
- Cirrhosis. It is commonly caused by excessive alcohol intake or hepatitis. Cirrhosis is the development of scar tissue on the liver caused by liver disease. Scar tissue inhibits the liver’s ability to function properly, causing fluid to accumulate in the abdomen.
- Kidney Failure. Kidney failure is frequently caused by diabetes and other metabolic illnesses. When the kidneys are not operating properly, fluid can build up in the body.
- Nephrotic syndrome. It is a condition in which the kidneys’ tiny blood vessels are damaged, resulting in excessive protein excretion in the urine. These blood vessels filter waste and excess water from the blood, and when they are damaged, the body is unable to eliminate the excess fluid.
- Other conditions. Other conditions, such as pregnancy, alter a woman’s hormonal balance and causes fluid retention. Premenstrual edema, or swelling that happens before a woman’s menstrual cycle, is another condition that can induce fluid overload.
- Intravenous (IV) Fluids. When someone is dehydrated or unable to consume enough fluids, such as after surgery, IV fluids can save a life. Too much IV fluid, on the other hand, can cause fluid overload, especially if other medical problems are present.
- Certain medications. Birth control pills, hormone replacement therapy, and other hormonal drugs that cause the body to retain too much salt and fluid can induce fluid overload. Mild fluid overload can also be caused by some antidepressants, blood pressure medicines, and nonsteroidal anti-inflammatory drugs (NSAIDs).
- Excessive salt consumption. According to a study, the average American eats 3,400 mg of salt per day, far more than the recommended maximum of 2,300 mg. When people eat too much sodium, the body retains water, causing moderate bloating and fluid overload. For generally healthy individuals, one salty meal is unlikely to cause difficulties. But excessive salt consumption can be fatal in small children, the elderly, and individuals with underlying health concerns.
Diagnosis of Fluid Overload
The following are methods commonly used to diagnose fluid overload:
- Medical History – there are a number of disorders that induce signs and symptoms similar to fluid overload, and they must be ruled out. Lung and heart issues, venous or lymphatic circulation problems, illnesses that cause low protein levels in the blood (hypoproteinemia), liver disease, and thyroid dysfunction are all examples of these conditions.
- Physical exam – if a person suspects or is exhibiting the signs of fluid overload, a physician should be consulted to confirm the diagnosis. A physical examination will be conducted by the doctor initially. Weight gain and swelling are two of the most common symptoms of fluid overload. Depending on whether an individual was sitting, reclining, or standing before the visit, one or more areas of the body may appear swollen.
- Blood tests – a blood test to monitor sodium levels and other electrolytes (biochemistry) is also likely to be performed by the physician. While total sodium levels in the body would rise as a result of fluid overload, sodium levels in blood tests may be high, normal, or low. A urine sodium test can aid establish whether fluid overload is caused by the kidneys or by something else. The urinary sodium level is frequently greater than 20 milliequivalents per liter (mEq/L) in kidney failure, but less than 10 mEq/L in heart failure, cirrhosis, and nephrotic syndrome.
- Imaging tests – several diagnostic tests, such as an electrocardiogram (ECG), an echocardiogram (ultrasound scanning of the heart), a chest X-ray, and other blood tests to check kidney function, blood count, liver function, and blood gases, may be recommended to rule out other conditions that resemble fluid overload or to determine the extent of complications if they have already occurred.
Complications of Fluid Overload
If left untreated, fluid overload or hypervolemia can lead to a wide range of complications, some of which are life-threatening. These are some of them:
- Congestive heart failure (CHF) or pericarditis
- Poor wound healing
- Tissue breakdown
- Impaired bowel function
- Pulmonary edema
Treatment of Fluid Overload
Fluid overload treatment varies from person to person and is dependent on the underlying cause of the condition. It is usually treated with the following medical interventions:
- Diuretics. Medications that aid in the removal of excess fluid from the body.
- Dialysis. A procedure in which the blood is filtered through a machine and is usually done in extreme cases.
- Paracentesis. A procedure in which a tiny tube is used to remove fluid from the abdomen.
- Limiting salt consumption. When a person consumes too much salt, the body retains additional sodium, increasing the volume of fluid outside of the cells in the body. This increase in fluid allows the body to keep its sodium and fluid retention while excreting more sodium in the urine.
- Weighing oneself every day. One way to assess if the condition is getting worse or need to adjust the medications to reduce extra fluid in the body is to weigh oneself every day.
- Lifestyle modifications. Smoking cessation, maintaining a healthy weight, avoiding alcohol and caffeine, eating a well-balanced diet, getting enough sleep, and stress management are all examples of lifestyle changes.
Fluid Overload Nursing Diagnosis
Fluid Overload Nursing Care Plan 1
Nursing Diagnosis: Fluid Volume Excess related to excessive fluid and sodium intake, and renal insufficiency as evidenced by edema, oliguria, shortness of breath, increased heart rate, elevated blood pressure, and electrolytes imbalances.
Desired Outcome: The patient will maintain a normal volume of fluid in the body as evidenced by urine output greater than or equal to 30 mL/hour, balanced intake and output, and vital signs within normal limits.
| Fluid Overload Nursing Interventions | Rationale |
| Evaluate the patient’s medical history to understand what is causing the fluid imbalance. | Increased fluids or sodium intake may be part of the history, which can help guide management. |
| Check the weight of the patient on a regular basis using the same scale and, ideally, at the same time of day while wearing the same type of clothes. | Rapid weight gain may suggest fluid overload. Weight disparities between scales and clothing might be misleading. |
| Keep a constant watch on the input and output of the patient. | Even if the overall fluid consumption is adequate, fluid shifting might cause dehydration. |
| Monitor and record the patient’s blood pressure and heart rate. | Early signs of fluid overload include sinus tachycardia and elevated blood pressure. |
| Palpate the tibia, ankles, feet, and sacrum for the presence and severity of edema. | Fluid accumulates in the extravascular spaces, causing edema. Edema indications appear more frequently in dependent areas. Another method of determining edema is to measure an extremity with a measuring tape. |
| Inform the patient, caregiver, and family members of the fluid restrictions, as needed. | Patients who will be co-managing fluids require a lot of information and awareness about their condition. |
| Keep the salt intake of the patient to a minimum, as directed by the physician. | Sodium restriction tends to decrease fluid overload. |
| Take diuretics exactly as directed. | The physician will normally prescribe diuretics to help with the elimination of excess fluid from the body. |
| Elevate the patient’s edematous extremities and handle them with caution. | Elevation promotes venous return to the heart, which reduces edema. Skin that is edematous is more prone to skin breakdown. |
| Position the patient in a semi-Fowler’s or high-Fowler’s position. | Breathing is better when the patient is placed in an upright position. |
| Encourage the patient to be repositioned every 2 hours, especially if he or she is unable to move. | Fluid accumulation in the dependent areas can be resolved and prevented through the help of gravity by means of repositioning. |
| Educate the patient and family members on the need for good nutrition, hydration, and dietary changes. | Awareness improves adherence to the treatment regimen. |
Fluid Overload Nursing Care Plan 2
Ineffective Breathing Pattern
Nursing Diagnosis: Ineffective Breathing Pattern secondary to fluid overload as evidenced by productive cough, shortness of breath, weakness, and pink frothy sputum.
Desired Outcome:
The patient’s breathing pattern will be efficient without inducing tiredness.
| Fluid Overload Nursing Interventions | Rationale |
| Monitor and document the vital signs of the patient. | To establish a baseline record of the patient. |
| Watch out for shortness of breath, nasal flaring, pursed-lip breathing, and the involvement of accessory muscles in breathing. | These findings point to increased respiratory effort. |
| Place the patient in a semi-Fowler’s or high-Fowler’s position. | Breathing is easier when the patient is placed in an upright position. |
| Support the patient in practicing relaxation techniques. | Relaxation techniques relieve muscle tension and make breathing comfortable. |
| Give enough time for the patient to rest. | By preserving the patient’s energy, adequate rest periods lessen the workload on the lungs. |
| Regularly practice breathing exercises, coughing, and changing positions. | These methods help to mobilize secretions, which reduces the risk of lung infections. |
| As needed, administer supplemental oxygen to the patient. | Pulmonary edema can be caused by fluid overload. It is essential to provide supplemental oxygen to improve the amount of oxygen available for effective breathing. |
Fluid Overload Nursing Care Plan 3
Nursing Diagnosis: Impaired comfort secondary to fluid overload as evidenced by facial grimace, restlessness, and verbal reports of headache, abdominal cramps, and stomachache.
Desired Outcome: The patient’s level of discomfort will be reduced and the patient will demonstrate effective ways to alleviate discomforts caused by fluid overload.
| Fluid Overload Nursing Interventions | Rationale |
| Assess the severity of the patient’s discomfort using a pain rating scale, as well as the site and triggering circumstances. | Identifying baseline data can aid in treatment planning. |
| Evaluate the patient’s response to the medications. | The effectiveness of medication and if additional interventions are required is determined by assessing response. |
| Aid with comfort measures. | To provide pain management that is not pharmacological. |
| Create a relaxing environment by reducing noise levels and ensuring that the room is well-lit and well-ventilated. | The patient’s energy demands are reduced in a relaxing setting. |
| Provide enough time for the patient to rest. | By preserving the patient’s energy, adequate rest periods lessen the workload on the lungs. |
| Teach the patient how to relax and how to employ relaxation techniques to relieve discomfort. | Discomfort is frequently triggered by a variety of stresses that can be alleviated through non-pharmacological methods such as relaxation. |
| Administer pain medications, as prescribed. | Pain relievers are commonly prescribed by the physician to deal with discomfort. |
| Encourage small frequent feedings instead of two or three large meals. | Small frequent meals make it easier for the stomach to process and digest food, which can help to alleviate the abdominal pain caused by fluid overload. |
Fluid Overload Nursing Care Plan 4
Anxiety
Nursing Diagnosis: Anxiety related to underlying pathophysiological process and changes in health condition secondary to fluid overload as evidenced by restlessness, expressed concern about lifestyle modifications, and fear of probable complications.
Desired Outcome: The patient will express anxiety awareness, identify tolerable anxiety levels, and display appropriate coping mechanisms.
| Fluid Overload Nursing Interventions | Rationale |
| Determine the patient’s degree of anxiety about fluid overload. | Anxiety arising from uncertainty over an unknown diagnosis and prognosis may be relieved with an adequate explanation. |
| Observe how the patient tries to deal with anxiety using coping skills and defensive mechanisms such as reading, singing, or physical activity like walking. | Individuals utilize defense mechanisms to maintain their egos and control their anxiety levels. |
| Engage presence, verbalization, and manner to encourage them to voice or clarify their needs, worries, unknowns, and inquiries about fluid overload to remind patients that they are not alone. | Communication is facilitated by being supportive and encouraging of the nurse. |
| Use basic language and short statements to communicate. | Patients suffering from moderate to severe anxiety may find it difficult to comprehend anything else than simple, clear, and short directions. |
| Support the patient in learning new anxiety-relieving practices like relaxation, breathing exercises, positive visualization, and soothing self-statements. | The patient can handle anxiety in a variety of ways by learning new coping methods. |
| Use non-medical words and a slow, calm voice to explain all procedures, and concerns involving the patient. When possible, do this ahead of time and confirm the patient’s comprehension. | Patients who receive pre-orientation usually report less anxiety and mental distress, as well as improved coping skills because they know what will happen. Anxiety is exacerbated by uncertainty. |
| Instruct the patient to avoid caffeine and other central nervous system stimulants. | Stimulants can aggravate anxiety’s physical effects. |
| Inform the patient and family members about the signs and symptoms of anxiety. | If the patient and family members can recognize anxiety responses, they will be able to intervene sooner than they would otherwise. |
| Instruct the patient on how to use anti-anxiety medications as prescribed. | Antianxiety drugs are sometimes recommended by doctors for short-term use to improve patient coping and minimize physiological signs of anxiety. |
| Avoid providing excessive reassurance; this may cause the patient to become overly worried. | For the anxious patient, reassurance is ineffective. |
| Instruct the patient to explain the occurrence as well as the circumstances that preceded and followed anxiety. The patient should keep track of how the anxiousness fades. | Recognizing and exploring the elements that cause or reduce anxiety are crucial steps in developing alternate responses. |
Fluid Overload Nursing Care Plan 5
Decreased Cardiac Output
Nursing Diagnosis: Decreased Cardiac Output related to alterations in rate, rhythm, and electrical conduction secondary to fluid overload as evidenced by increased heart rate, changes in blood pressure, decreased urine output, extra heart sounds, edema, and shortness of breath.
Desired Outcome:
The patient will demonstrate adequate cardiac output as evidenced by vital signs within acceptable ranges, decreased episodes of shortness of breath, and adequate urinary output.
| Fluid Overload Nursing Interventions | Rationale |
| Closely monitor and document the patient’s heart rate | The body’s first response to compensate for decreased cardiac output caused by fluid overload is an increase in heart rate. This compensatory response improves cardiac output at first, but persistent tachycardia is damaging over time and can lead to heart failure. |
| Palpate the patient’s peripheral pulses. | Weak radial, popliteal, dorsalis pedis, and post tibial pulses may indicate a decrease in cardiac output. |
| Always check the patient’s urine output, noting any changes in volume or concentration. | Urine output may be lowered as a result of reduced renal perfusion — kidneys retain water and sodium in response to decreasing cardiac output. |
| Keep a constant watch on the patient’s oxygen saturation and ABGs. | The diagnosis and severity of heart failure, a complication of fluid overload, can be determined using baseline oxygen saturation. |
| Provide supplemental oxygen as suggested by the patient’s symptoms, oxygen saturation, and arterial blood gases (ABGs). | Supplemental oxygen enhances oxygen availability to the myocardium, which can help alleviate hypoxemia, ischemia, and associated exercise intolerance symptoms. |
| Assist with activities while providing a relaxing environment and encouraging periods of relaxation and sleep. | Cardiac activity and oxygen demand are reduced when manageable stressors and unwanted disruptions are minimized. The patient can conserve energy by resting physically and emotionally. |
| Help the patient assume a high Fowler’s position. | This position enables more chest expansion, resulting in increased pulmonary function. The venous return to the heart is minimized in this position, pulmonary congestion is relieved, and pressure on the diaphragm is lowered. |
| Elevate the legs to avoid pressure under the knees or to a comfortable position for the patient. | Leg elevation reduces venous return and preload, which may help prevent thrombus and embolus development. |
| Reposition the patient once every two hours. | Prolonged immobility should be avoided for patients on bed rest due to its deconditioning effects and incidence of pressure ulcers, especially in patients with edema due to fluid overload. |
| Administer drugs like diuretics as the doctor prescribes. | For all patients with symptoms of fluid overload, diuretics are the first-line treatment. It reduces blood volume, which lowers blood vessel pressure, pulmonary edema, peripheral edema, and heart dilatation. It also promptly relieves discomfort and reduces fluid retention. |
| Educate the patient about the disease’s pathophysiology and how medicine works. | Fluid overload and its complications require patient education to be successfully managed. |
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. (2018). 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
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