Hypervolemia Nursing Diagnosis and Nursing Care Plan

Nursing Books

Hypervolemia Nursing Care Plans Diagnosis and Interventions

Hypervolemia NCLEX Review and Nursing Care Plans

Hypervolemia is a condition when there is too much fluid in the body. About 50% to 60% of the body is made up of fluid, including lymphatic fluid, blood, and water, all of which are crucial for maintaining the function of the organs.

The body naturally contains a specific amount of fluids, however too much fluid can be harmful to our health. Hypervolemia frequently affects pregnant women, and persons with heart and kidney diseases. Swelling, high blood pressure, and potential heart issues can all be caused by an excessive amount of fluid in the body.

Signs and Symptoms of Hypervolemia

The signs and symptoms of hypervolemia might vary in severity depending on the individual. These may generally include:

  • Swelling, also known as edema, is when an area of the body, typically the feet, ankles, wrists, and face, appears larger than it did the day before.
  • Bloated stomach
  • Minimal discomforts, such as headaches or cramps
  • Rapidly gaining weight
  • High blood pressure that is brought on by too much fluid in the blood
  • The inability to breathe normally due to more fluid entering the lungs causing shortness of breath
  • Cardiovascular issues because too much fluid can injure the heart muscles, expand the size of the heart, and affect the heart rhythm.

Causes of Hypervolemia

The following are the most typical causes of hypervolemia:

  • Salt (sodium). Water helps the body regulate how much salt we consume. Our bodies need water to bring sodium levels back to normal if we consume foods high in sodium. This is why, after consuming a lot of salty meals, we could feel thirsty. Some fluids contain sodium if a patient receives intravenous (IV) fluids following surgery or if they are dehydrated. Due to an imbalance in the body’s sodium levels, receiving fluids through an IV may trigger hypervolemia symptoms.
  • Underlying health problems. Some illnesses have an impact on how the body handles fluid. The following common diseases could manifest as a sign of hypervolemia:
    • Kidney disorders

Hypervolemia can also be a side effect of some medications used to treat these disorders, particularly those used to lower blood pressure or pain. Hypervolemia might be relieved and kept from returning by treating or controlling the underlying disease.

  • Pregnancy and hormonal fluctuations. Hypervolemia can result from hormonal changes, most frequently during menstruation or pregnancy when the body stores more sodium and water. Because the uterus puts pressure on the blood arteries in the lower trunk of the body, people who are pregnant frequently suffer swelling in their legs or ankles. The circulatory system cannot move fluid freely due to this pressure.

Complications of Hypervolemia

The adverse effects of having too much fluid in the body can be severe, so it is crucial for patients to receive the care they require to avoid long-term impairment. For those who are diagnosed with hypervolemia, the prognosis is favorable with early detection and treatment. On the other side, untreated hypervolemia can result in a number of complications, some of which are life-threatening, such as:

  • Pericarditis, or heart tissue swelling
  • Heart failure
  • Delayed healing of wounds
  • Tissue disintegration
  • Reduced bowel function

Diagnosis of Hypervolemia

Typically, the following should be part of the diagnosis:

  • Physical exam and Patient history. To determine the presence of the primary diagnostic markers of hypervolemia, weight gain, and swelling, the doctor will perform a physical examination and review the patient’s medical history. Depending on whether the patient was lying, sitting, or standing prior to the appointment, one or more body regions may appear swollen.
  • Blood and urine tests. To determine the patient’s sodium levels, the doctor may also draw blood. The sodium levels in the blood work may be high, normal, or low, despite the fact that the body’s total sodium levels would rise if the patient has hypervolemia. It can also be determined whether the kidneys are the cause of the hypervolemia or whether there is another cause by running a sodium test on the urine. Urinary sodium content is often higher than 20 mEq/L in renal failure, whereas it will be less than 10 mEq/L in cases of heart failure, cirrhosis, and nephrotic syndrome.
  • Imaging test. Additional imaging tests, including x-rays or ultrasounds, will be recommended if the healthcare professional believes that the diagnosis of hypervolemia is a symptom of an underlying disease.

Treatment for Hypervolemia

Mild hypervolemia can resolve on its own in a few days, but it’s essential to consult the doctor to determine whether the patient requires treatment. A more serious instance may take longer to recover from, especially if it is a sign of a more serious condition. The patient can recover more quickly from treating the underlying illness that led to hypervolemia, but symptoms may persist for a few weeks after treatment starts.

Depending on the underlying cause of the disorder, treatment for hypervolemia varies from person to person but always focuses on lowering the body’s fluid retention. The best way to treat hypervolemia is to address the underlying cause of the problem, which will also stop any future recurrence of symptoms. There are many ways to manage hypervolemia, including:

  • Medications. All those with hypervolemia often receive a course of diuretics, which are drugs that flush out extra fluid in the body.
  • Invasive procedures. In severe situations, a doctor may advise either paracentesis, or fluid removal through the abdomen, and dialysis, which removes fluid through the kidneys.
  • Diet. The patient will also be required by the healthcare practitioner to limit their fluid consumption and their dietary sodium intake.

Prevention of Hypervolemia

Even if people can’t stop all occurrences of hypervolemia, one can lower the risk by:

  • Consuming a diet low in sodium.
  • Keeping an eye on how much water you consume each day.
  • Reducing fluid intake and relieving thirst with low-fluid, thirst-quenching meals such as frozen grapes, ice chips, and sugar-free candies
  • Keeping track of the weight to look for dramatic shifts.
  • Managing or taking care of any underlying medical issues that may have.

Hypervolemia Nursing Diagnosis

Hypervolemia Nursing Care Plan 1

Compromised Regulatory Mechanism

Nursing Diagnosis: Excess Fluid Volume related to compromised regulatory mechanism secondary to hypervolemia as evidenced by high blood pressure, ascites, sudden weight gain, dependent edema, and shortness of breath.

Desired Outcomes:

  • The patient will exhibit stable fluid volume as shown by steady vital signs, balanced fluid intake and output, stable weight, and lack of edema indicators.
  • The patient will display measures to constantly check on their fluid levels and restrict or prevent a recurrence.
Hypervolemia Nursing InterventionsRationale
Keep an eye on the patient’s vital signs and take note of any neck or peripheral vein distention, pitting edema, or dyspnea.Common symptoms include tachypnea, which frequently coexists with dyspnea, and hypertension. Neck and peripheral vein enlargement are indications of cardiac decompensation and heart failure.
Weigh the patient daily to check for unexpected weight gain.A kilogram of weight is added for every liter of retained fluid.
Regularly auscultate the patient’s heart and lungs.Crackles and additional heartbeats (S3) are atypical sounds that point to fluid retention and may reappear during the rapid progression of pulmonary edema.
Keep a constant watch on the intake and output. On 24-hour calculations, take note of the decreased urine production and the positive fluid balance.Edema development and decreased urine output may be brought on by cardiac failure, fluid changes, and diminished renal perfusion.
Use caution while administering oral fluids and follow a 24-hour fluid plan if oral fluid intake is restricted.Mucous membranes can become more dried out as a result of fluid limits and extracellular changes, and the client may want to drink more sensible fluids.
Instruct the patient to practice deep breathing and coughing regularly.Respiratory problems are exacerbated by pulmonary fluid changes.
Keep the patient in a semi-Fowler position if dyspnea or ascites are present.By lowering the diaphragm and moving fluid to the lower abdominal cavity, gravity enhances lung expansion.
Provide safety precautions including a low-lying bed, regular inspection, gentle restraints, and the deployment of side rails.Fluid changes can result in mentation abnormalities and cerebral edema, especially in older people.

Hypervolemia Nursing Care Plan 2

Total Parenteral Feeding

Nursing Diagnosis: Risk for Excess Fluid Volume related to possible hypervolemia secondary to total parental feeding.

Desired Outcome: The patient will maintain normal fluid volume as demonstrated by balanced intake and output, and the absence of swelling and unnecessary weight gain.

Hypervolemia Nursing InterventionsRationale
Regularly monitor the patient for edema, jugular vein distention, shortness of breath, crackles on auscultation, and other indications and symptoms of excess fluid volume.The accumulation of fluid in the lungs is the root cause of these respiratory changes. Fluid accumulates in the extravascular spaces, resulting in edema, which usually begins in the fingers, face, and presacral region. Anasarca, also known as generalized edema, affects the entire body and appears later on. Weight gain of more than half a pound per day indicates the presence of extra fluid volume. The first sign of high central venous pressure is jugular vein distension.
Keep track of the patient’s laboratory results, such as serum sodium levels.By retaining fluid in the extravascular spaces, hypernatremia can cause or worsen edema.
Position the client in a semi-Fowler’s a high-Fowler’s position.Maintaining the head of the bed elevated promotes ease of breathing, allows fluid to pool in the bases, and allows gas exchange to be more available to the lung tissue.
Handle the patient with caution on edematous extremities.Skin that is edematous is more prone to injury and breakdown.
Monitor the patient’s weight daily to check for unexpected weight gain.A kilogram of weight is added for every liter of retained fluid.
Closely monitor the infusion rate of parenteral fluids; an infusion pump may also be used if necessary.A rapid fluid bolus or prolonged excessive administration increases the risk of volume overload and cardiac decompensation.

Hypervolemia Nursing Care Plan 3

Pulmonary Edema

Nursing Diagnosis: Excess Fluid Volume related to possible hypervolemia secondary to pulmonary edema as evidenced by difficulty of breathing, increased heart rate, productive cough, anxiety, and easy fatiguability.

Desired Outcome: The patient will exhibit stable fluid volume as evidenced by balanced intake and output, clear breath sounds, stable weight, and the absence of edema.

Hypervolemia Nursing InterventionsRationale
Maintain a 24-hour intake and output balance for the patient. Take note of the quantity and color of the urine as well.Despite the presence of edema and ascites, diuretic therapy can cause significant fluid loss in a short period of time in patients with advanced or congestive heart failure. On the other hand, urine production may be spared and concentrated during the day because of decreased renal perfusion,
Keep the patient in bed or on a chair in a semi-Fowler’s position during the acute phase of the disease.Recumbency increases glomerular filtration rate and decreases anti-diuretic hormone (ADH) production, improving diuresis.
Check the patient’s weight and serum electrolytes levels, such as potassium, sodium, chloride, and magnesium, as well as blood urea nitrogen (BUN) and creatinine levels on a daily basis.A rise in body weight indicates an excess of fluid volume, which is a sensitive indicator of fluid balance. Changes in edema or its improvement as a result of therapy must be documented, as a 5-pound weight gain represents approximately 2 liters of fluid. Diuretics, on the other hand, can result in rapid and excessive changes in body fluids as well as weight loss.
Allow the patient to change positions often, and when seated, elevate the patient’s feet. Examine the skin and provide any necessary padding while keeping the skin’s surface dry.Edema, decreased circulation, dietary changes, and extended periods of immobility or bed rest are all accumulated factors that affect the integrity of the skin and call for ongoing monitoring and preventive care.
Assess the patient’s breath sounds and take note of any abnormalities, such as decreased sounds or the presence of atypical breath sounds like wheezes and crackles. It’s important to take note of any increased dyspnea, tachypnea, or persistent cough.An excessive volume of fluid commonly contributes to pulmonary congestion. Pulmonary edema symptoms may be brought on by acute life-sided heart failure. In right-sided heart failure, respiratory symptoms such as dyspnea, coughing, and orthopnea may develop later and are more challenging to treat. Crackles on auscultation indicate fluid movement within the alveolar septum when pulmonary capillary hydrostatic pressure exceeds oncotic pressure.
Provide small, frequent, and easily digestible foods to the patient.Excessive fluid volume may cause reduced stomach motility, which could make digestion and absorption more challenging. Small, frequent feedings may aid in nutrient absorption, digestion, and the prevention of stomach distress.
Assess the patient for increased exhaustion, hypotension, and muscle cramps.These are the signs of sodium and potassium depletion, which can have detrimental effects on one’s health. These could be brought on by diuretic medication and fluid fluctuations.

Hypervolemia Nursing Care Plan 4

Pregnancy

Nursing Diagnosis: Risk for Excess Fluid Volume related to possible hypervolemia secondary to pregnancy.

Desired Outcomes:

  • The patient will not exhibit any symptoms of generalized, pulmonary, or cerebral edema, such as headaches, disorientation, dyspnea, nausea, or vomiting.
  • The patient will express verbally their knowledge of the importance of close monitoring of their weight, blood pressure, urine protein, and edema, and they will follow the recommended therapeutic routine and monitoring schedule.
Hypervolemia Nursing InterventionsRationale
Take note of any changes in the patient’s hematocrit and hemoglobin levels.Determines the level of fluid shift-induced hemoconcentration. Hemoconcentration exists if the hematocrit is less than three times the hemoglobin level. When the increase in plasma volume exceeds the rise in erythrocyte synthesis, hemoconcentration results.
Keep a watch on the patient’s intake and output, record the color of their urine, and measure their specific gravity as directed.A sensitive indicator of circulatory blood volume is urine production, as urine output is decreased when blood supply to the kidneys is reduced. Oliguria with a specific gravity of 1.040 points to renal involvement and severe hypovolemia.
Encourage the patient to eat more protein.Prenatal hypovolemia and hypoperfusion are less common when proper nutrition is followed; preeclampsia and edema formation are more likely when insufficient protein and calories are consumed. To make up for losses, a daily protein intake of 80–100 g may be necessary. As the glomeruli deteriorate and can no longer stop the protein from being expelled through the urine, protein levels become low.
Review the patient’s daily sodium intake of up to 6 g, and urge them to study food labels and keep away from salty foods.Because levels below 2-4 g/day induce increased dehydration in some customers, some sodium intake is required. Processed meats like bacon, luncheon meats, hot dogs, potato chips, etc. are high in salt. However, too much sodium can worsen edema and raise the risk of hypertension.
Schedule the prenatal appointment every 1-2 weeks for mild preeclampsia and weekly for severe cases.It’s crucial to keep a close watch on changes for the sake of the patient and fetus. It may be necessary to perform blood pressure checks twice a week in addition to fetal non-stress tests, amniotic fluid index measurements, and laboratory tests.
Inform the patient as well as any relevant family members or close friends about home monitoring and daycare programs.If proper monitoring and support are offered, and the patient and family actively participate in the treatment plan, some slightly hypertensive clients without proteinuria may be maintained on an outpatient basis.
Encourage the patient to work with a dietician, as directed.In order to determine specific needs and dietary regimens, a nutritional consultation may be helpful. It is thought that dietary salt and potassium intake considerably influences blood pressure variations in both the general population and hypertensive individuals.

Hypervolemia Nursing Care Plan 5

Nephrotic Syndrome

Nursing Diagnosis: Excess Fluid Volume related to possible hypervolemia secondary to nephrotic syndrome as evidenced by generalized edema, decreased urine output, abdominal ascites, and altered electrolytes, specific gravity, and blood pressure.

Desired Outcome:  The patient’s edema will lessen and will attain ideal body weight without retaining excess fluids.

Hypervolemia Nursing InterventionsRationale
Use the same weighing scale every day to weigh the patient.Body weight on a daily basis is an effective measure of hydration. More than 0.5 kg of weight gain per day shows fluid retention.
Strictly observe and document the patient’s intake and output.Fluid balance is determined via precise measurement.
Identify any possible sources of extra fluid, such as meals or drugs.Finding additional sources of extra fluid helps with the treatment plan.
Instruct the patient to follow the prescribed fluid restriction.Depending on the patient’s weight, urine production, and reaction to treatment, the amount of fluid intake is decided.
Administer corticosteroids as directed by the attending physician.The use of corticosteroids is continued until the urine is free of protein and remains normal for 10 to 2 weeks. In one to three weeks, a therapeutic reaction frequently materializes.
6.      Encourage the family member to provide proper oral hygiene to the patient frequently.Mucous membranes and mouth dryness are lessened by good oral hygiene.
Inform the patient and their family about kidney disease and function.Knowing the nature of the illness makes it possible for the patient to adhere to the prescribed course of treatment.

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

Nursing Stat Facts
Nursing Stat Facts

Disclaimer:

Please follow your facilities guidelines, 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 intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

Facebookredditpinterest

Leave a Comment

This site uses Akismet to reduce spam. Learn how your comment data is processed.