Hypervolemia, also known as fluid overload, is a condition characterized by excessive fluid volume in the intravascular and interstitial spaces. This nursing diagnosis focuses on identifying and managing increased fluid volume to prevent complications and restore normal fluid balance.
Causes (Related to)
Hypervolemia can develop due to various factors affecting fluid balance regulation:
- Excessive fluid intake or administration
- Decreased cardiac output
- Impaired renal function
- Medical conditions such as:
- Congestive heart failure
- Acute/chronic kidney disease
- Cirrhosis
- Nephrotic syndrome
- Iatrogenic factors including:
- Excessive IV fluid administration
- Medications (corticosteroids, NSAIDs)
- Blood product administration
- Hormonal imbalances affecting fluid retention
Signs and Symptoms (As evidenced by)
Hypervolemia presents with characteristic signs and symptoms that nurses must recognize for accurate diagnosis and intervention.
Subjective: (Patient reports)
- Shortness of breath
- Orthopnea
- Fatigue
- Anxiety
- Decreased exercise tolerance
- The feeling of tightness in jewelry or clothing
Objective: (Nurse assesses)
- Weight gain over short period
- Edema (peripheral, sacral, or general)
- Elevated blood pressure
- Increased central venous pressure
- Distended neck veins
- Crackles in lung fields
- S3 heart sound
- Decreased urine output
- Changes in mental status
Expected Outcomes
The following outcomes indicate successful management of hypervolemia:
- The patient will demonstrate decreased edema
- The patient will maintain stable vital signs
- The patient will show improved breathing patterns
- The patient will achieve optimal fluid balance
- The patient will comply with fluid restrictions
- The patient will understand dietary sodium restrictions
- The patient will demonstrate weight reduction to baseline
Nursing Assessment
Monitor Fluid Status
- Track daily weights
- Measure intake and output
- Assess edema and location
- Monitor vital signs
- Document skin turgor
Evaluate Cardiovascular Status
- Assess heart sounds
- Monitor blood pressure trends
- Check jugular vein distention
- Evaluate peripheral pulses
- Document exercise tolerance
Assess Respiratory Function
- Monitor breathing patterns
- Auscultate lung sounds
- Check oxygen saturation
- Note the use of accessory muscles
- Document dyspnea
Monitor Renal Function
- Track urine output
- Assess urine characteristics
- Monitor lab values
- Check for bladder distention
- Document changes in renal function
Review Risk Factors
- Assess cardiac function
- Document kidney status
- Review medication history
- Check dietary compliance
- Monitor sodium intake
Nursing Care Plans
Nursing Care Plan 1: Excess Fluid Volume
Nursing Diagnosis Statement:
Excess Fluid Volume related to impaired regulatory mechanisms as evidenced by edema, increased blood pressure, and weight gain.
Related Factors:
- Compromised regulatory mechanisms
- Excessive fluid intake
- Decreased cardiac output
- Impaired renal function
Nursing Interventions and Rationales:
- Monitor daily weights
Rationale: Provides an objective measure of fluid status changes - Restrict fluid intake as ordered
Rationale: Helps maintain appropriate fluid balance - Monitor vital signs and hemodynamics
Rationale: Identifies cardiovascular complications
Desired Outcomes:
- The patient will demonstrate weight reduction toward the baseline
- The patient will show decreased edema
- The patient will maintain stable vital signs
Nursing Care Plan 2: Impaired Gas Exchange
Nursing Diagnosis Statement:
Impaired Gas Exchange related to altered ventilation-perfusion from fluid overload as evidenced by dyspnea and decreased oxygen saturation.
Related Factors:
- Fluid accumulation in lung tissue
- Altered ventilation-perfusion ratio
- Increased work of breathing
- Compromised gas exchange
Nursing Interventions and Rationales:
- Position patient upright
Rationale: Improves lung expansion and ventilation - Monitor oxygen saturation
Rationale: Assesses the effectiveness of interventions - Administer oxygen as ordered
Rationale: Supports adequate oxygenation
Desired Outcomes:
- The patient will maintain oxygen saturation >95%
- The patient will report decreased dyspnea
- The patient will demonstrate an improved breathing pattern
Nursing Care Plan 3: Decreased Cardiac Output
Nursing Diagnosis Statement:
Decreased Cardiac Output related to fluid volume overload as evidenced by decreased exercise tolerance and fatigue.
Related Factors:
- Increased preload
- Altered contractility
- Increased afterload
- Compromised heart function
Nursing Interventions and Rationales:
- Monitor cardiovascular status
Rationale: Identifies changes in cardiac function - Implement activity restrictions
Rationale: Reduces cardiac workload - Administer medications as ordered
Rationale: Supports cardiac function
Desired Outcomes:
- The patient will demonstrate improved exercise tolerance.
- The patient will maintain stable vital signs
- The patient will report decreased fatigue
Nursing Care Plan 4: Activity Intolerance
Nursing Diagnosis Statement:
Activity Intolerance related to imbalance between oxygen supply and demand as evidenced by excessive fatigue and dyspnea with activity.
Related Factors:
- Fluid overload
- Decreased cardiac output
- Increased work of breathing
- Generalized weakness
Nursing Interventions and Rationales:
- Plan activities with rest periods
Rationale: Conserves energy - Monitor response to activity
Rationale: Prevents overexertion - Assist with ADLs as needed
Rationale: Maintains function while preventing exhaustion
Desired Outcomes:
- The patient will demonstrate improved activity tolerance.
- The patient will maintain adequate rest periods
- The patient will participate in daily activities without excessive fatigue
Nursing Care Plan 5: Risk for Impaired Skin Integrity
Nursing Diagnosis Statement:
Risk for Impaired Skin Integrity related to edema and altered tissue perfusion.
Related Factors:
- Fluid accumulation in tissues
- Decreased peripheral circulation
- Altered nutrition
- 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: Supports skin integrity
Desired Outcomes:
- The patient will maintain intact skin
- The patient will demonstrate improved tissue perfusion
- The patient will participate in skin care measures
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Claure-Del Granado R, Mehta RL. Fluid overload in the ICU: evaluation and management. BMC Nephrol. 2016 Aug 2;17(1):109. doi: 10.1186/s12882-016-0323-6. PMID: 27484681; PMCID: PMC4970195.
- Hansen B. Fluid Overload. Front Vet Sci. 2021 Jun 29;8:668688. doi: 10.3389/fvets.2021.668688. PMID: 34268347; PMCID: PMC8275824.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Messmer AS, Zingg C, Müller M, Gerber JL, Schefold JC, Pfortmueller CA. Fluid Overload and Mortality in Adult Critical Care Patients-A Systematic Review and Meta-Analysis of Observational Studies. Crit Care Med. 2020 Dec;48(12):1862-1870. doi: 10.1097/CCM.0000000000004617. PMID: 33009098.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
