A MERLIN Site



Nursing Care Plans: Nursing Diagnosis and Intervention, 5/e
Back to 5th edition


Fluid Volume Excess - Hypervolemia; Fluid Overload
Sue Galanes, RN, MS, CCRN
Meg Gulanick, RN, PhD

NANDA: The state in which an individual experiences increased fluid retention and edema

Fluid volume excess, or hypervolemia, occurs from an increase in total body sodium content and an increase in total body water. This fluid excess usually results from compromised regulatory mechanisms for sodium and water as seen in congestive heart failure (CHF), kidney failure, and liver failure. It may also be caused by excessive intake of sodium from foods, intravenous (IV) solutions, medications, or diagnostic contrast dyes. Hypervolemia may be an acute or chronic condition managed in the hospital, outpatient center, or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of fluid and sodium restriction, and the use of diuretics. For acute cases dialysis may be required.

Related Factors

Defining Characteristics

Expected Outcome

Patient maintains adequate fluid volume and electrolyte balance as evidenced by: vital signs within normal limits, clear lung sounds, pulmonary congestion absent on x-ray, and resolution of edema.

Ongoing Assessment

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Obtain patient history to ascertain the probable cause of the fluid disturbance.
Which can help to guide interventions. May include increased fluids or sodium intake, or compromised regulatory mechanisms.
(i) Assess or instruct patient to monitor weight daily and consistently, with same scale and preferably at the same time of day.
To facilitate accurate measurement and to follow trends.
(i) Monitor for a significant weight change (2 lb) in one day.
(i) Evaluate weight in relation to nutritional status.
In some heart failure patients, weight may be a poor indicator of fluid volume status. Poor nutrition and decreased appetite over time result in a decrease in weight, which may be accompanied by fluid retention even though the net weight remains unchanged.
(i) If patient is on fluid restriction, review daily log or chart for recorded intake.
Patients should be reminded to include items that are liquid at room temperature such as Jello, sherbet, and popsicles.
(i) Monitor and document vital signs.
Sinus tachycardia and increased blood pressure are seen in early stages. Elderly patients have reduced response to catecholamines; thus their response to fluid overload may be blunted, with less rise in heart rate.
(i) Monitor for distended neck veins and ascites. Monitor abdominal girth to follow any ascites accurately.
(i) Auscultate for a third sound, and assess for bounding peripheral pulses.
These are signs of fluid overload.
(i) Assess for crackles in lungs, changes in respiratory pattern, shortness of breath, and orthopnea.
For early recognition of pulmonary congestion.
(i) Assess for presence of edema by palpating over tibia, ankles, feet, and sacrum.
Pitting edema is manifested by a depression that remains after one's finger is pressed over an edematous area and then removed. Grade edema trace, indicating barely perceptible, to 4, which indicates severe edema. Measurement of an extremity with a measuring tape is another method of following edema.
(c) Monitor chest x-ray reports.
As interstitial edema accumulates, the x-rays show cloudy white lung fields.
(i) Monitor input and output closely.
Although overall fluid intake may be adequate, shifting of fluid out of the intravascular to the extravascular spaces may result in dehydration. The risk of this occurring increases when diuretics are given. Patients may use diaries for home assessment.
(i) Evaluate urine output in response to diuretic therapy.
Focus is on monitoring the response to the diuretics, rather than the actual amount voided. At home, it is unrealistic to expect patients to measure each void. Therefore recording two voids versus six voids after a diuretic medication may provide more useful information. NOTE: Fluid volume excess in the abdomen may interfere with absorption of oral diuretic medications. Medications may need to be given intravenously by a nurse in the home or outpatient setting.
(i) Monitor for excessive response to diuretics: 2-lb loss in 1 day, hypotension, weakness, blood urea nitrogen (BUN) elevated out of proportion to serum creatinine level.
(c) Monitor serum electrolytes, urine osmolality, and urine-specific gravity.
(i) Assess the need for an indwelling urinary catheter.
Treatment focuses on diuresis of excess fluid.
(i) During therapy, monitor for signs of hypovolemia.
To prevent complications associated with therapy.
(c) If hospitalized, monitor hemodynamic status including CVP, PAP, and PCWP, if available.
This direct measurement serves as optimal guide for therapy.

Therapeutic Interventions

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(c) Institute/instruct patient regarding fluid restrictions as appropriate.
To help reduce extracellular volume. For some patients, fluids may need to be restricted to 100 ml per day.
(i) Provide innovative techniques for monitoring fluid allotment at home. For example, suggest that patient measure out and pour into a large pitcher the prescribed daily fluid allowance (e.g., 1000 ml). Then, every time patient drinks some fluid he or she is to remove that amount from the pitcher.
This provides a visual guide for how much fluid is still allowed throughout the day.
(c) Restrict sodium intake as prescribed.
Sodium diets of 2 to 3 gm are usually prescribed.
(c) Administer or instruct patient to take diuretics as prescribed.
Diuretic therapy may include several different types of agents for optimal therapy, depending on the acuteness or chronicity of the problem. For chronic patients, compliance is often difficult for patients trying to maintain a normal lifestyle.
(i) Instruct patient to avoid medications that may cause fluid retention, such as over-the-counter nonsteroidal antiinflammatory agents, certain vasodilators, and steroids.
(i) Elevate edematous extremities.
To increase venous return and, in turn, decrease edema.
(i) Reduce constriction of vessels (use appropriate garments, avoid crossing of legs or ankles).
To prevent venous pooling.
(c) Instruct in need for antiembolic stockings or bandages as ordered.
To help promote venous return and to minimize fluid accumulation in the extremities.
(i) Provide interventions related to specific etiologic factors (i.e., inotropic medications for heart failure, paracentesis for liver disease, and others).
For acute patients:
(c) Consider admission to acute care setting for hemofiltration or ultrafiltration.
This is a very effective method to draw off excess fluid.
(c) Collaborate with the pharmacist to maximally concentrate IVs and medications.
To decrease unnecessary fluids.
(i) Apply heparin lock on IV line.
To maintain patency but to decrease fluid delivered to patient in a 24-hour period.
(c) Administer IV fluids through infusion pump, if possible.
To ensure accurate delivery of IV fluids.
(i) Provide adequate activity or position changes as able.
To prevent fluid accumulation in dependent areas.
(i) Assist with repositioning every 2 hours if patient is not mobile.

Education/Continuity of Care

Actions/Interventions
Key:
(i) independent
(c) collaborative
(i) Teach causes of fluid volume excess and/or excess intake to patient or caregiver.
(i) Provide information as needed regarding the individual's medical diagnosis (e.g., congestive heart failure [CHF], renal failure).
(i) Explain or reinforce rationale and intended effect of treatment program.
(i) Identify signs and symptoms of fluid volume excess.
(i) Explain importance of maintaining proper nutrition and hydration, and diet modifications.
(i) Identify symptoms to be reported.

NIC

Fluid Monitoring; Fluid Management

~ Care Plan Index ~ Outcomes Index ~
~ Care Plan Constructor Home ~