Fluid Volume Excess - Hypervolemia; Fluid Overload
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.
- Excessive fluid intake
- Excessive sodium intake
- Renal insufficiency or failure
- Steroid therapy
- Low protein intake or malnutrition
- Decreased cardiac output; chronic or acute heart disease
- Head injury
- Liver disease
- Severe stress
- Hormonal disturbances
- Weight gain
- Bounding pulses
- Shortness of breath; orthopnea
- Pulmonary congestion on x-ray
- Abnormal breath sounds: crackles (rales)
- Change in respiratory pattern
- Third heart sound S3
- Intake greater than output
- Decreased hemoglobin or hematocrit
- Increased blood pressure
- Increased central venous pressure (CVP)
- Increased pulmonary artery pressure (PAP)
- Jugular vein distention
- Change in mental status (lethargy or confusion)
- Specific gravity changes
- Change in electrolytes
- Restlessness and anxiety
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.
- (i) independent
- (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
- (i) Assess or instruct patient to monitor
weight daily and consistently, with same scale and preferably at the same time
- To facilitate accurate measurement and to follow
- (i) Monitor for a significant weight change (2
lb) in one day.
- (i) Evaluate weight in relation to nutritional
- 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
- (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
- (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
- 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
- (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
- Treatment focuses on diuresis of excess fluid.
- (i) During therapy, monitor for signs of
- 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
- (i) independent
- (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
- (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:
Consider admission to acute care setting for hemofiltration or
- This is a very effective method to draw off excess
- (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
- (i) independent
- (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
- (i) Explain or reinforce rationale and
intended effect of treatment program.
- (i) Identify signs and symptoms of fluid
- (i) Explain importance of maintaining proper
nutrition and hydration, and diet modifications.
- (i) Identify symptoms to be reported.
Fluid Monitoring; Fluid Management
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