Nursing diagnosis: Excess Fluid Volume related to Compromised regulatory mechanism—syndrome of inappropriate antidiuretic hormone (SIADH), decreased plasma proteins, malnutrition, Excess sodium and fluid intake
Possibly evidenced by
Edema, anasarca, weight gain
Intake greater than output, oliguria, changes in urine specific gravity
Dyspnea, adventitious breath sounds, pleural effusion
Blood pressure (BP) changes, altered central venous pressure (CVP)
JVD, positive hepatojugular reflex
Altered electrolyte levels
Change in mental status
Desired Outcomes/Evaluation Criteria—Client Will
Demonstrate stabilized fluid volume, with balanced intake and output (I&O), stable weight, vital signs within client’s normal range, and absence of edema.
Nursing intervention with rationale:
1. Measure I&O, noting positive balance—intake in excess of output. Weigh daily, and note gain more than 0.5 kg/day.
Rationale: Reflects circulating volume status, developing or resolving fluid shifts, and response to therapy. Positive fluid balance and weight gain often reflects continuing fluid retention. Note: Decreased circulating volume and fluid shifts can directly affect renal function and urine output, resulting in hepatorenal syndrome.
2. Monitor BP and CVP, if available. Note JVD and abdominal vein distention.
Rationale: BP elevations are usually associated with fluid volume excess but may not occur because of fluid shifts out of the vascular space. JVD and presence of distended abdominal veins are associated with vascular congestion.
3. Assess respiratory status, noting increased respiratory rate and dyspnea.
Rationale: Indicative of pulmonary congestion or edema.
4. Auscultate lungs, noting diminished or absent breath sounds and developing adventitious sounds—crackles.
Rationale: Increasing pulmonary congestion may result in consolidation, impaired gas exchange, and complications, such as pulmonary edema.
5. Monitor for cardiac dysrhythmias. Auscultate heart sounds, noting development of S3/S4 gallop rhythm.
Rationale: May be caused by HF, decreased coronary arterial perfusion, or electrolyte imbalance.
6. Assess degree of peripheral and dependent edema.
Rationale: Fluids shift into tissues as a result of sodium and water retention, decreased albumin, and increased antidiuretic hormone (ADH).
7. Measure abdominal girth.
Rationale: Reflects accumulation of fluid or ascites resulting from loss of plasma proteins and fluid into peritoneal space. Note: Excessive fluid accumulation can reduce circulating volume, resulting in hypotension and dehydration.
8. Encourage bedrest when ascites is present.
Rationale: May promote recumbency-induced diuresis.
9. Provide frequent mouth care and occasional ice chips, particularly if NPO; schedule fluid intake around the clock.
Rationale: Decreases sensation of thirst, especially when fluid intake is restricted.
10. Monitor serum albumin and electrolytes, particularly potassium and sodium.
Rationale: Decreased serum albumin affects plasma colloid osmotic pressure, resulting in edema formation. Reduced renal blood flow, accompanied by elevated ADH and aldosterone levels and the use of diuretics to reduce total body water, may cause various electrolyte shifts and imbalances.