Nursing diagnosis: excess Fluid Volume related to excess fluid or sodium intake; compromised regulatory mechanism
Possibly evidenced by
Signs and symptoms noted in database
Desired Outcomes/Evaluation Criteria—Client Will
Fluid Overload Severity
Demonstrate stabilized fluid volume as evidenced by balanced intake and output (I&O), vital signs within client’s normal range, stable weight, and absence of signs of edema.
Knowledge: Treatment Regimen
Verbalize understanding of individual dietary and fluid restrictions.
Demonstrate behaviors to monitor fluid status and prevent or limit recurrence.
Nursing intervention with rationale:
1. Monitor vital signs as well as CVP, if available.
Rationale: Tachycardia and hypertension are common manifestations. Tachypnea usually present with or without dyspnea. Elevated CVP may be noted before dyspnea and adventitious breath sounds occur. Hypertension may be a primary disorder or occur secondary to other associated conditions such as HF.
2. Auscultate lung and heart sounds.
Rationale: Adventitious sounds (crackles) and extra heart sounds (S3) are indicative of fluid excess, possibly resulting in rapid development of pulmonary edema.
3. Assess for presence and location of edema formation.
Rationale: Edema can be either a cause or a result of various pathological conditions reflecting four competing forces: blood hydrostatic and osmotic pressures and interstitial fluid hydrostatic and osmotic pressures. The dynamic interaction of these four forces allows fluid to shift from one body compartment to another. Edema may be generalized or localized in dependent areas. Elderly clients may develop dependent edema with relatively little excess fluid.
4. Note presence of neck and peripheral vein distention, along with pitting edema, and dyspnea.
Rationale: Signs of cardiac decompensation and HF.
5. Maintain accurate I&O. Note decreased urinary output and positive fluid balance on 24-hour calculations.
Rationale: Maintain accurate I&O. Note decreased urinary output and positive fluid balance on 24-hour calculations.
6. Weigh, as indicated. Be alert for acute or sudden weight gain.
Rationale: One liter of fluid retention equals a weight gain of 1 kilogram (2.2 pounds).
7. Give oral fluids with caution. If fluids are restricted, set up a 24-hour schedule for fluid intake.
Rationale: Fluid restrictions, as well as extracellular shifts, can aggravate drying of mucous membranes, and client may desire more fluids than are prudent.
8. Monitor infusion rate of parenteral fluids closely; administer via control device, as necessary.
Rationale: Rapid fluid bolus or prolonged excessive administration potentiates volume overload and risk of cardiac decompensation.
9. Provide safety precautions as indicated, such as use of side rails, bed in low position, frequent observation, and soft restraints, if required.
Rationale: Fluid shifts may cause cerebral edema and changes in mentation, especially in the geriatric population. Note: Use of restraints may increase agitation and can pose a safety threat.
10. Administer diuretics: loop diuretic such as furosemide (Lasix), thiazide diuretic such as hydrochlorothiazide (Esidrix), or potassium-sparing diuretic such as spironolactone (Aldactone).
Rationale: To achieve excretion of excess fluid, either a single thiazide diuretic or a combination of agents may be selected, such as thiazide and spironolactone. The combination can be particularly helpful when two drugs have different sites of action, allowing more effective control of fluid excess.