Excess Fluid Volume

excess fluid volume nursing care plan

Introduction/Pathophysiology [1,2,3]

Reduced glomerular filtration, decreased cardiac output, increased antidiuretic hormone production and sodium/water retention can all lead to excess fluid volume/fluid overload. Excess fluid volume may be manifested by venous engorgement and edema formation. Peripheral edema begins in feet/ankles and ascends as failure worsens. Excess fluid volume often leads to pulmonary congestions and pulmonary edema. Excess Fluid Volume Nursing Diagnosis and the Excess Fluid Volume Nursing Care Plan are a crucial part of providing wholesome care for clients.

Causes[1,2]

  • Renal impairment
  • Decreased cardiac output
  • Heart failure
  • Increased antidiuretic hormone production
  • Diet high in sodium

Symptoms[1,2]

Subjective (client may report)

  • shortness of breath
  • weight gain
  • swelling
  • abdominal pain
  • nausea

Objective[1,2]

  • weight gain
  • decreased hemoglobin and hematocrit (Hct)
  • oliguria
  • edema
  • pleural effusion
  • orthopnea
  • changes in heart sounds
  • pulmonary congestion
  • JVD
  • positive hepatojugular reflux
  • respiratory distress, abnormal breath sounds
  • changes in mental status
  • BP changes
  • pulmonary artery pressure changes
  • pulmonary edema
  • altered electrolytes
  • anxiety, restlessness
  • increased central venous pressure
  • positive hepatojugular reflux
  • ascites
  • fluid and electrolyte imbalance

Risk factors[1,2]:

  • Hypertension
  • Recent/acute MI
  • Heart failure
  • Presence of kidney disease
  • Compromised regulatory systems
  • Excess sodium intake
  • Excess fluid intake

Intervention[1]

Assessment[1]

Collect client history, including risk factors and symptoms (objective and subjective data)

Cardiac Function:

  • BP and pulse
  • Central venous pressure (if available)

Respiratory function

  • Shortness of breath
  • Cough
  • Pulmonary x-ray

Neurologic/Sensory function

  • Altered mental status
  • Anxiety
  • Restlessness

Visual appearance/labs

  • Edema
  • Ascites
  • Anorexia
  • Skin surface/integrity
  • Urine color
  • Electrolyte imbalance (Na, K)
  • Decreased hematocrit
  • Changes in renal function tests

Excess Fluid Volume Nursing Diagnosis[1]

Assessment of client response to activity

  • Assess for distended neck and peripheral vessels
  • Inspect dependent body areas for edema with and without pitting
    • Pitting edema is generally obvious only after 10lbs weight gain
  • Note presence of generalized body edema; anasarca
  • Inspect skin surface/integrity
  • Bowel sounds
  • Measure abdominal girth, as indicated
  • Palpate abdomen
    • Note reports of right upper quadrant/tenderness

Rationale: 

  • Urine output may be scanty and concentrated because of decreased renal perfusion
  • Diuretic therapy may result in sudden fluid decrease-respite edema remaining
  • A weight gain of 5lbs represents about 2L of fluid excess
    • Weight gain 2% or greater in short time
  • Edema formation, slowed circulation and prolonged immobility can affect skin integrity
  • Pulmonary edema may develop more rapidly, and immediate intervention is necessary
  • Visceral congestion can alter gastric function

Planning[1,2]

  • Reduce fluid volume overload
  • Prevent complications
  • Provide information about disease/prognosis, therapy needs, and prevention of recurrences
  • Client education

Excess Fluid Volume Nursing Care Plan[1,2]

Perform:

  • Weight in daily- document changes in weight in response to therapy for edema
  • Frequent position changes in bed, elevate feet when sitting

Provide:

  • Fluid intake schedule if fluids are medically restricted, incorporate beverage preferences if possible
  • Frequent mouth care and ice chips
  • Assistance with Rotation of tourniquets/phlebotomy, dialysis, or ultrafiltration

Administer:

  • Diuretics, thiazides with potassium sparing agents, potassium supplements

Monitor:

  • Urine output, noting amount, color, time of day diuresis occurs
  • 24-hour intake and output (I&O)
  • Reports of sudden extreme dyspnea/air hunger
  • Cognitive level; anxiousness, panic, impending doom
  • Central venous pressure(CVP) if available
  • Blood pressure
  • Chest X-ray

Avoid:

  • large volume intravenous medications, consult pharmacist how to prevent excessive fluid administration of IV medications

Encourage:

  • Bed rest and sitting in semi-Fowler’ position during acute phases
  • Engaging client in therapy regimen as it may enhance sense of control and cooperation with restrictions
  • Verbalization of feelings regarding limitations
  • Small frequent meals to enhance digestion and prevent abdominal discomfort
  • Maintaining fluid/sodium restrictions
  • Consultation with dietitian

Goals and Outcomes[1,2]

  • Client demonstrates stabilized fluid volume with balanced intake and output
  • Breath sounds are clear
  • Vital signs within acceptable range
  • Stable weight
  • Absence of edema
  • Client understands fluid and dietary restrictions
  • BP within normal range
  • BUN and Hct within normal limitations
  • Usual mental status

Post intervention evaluation/monitoring [1]

Monitor[1]

  • Cardiac rate and BP
  • Renal function-BUN, CrCl
  • Liver function-AST, ALT
  • Weight
  • Edema
  • Electrolytes: sudden fluid shifts may lead to sodium and potassium imbalance/deficiency
  • Mental status
  • Intake and output
  • CVP readings

Future goals [1]

  • Prevent reoccurrence
  • Initiate supportive medication therapy
  • maintain healthy diet and weight goal

Prevention[1,2,3]

  • Promote healthy lifestyle
  • Educate about fluid and sodium intake

Supplemental material

Client case

Client presents to the emergency department with the chief complaint of peripheral edema, shortness of breath at rest and recent weight gain of about 10lbs. Client has history of stage 2 chronic kidney disease, heart failure, hypertension, is obese and drinks 3-4 alcoholic beverages per day.

Questions: 

Based on the client case, what are the symptoms predictive of excess fluid volume?

Answer: weight gain, SOB, peripheral edema

When treating clients experiencing fluid excess volume, providers should avoid administration of:

  1. diuretics
  2. thiazides
  3. high volume IV drugs
  4. Potassium supplements

Excess in fluid volume is often associated with:

  1. Decrease in hemoglobin
  2. Increase in hemoglobin
  3. Increase in CrCl
  4. Weight loss

Clients with edema are at risk for:

  1. Altered gastric function
  2. Pulmonary congestion
  3. Impaired skin integrity
  4. Altered mental status
  5. All of the above

List at least 3 tips for preventing fluid overload

  1. Decrease the amount of sodium in your diet
  2. Eliminate alcoholic beverages
  3. Treat underlying conditions, high blood pressure
  4. Take your medications daily
  5. When choosing fluids, choose water and unsweetened beverages

References:

  1. Doenges, Marilynn E., et al. Nursing Care Plans: Guidelines for Individualizing Client Care. F.A. Davis, 2006.
  2. Haugen, Nancy, et al. Ulrich & Canale’s Nursing Care Planning Guides: Prioritization, Delegation, and Critical Reasoning. Elsevier, 2020.
  3. Assis, Cinthia Calsinski de, and Alba Botura Leite de Barros. “Nursing Diagnoses in Clients With Congestive Heart Failure.” Wiley Online Library, John Wiley & Sons, Ltd, 25 July 2008, onlinelibrary.wiley.com/doi/abs/10.1111/j.1744-618X.2003.001.x.