Nursing Diagnosis: Excess Fluid volume

Betty J. Ackley and Martha A. Spies

NANDA Definition: Increased isotonic fluid retention

Defining Characteristics: Jugular vein distention;

decreased hemoglobin and hematocrit; weight gain over short
period; changes in respiratory pattern, dyspnea or shortness
of breath; orthopnea; abnormal breath sounds (rales or
crackles); pulmonary congestion; pleural effusion; intake
exceeds output; S3 heart sound; change in mental status;
restlessness; anxiety; blood pressure changes; pulmonary
artery pressure changes; increased central venous pressure;
oliguria; azotemia; specific gravity changes; altered
electrolytes; edema, may progress to anascara; positive
hepatojugular reflex

Related Factors: Compromised regulatory mechanism;

excess fluid intake; excess sodium intake

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Electrolyte and Acid-Base Balance

Fluid Balance

Hydration

Client Outcomes

Remains free of edema, effusion, anascara;

weight appropriate for client

Maintains clear lung sounds; no evidence of

dyspnea or orthopnea

Remains free of jugular vein distention,

positive hepatojugular reflex, and gallop heart
rhythm
 Maintains normal central venous pressure,
pulmonary capillary wedge pressure, cardiac
output, and vital signs

Maintains urine output within 500 ml of intake

and normal urine osmolality and specific gravity

Remains free of restlessness, anxiety, or

confusion

Explains measures that can be taken to treat

or prevent excess fluid volume, especially fluid
and dietary restrictions and medications

Describes symptoms that indicate the need to

consult with health care provider

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Fluid Management

Fluid Monitoring

Nursing Interventions and Rationales

Monitor location and extent of edema; use a

millimeter tape in the same area at the same time
each day to measure edema in extremities. Heart
failure and renal failure are usually associated
with dependent edema because of increased
hydrostatic pressure; dependent edema will cause
swelling in the legs and feet of ambulatory clients
and the presacral region of clients on bed rest.
Dependent edema was found to demonstrate the
greatest sensitivity as a defining characteristic for
excess fluid volume (Rios et al, 1991).
Generalized edema (e.g., in the upper extremities
and eyelids) is associated with decreased oncotic
 pressure as a result of nephrotic syndrome.
Measuring the extremity with a millimeter tape is
more accurate than using the 1 to 4 scale
(Metheny, 2000).

Monitor daily weight for sudden increases;

use same scale and type of clothing at same time
each day, preferably before breakfast. Body
weight changes reflect changes in body fluid
volume. Clinically it is extremely important to get
an accurate body weight of a client with fluid
imbalance (Metheny, 2000).

Monitor lung sounds for crackles, monitor

respirations for effort, and determine the presence
and severity of orthopnea. Pulmonary edema
results from excessive shifting of fluid from the
vascular space into the pulmonary interstitial
space and alveoli. Pulmonary edema can interfere
with the oxygen-carbon dioxide exchange at the
alveolar-capillary membrane (Metheny, 2000),
resulting in dyspnea and orthopnea.

With head of bed elevated 30 to 45 degrees,

monitor jugular veins for distention in the upright
position; assess for positive hepatojugular reflex.
Increased intravascular volume results in jugular
vein distention, even in a client in the upright
position, and also a positive hepatojugular reflex.

Monitor central venous pressure, mean

arterial pressure, pulmonary artery pressure,
pulmonary capillary wedge pressure, and cardiac
output; note and report trends indicating
increasing pressures over time. Increased
vascular volume with decreased cardiac
contractility increases intravascular pressures,
which are reflected in hemodynamic parameters.
Over time, this increased pressure can result in
uncompensated heart failure.
 Monitor vital signs; note decreasing blood
pressure, tachycardia, and tachypnea. Monitor for
gallop rhythms. If signs of heart failure are
present, see nursing care plan for Decreased
Cardiac output. Heart failure results in
decreased cardiac output and decreased blood
pressure. Tissue hypoxia stimulates increased
heart and respiratory rates.

Monitor serum osmolality, serum sodium,

blood urea nitrogen (BUN)/creatinine ratio, and
hematocrit for decreases. These are all measures
of concentration and will decrease (except in the
presence of renal failure) with increased
intravascular volume. In clients with renal failure
the BUN will increase because of decreased renal
excretion.

Monitor intake and output; note trends

reflecting decreasing urine output in relation to
fluid intake. Accurately measuring intake and
output is very important for the client with fluid
volume overload.

Monitor client's behavior for restlessness,

anxiety, or confusion; use safety precautions if
symptoms are present. When excess fluid volume
compromises cardiac output, the client will
experience tissue hypoxia. Cerebral tissue is
extremely sensitive to hypoxia, and the client may
demonstrate restlessness and anxiety before any
physiological alterations occur. When the excess
fluid volume results in hyponatremia, the cerebral
function will also be altered because of cerebral
edema (Fauci et al, 1998).

Monitor for the development of conditions that

increase the client's risk for excess fluid volume.
Common causes are heart failure, renal failure,
and liver failure, all of which result in decreased
glomerular filtration rate and fluid retention. Other
 causes are increased intake of oral or IV fluids in
excess of the client's cardiac and renal reserve
levels, increased levels of antidiuretic hormone, or
movement of fluid from the interstitial space to
the intravascular space (Fauci et al, 1998). Early
detection allows the institution of specific
treatment measures before the client develops
pulmonary edema.

Provide a restricted-sodium diet as

appropriate if ordered. Restricting the sodium in
the diet will favor the renal excretion of excess
fluid. Take care to avoid hyponatremia.
Decreasing sodium can be more important that
restricting fluid intake (Fauci et al, 1998).

Monitor serum albumin level and provide

protein intake as appropriate. Serum albumin is
the main contributor to serum oncotic pressure,
which favors the movement of fluid from the
interstitial space into the intravascular space.
When serum albumin is low, peripheral edema
may be severe.

Administer prescribed loop, thiazide, and/or

potassium-sparing diuretics as appropriate; these
may be given intravenously or orally. Therapeutic
responses to diuretic therapy include natriuresis,
diuresis, elimination of edema, vasodilation,
reduction of cardiac filling pressures, decreased
renal vasculature resistance, and increased renal
blood flow (Cody, Kubo, Pickworth, 1994;
DePriest, 1997).

Monitor for side effects of diuretic therapy:

orthostatic hypotension (especially if client is also
receiving angiotensin-converting enzyme [ACE]
inhibitors) and electrolyte and metabolic
imbalances (hyponatremia, hypocalcemia,
hypomagnesemia, hyperuricemia, and metabolic
alkalosis). In clients receiving loop or thiazide
diuretics, observe for hypokalemia. Observe for
 hyperkalemia in clients receiving a potassium-
sparing diuretic, especially with the concurrent
administration of an ACE inhibitor. The blood
pressure reduction in response to ACE inhibitors is
greater in the presence of sodium depletion and
diuretic therapy. The incidence of electrolyte and
metabolic imbalances ranges from 14% to 60%;
the most common is hypokalemia (Cody, Kubo,
Pickworth, 1994).

Implement fluid restriction as ordered,

especially when serum sodium is low; include all
routes of intake. Schedule fluids around the clock,
and include the type of fluids preferred by the
client. Fluid restriction may decrease intravascular
volume and myocardial workload. Overzealous
fluid restriction should not be used because
hypovolemia can worsen heart failure. In one
study, instituting fluid restriction, distributing
fluids over a 24-hour period, and using a fluid
restriction when the client had hyponatremia all
had high intervention content validity scores for
the fluid management intervention label (Cullen,
1992). Client involvement in planning will enhance
participation in the necessary fluid restriction.

Maintain the rate of all IV infusions carefully.

This is done to prevent inadvertant exacerbation
of excess fluid volume.

Turn clients with dependent edema frequently

(i.e., at least every 2 hours). Edematous tissue is
vulnerable to ischemia and pressure ulcers
(Cullen, 1992).

Provide for scheduled rest periods. Bed rest

can induce diuresis related to diminished
peripheral venous pooling, resulting in increased
intravascular volume and glomerular filtration rate
(Metheny, 2000).
 Promote a positive body image and good self-
esteem. Visible edema may alter the client's body
image (Cullen, 1992). See the care plan for
Disturbed Body image.

Consult with physician if signs and symptoms

of excess fluid volume persist or worsen. Because
excess fluid volume can result in pulmonary
edema, it must be treated promptly and
aggressively (Fauci et al, 1998).
Geriatric

Recognize that the presence of risk factors for

excess fluid volume is particularly serious in the
elderly. Decreased cardiac output and stroke
volume are normal aging changes that increase
the risk for excess fluid volume (Metheny, 2000).

Home Care Interventions

Assess client and family knowledge of disease

process causing excess fluid volume. Teach about
disease process and complications of excess fluid
volume, including when to contact physician.
Knowledge of disease and complications promotes
early detection of and intervention for pending
problems.

Assess client and family knowledge and

compliance with medical regimen, including
medications, diet, rest, and exercise. Assist family
with integrating restrictions into daily living.
Knowledge promotes compliance. Assistance with
integration of cultural values, especially those
related to foods, with medical regimen promotes
compliance and decreased risk of complications.
 If client is confined to bed rest or has
difficulty reclining, follow previously mentioned
positioning recommendations.

Teach and reinforce knowledge of

medications. Instruct client not to use over-the-
counter medications (e.g., diet medications)
without first consulting the physician. Instruct
client to make primary physician aware of
medications ordered by other physicians. There is
potential for undesirable interaction among
multiple medications, especially when use of over-
the-counter and other prescribed medications is
not monitored.

Identify emergency plan for rapidly

developing or critical levels of excess fluid volume
when diuresing is not safe at home. When out of
control, excess fluid volume can be life
threatening.

Teach about signs and symptoms of both

excess and deficient fluid volume and when to call
physician. Fluid volume balance can change
rapidly with aggressive treatment.

Client/Family Teaching

Describe signs and symptoms of excess fluid

volume and actions to take if they occur. Teach
the importance of fluid and sodium restrictions.
Help client and family to devise a schedule for
intake of fluids throughout entire day. Refer to
dietitian concerning implementation of low-sodium
diet.

Teach how to take diuretics correctly: take

one dose in the morning and second dose (if
taken) no later than 4 PM. Adjust potassium
intake as appropriate for potassium-losing or
potassium-sparing diuretics. Note the appearance
of side effects such as weakness, dizziness,
muscle cramps, numbness and tingling, confusion,
hearing impairment, palpitations or irregular
heartbeat, and postural hypotension. Emphasise
the need to consult with health care provider
before taking over-the-counter medications
(Byers, Goshorn, 1995; Dunbar, Jacobson,
Deaton, 1998).