Nursing Care Plan for Nursing Diagnosis of Excess Fluid Volume

Excess fluid volume, also known as hypervolemia or fluid overload, is a condition where the body retains too much fluid. This occurs when fluid intake exceeds fluid output, or when the body’s mechanisms for regulating fluid balance are compromised. While mild hypervolemia can be temporary and benign, often linked to hormonal changes or high sodium intake, significant fluid overload is usually indicative of underlying health issues such as heart failure, kidney failure, or liver cirrhosis. Understanding the causes, symptoms, and appropriate nursing interventions is crucial for effective patient care.

Causes (Related Factors)

Excess fluid volume can stem from various factors that disrupt the body’s fluid balance. Common causes include:

• Underlying Diseases: Conditions like heart failure, kidney failure, and liver cirrhosis are primary culprits as they impair the body’s ability to regulate fluid.
• Syndrome of Inappropriate Antidiuretic Hormone (SIADH): This condition leads to excessive water retention due to hormonal imbalances.
• Excessive Fluid Intake: Overly aggressive fluid administration, either orally or intravenously, can lead to fluid overload, especially in patients with compromised regulatory systems.
• High Sodium Intake: Sodium causes the body to retain water, and excessive sodium consumption can contribute to fluid volume excess.
• Steroid Use: Corticosteroids can cause fluid and sodium retention as a side effect.
• Hormonal Imbalances: Hormonal fluctuations, particularly those related to antidiuretic hormone and aldosterone, can affect fluid balance.
• Malnutrition: While seemingly counterintuitive, certain forms of malnutrition, particularly protein deficiency, can lead to fluid shifts and edema due to decreased oncotic pressure.

Signs and Symptoms (Defining Characteristics)

Recognizing the signs and symptoms of excess fluid volume is vital for prompt intervention. These indicators can be categorized as subjective (patient-reported) and objective (nurse-assessed) data:

Subjective Data (Patient Reports)

• Dyspnea (Difficulty breathing): Patients may experience shortness of breath or labored breathing due to fluid accumulation in the lungs.
• Anxiety: Fluid overload can cause discomfort and anxiety related to breathing difficulties and overall physiological stress.
• Weight Gain and Swelling: Noticeable weight gain over a short period and swelling in extremities are common patient-reported symptoms.

Objective Data (Nurse Assessment)

• Shortness of Breath: Observable signs include orthopnea (difficulty breathing when lying down), dyspnea, and an increased respiratory rate (tachypnea).
• Adventitious Breath Sounds: Auscultation may reveal abnormal lung sounds like rales or crackles, indicating fluid in the alveoli.
• Abnormal Electrolyte Levels: Dilutional hyponatremia (low sodium) and other electrolyte imbalances can occur due to fluid excess.
• Hypertension (High Blood Pressure): Increased fluid volume can lead to elevated blood pressure.
• Edema: Peripheral edema, particularly pitting edema in the extremities (legs, ankles, feet, hands, arms), is a hallmark sign. Ascites (fluid accumulation in the abdominal cavity) may also be present, especially in liver disease.
• Change in Mental Status: Confusion, restlessness, and altered mental status can arise from fluid overload affecting brain function.
• Restlessness: General unease and restlessness can be associated with the physiological discomfort of fluid overload.
• Decreased Hemoglobin and Hematocrit: Dilution of blood components can lead to decreased hemoglobin and hematocrit levels.
• Increased Central Venous Pressure (CVP): Elevated CVP indicates increased fluid volume in the vascular system.
• Jugular Vein Distention (JVD): Visible distention of the jugular veins in the neck is another sign of increased fluid volume.
• Oliguria: While seemingly contradictory, in some cases of fluid overload, especially related to kidney dysfunction, urine output may decrease (oliguria) as the kidneys struggle to excrete excess fluid.
• Tachycardia: The heart may beat faster (tachycardia) to compensate for the increased circulatory volume.
• Pulmonary Congestion/Edema: Chest X-rays or other imaging may show signs of pulmonary congestion or edema, confirming fluid accumulation in the lungs.

Expected Outcomes

The overarching goals in managing excess fluid volume are to restore fluid balance and alleviate associated symptoms. Expected outcomes for patients with excess fluid volume include:

• Restoration of Normal Fluid Volume: Patient will demonstrate balanced fluid volume, evidenced by stable intake and output.
• Absence of Edema and Sudden Weight Gain: Patient will exhibit no signs of edema or rapid weight fluctuations.
• Clear Breath Sounds and Normal Respiratory Rate: Patient will present with clear lungs upon auscultation and a normal respiratory rate and pattern.
• Understanding of Fluid Restrictions: If fluid restrictions are prescribed, the patient will verbalize comprehension of their importance.
• Self-Monitoring for Fluid Overload: Patient will articulate how to recognize and monitor for signs of excess fluid volume.

Nursing Assessment

A comprehensive nursing assessment is the cornerstone of managing excess fluid volume. This involves gathering both subjective and objective data to identify the extent of fluid overload and guide interventions. Key assessment components include:

1. Identify Potential Underlying Causes:

• Assess the patient’s medical history for pre-existing conditions such as heart failure, kidney disease, liver disease, and SIADH, as these are strongly linked to fluid volume excess.

2. Monitor Intake and Output (I&O):

• Accurately measure and document all fluid intake (oral, intravenous, enteral) and output (urine, liquid stool, emesis, drainage). Compare intake and output over 24 hours to identify fluid balance discrepancies. For patients with urinary catheters, hourly urine output monitoring is crucial in acute settings.

3. Monitor Vital Signs:

• Regularly assess blood pressure, heart rate, and respiratory rate. Elevated blood pressure, tachycardia, and tachypnea can be early indicators of fluid overload.

4. Auscultate Lung Sounds:

• Assess breath sounds for adventitious sounds, particularly crackles (rales), which suggest pulmonary congestion due to fluid accumulation in the lungs.

5. Assess for Edema and Weight Changes:

• Evaluate for peripheral edema, noting the location, extent, and degree of pitting (if present). Daily weight monitoring is essential; rapid weight gain is a sensitive indicator of fluid retention. In patients with liver disease, assess for ascites by measuring abdominal girth.

6. Palpate Peripheral Pulses:

• Assess peripheral pulses for strength and quality. Bounding pulses can indicate increased fluid volume within the vascular system.

7. Review Laboratory Values:

• Monitor relevant laboratory values, including serum electrolytes (sodium, potassium), serum osmolality, hematocrit, blood urea nitrogen (BUN), and creatinine. Dilutional hyponatremia, decreased serum osmolality, and decreased hematocrit can be associated with fluid overload. BUN and creatinine levels help assess kidney function, which is crucial in fluid regulation.

Nursing Interventions

Nursing interventions for excess fluid volume aim to promote fluid excretion, manage symptoms, and prevent complications. Key interventions include:

1. Implement and Educate on Fluid Restrictions:

• If prescribed, strictly adhere to fluid restrictions. Educate the patient and family about the rationale for fluid restriction and strategies for managing thirst and adhering to the plan.

2. Maintain Accurate Intake and Output Records:

• Meticulously record all fluid intake and output to monitor fluid balance and the effectiveness of interventions.

3. Monitor Daily Weights:

• Obtain daily weights at the same time each day, using the same scale, and with the patient wearing similar clothing. This provides a reliable measure of fluid status changes.

4. Patient and Family Education on Recognizing Fluid Overload:

• Teach patients and their families to recognize early signs of fluid overload, such as swelling in extremities, shortness of breath, orthopnea, rapid weight gain (e.g., 2 pounds in 24 hours or 5 pounds in a week), and changes in mental status. Emphasize the importance of reporting these symptoms promptly.

5. Administer Diuretics as Prescribed:

• Administer diuretic medications as ordered by the physician. Monitor blood pressure and urine output closely, especially after diuretic administration. Diuretics promote fluid excretion by the kidneys.

6. Review and Implement Dietary Restrictions:

• Implement and educate patients on sodium-restricted diets as prescribed. Provide guidance on reading food labels, avoiding high-sodium foods (processed, fast foods, frozen meals), and using salt substitutes cautiously.

7. Dietary Consultation:

• If dietary management is challenging or the patient requires more specialized nutritional guidance, consult with a registered dietitian for comprehensive nutritional assessment and individualized meal planning.

8. Provide Oral Hygiene:

• Offer frequent oral care, including mouth swabs and mouthwash, as fluid restrictions can lead to dry mouth and discomfort.

9. Assist with Therapeutic Procedures:

• Prepare and assist with procedures like paracentesis (fluid removal from the abdomen) for ascites or dialysis for patients with kidney failure to remove excess fluid and waste products.

10. Positioning and Skin Care:

• Position patients in Semi-Fowler’s or High-Fowler’s position as tolerated to promote lung expansion and ease breathing. Reposition patients at least every two hours and elevate edematous extremities to enhance venous return and reduce edema. Provide meticulous skin care, as edema increases the risk of skin breakdown.

Nursing Care Plans Examples

Here are examples of nursing care plans for excess fluid volume, tailored to different underlying causes:

Care Plan #1: Excess Fluid Volume related to Inadequate Lymphatic Drainage

Diagnostic Statement: Excess fluid volume related to inadequate lymphatic drainage secondary to mastectomy as evidenced by edema in the affected arm.

Expected Outcomes:

• Patient will demonstrate reduced or absent edema in the affected arm.
• Patient will verbalize understanding of measures to manage and prevent post-mastectomy lymphedema.

Assessments:

1. Monitor Edema: Regularly assess the affected arm for edema, noting the location, extent, and grade (trace to severe). Utilize tape measurements to track changes in limb circumference.
2. Assess for Infection: Monitor for signs and symptoms of infection in the affected limb, such as fever, warmth, redness, pain, and swelling, as lymphedema increases infection risk.

Interventions:

1. Lymphedema Management: Implement lymphedema management techniques, including compression bandages or garments, manual lymphatic drainage (if prescribed), and elevation of the affected arm above heart level to promote fluid drainage.
2. Avoid Procedures on Affected Arm: Avoid blood pressure measurements, venipunctures, and injections in the affected arm whenever possible to minimize trauma and infection risk. Use the contralateral arm for these procedures unless absolutely necessary.
3. Range of Motion (ROM) Exercises: Encourage and assist the patient with ROM exercises for the affected arm to improve lymphatic drainage and circulation.
4. Patient Education on Lymphedema Prevention: Educate the patient on long-term measures to prevent trauma and infection in the affected arm:
   • Wash the skin daily with mild soap and water.
   • Avoid cutting cuticles or picking at nails.
   • Apply moisturizing lotion to prevent dryness and cracking.
   • Use an electric razor for shaving underarms.
   • Wear sunscreen and insect repellent to prevent sunburn and bites.
   • Contact healthcare provider for any cuts, bites, or signs of infection.

Care Plan #2: Excess Fluid Volume related to Protein Malnutrition

Diagnostic Statement: Excess fluid volume related to low protein intake as evidenced by generalized edema.

Expected Outcomes:

• Patient will exhibit improvement in nutritional status and reduction of malnutrition symptoms.
• Patient will demonstrate resolution of edema related to protein deficiency.
• Patient will adhere to a balanced meal plan to maintain adequate protein intake.

Assessments:

1. Dietary History: Obtain a detailed dietary history, focusing on protein intake and eating habits, to identify protein deficiency as a contributing factor to edema.
2. Assess Malnutrition Complications: Assess for other complications of malnutrition, such as hypoglycemia, hypothermia, dehydration, electrolyte imbalances, and micronutrient deficiencies.

Interventions:

1. Treat Malnutrition Complications: Address immediate complications of malnutrition, such as hypoglycemia and dehydration, with appropriate medical interventions, including cautious refeeding to prevent refeeding syndrome.
2. Correct Electrolyte Imbalances: Monitor and correct electrolyte imbalances as indicated, often through electrolyte replacement formulas or intravenous therapy in severe cases.
3. Provide and Educate on Balanced Meal Plan: Collaborate with a dietitian to develop a balanced meal plan with adequate protein, calories, and micronutrients to address malnutrition and fluid imbalance. Educate the patient on the importance of protein intake and provide dietary guidance.
4. Dietitian Consultation: Refer to a registered dietitian for comprehensive nutritional assessment, individualized meal planning, and ongoing dietary counseling.

Care Plan #3: Excess Fluid Volume related to Chronic Renal Failure

Diagnostic Statement: Excess fluid volume related to compromised fluid regulatory mechanisms secondary to chronic renal failure as evidenced by imbalanced intake and output and edema.

Expected Outcomes:

• Patient will maintain a urine output of at least 0.5 mL/kg/hr with normal urine osmolality and specific gravity (or within patient’s baseline in chronic kidney disease).
• Patient will exhibit reduced or absent edema and effusions.
• Patient will adhere to prescribed fluid and dietary restrictions.

Assessments:

1. Daily Weight Monitoring: Monitor daily weight for sudden increases, using consistent methods and timing.
2. Intake and Output Monitoring: Accurately monitor and document intake and output, noting trends in urine output relative to fluid intake.
3. Laboratory Value Monitoring: Regularly monitor serum and urine osmolality, serum sodium, BUN/creatinine ratio, estimated glomerular filtration rate (eGFR), and hematocrit to assess renal function and fluid status.

Interventions:

1. Renal Diet: Implement a renal diet as prescribed, typically including restrictions in sodium, potassium, protein, and phosphorus, tailored to the individual patient’s needs and stage of renal failure.
2. Administer Diuretics: Administer prescribed diuretics, ensuring adequate blood pressure before administration and monitoring blood pressure and urine output post-administration.
3. Fluid Restriction: Implement fluid restrictions as ordered, distributing fluid allowance throughout the day and considering patient preferences for fluid types.
4. Positioning and Skin Care for Edema: Turn patients with dependent edema at least every 2 hours and provide meticulous skin care to prevent skin breakdown.
5. Prepare for Hemodialysis: Prepare the patient for hemodialysis if necessary, providing education about the procedure and monitoring for dialysis-related complications.

References

1. Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
2. Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
3. Cleveland Clinic. (2023). Kwashiorkor. https://my.clevelandclinic.org/health/diseases/23099-kwashiorkor
4. Daily Weights. (n.d.). American Association of Heart Failure Nurses. https://www.aahfn.org/mpage/dailyweights
5. Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
6. Fluid Excess/Intoxication. (n.d.). Physiopedia. https://www.physio-pedia.com/Fluid_Excess/Intoxication
7. Gillespie, T. C., Sayegh, H. E., Brunelle, C. L., Daniell, K. M., & Taghian, A. G. (2018). Breast cancer-related lymphedema: risk factors, precautionary measures, and treatments. Gland surgery, 7(4), 379–403. https://doi.org/10.21037/gs.2017.11.04
8. Gulanick, M. & Myers, J.L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
9. Herdman, T. H., Kamitsuru, S., & Lopes, C. (Eds.). (2024). NANDA-I International Nursing Diagnoses: Definitions and Classification, 2024-2026. Thieme. 10.1055/b000000928
10. Lewis, S. (2020, December 4). Hypervolemia (Fluid Overload). Healthgrades. https://www.healthgrades.com/right-care/symptoms-and-conditions/hypervolemia-fluid-overload
11. Mayo Clinic. (2023). Edema. https://www.mayoclinic.org/diseases-conditions/edema/diagnosis-treatment/drc-20366532
12. Mehrara, B. (2023). Patient education: Lymphedema after cancer surgery (beyond the basics). Uptodate. https://www.uptodate.com/contents/lymphedema-after-cancer-surgery-beyond-the-basics#H3705030