Nursing Diagnosis: Excess Fluid volume Application of NANDA, NOC, NIC

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).