Nursing Diagnosis Fluid Volume Excess
Excess fluid volume related to decreased glomerular filtration rate (decrease in cardiac output) and the retention of sodium / water.
Characterized by:
Orthopnea, S3 heart sound, oliguria, edema, weight gain, hypertension, respiratory distress, abnormal heart sounds.
Objectives / evaluation criteria:
Clients will be demonstrating the stable fluid volume with the balance of inputs and expenditures, breath sounds clean / clear, vital signs within an acceptable range, stable weight and no edema, fluid restriction expressed understanding of the individual.
Nursing Interventions Volume Excess Fluid:
Monitor urine output, record the number and color of the time in which diuresis occurs.
Rational: Spending a little and concentrated urine may be due to decreased renal perfusion. Supine position so that helps diuresis of urine may be increased during bed rest.
Monitor / calculate the balance of income and expenditure for 24 hours.
Rational: diuretic therapy may be caused by a sudden loss of fluid / redundant (hypovolaemia), although edema / ascites is still there.
Keep sitting or bed rest with semifowler position during the acute phase.
Rationale: The position is increasing kidney filtration thus improving diuresis.
Monitor blood pressure and CVP (if any).
Rational: Hypertension and increased CVP indicates fluid overload and may indicate an increase in pulmonary congestion, heart failure.
Assess bowel sounds. Record complaints of anorexia, nausea, abdominal distension and constipation.
Rational: visceral congestion can interfere with the function of gastric / intestinal tract.
Administration of drugs as indicated (collaboration)
Consult with the dietitian.
Rational: to provide an acceptable diet that meets client needs calories in sodium restriction.
Source : http://nursing-diagnosis-nanda.blogspot.com/2011/10/nursing-diagnosis-interventions-for.html
