Nursing Diagnosis - Interventions for Excess Fluid Volume
Nursing Diagnosis 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 Excess Fluid Volume :
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.
Nursing Diagnosis 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 Excess Fluid Volume :
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.
