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EXCESS FLUID VOLUME Nursing Care Plan

Excess Fluid Volume

NANDA-I Definition
Increased isotonic fluid retention
Defining Characteristics
Major (Must Be Present, One or More)
Edema (peripheral, sacral)
Taut, shiny skin
Minor (May Be Present)
Intake greater than output
Weight gain
Related Factors
Pathophysiologic
Related to compromised regulatory mechanisms secondary to:
Renal failure (acute or chronic)
Systemic and metabolic abnormalities
Endocrine dysfunction
Lipedema
Related to portal hypertension, lower plasma colloidal osmotic pressure,
and sodium retention secondary to:
Liver disease
Cirrhosis
Ascites
Cancer
Related to venous and arterial abnormalities secondary to:
Varicose veins
Phlebitis
Infection
Peripheral vascular disease
Immobility
Trauma
Thrombus
Lymphedema
Neoplasms
Treatment Related
Related to sodium and water retention secondary to corticosteroid
therapy
Related to inadequate lymphatic drainage secondary to mastectomy
Situational (Personal, Environmental)
Related to excessive sodium intake/fluid intake
Related to low protein intake:
Fad diets Malnutrition
Related to dependent venous pooling/venostasis secondary to:
Standing or sitting for long periods
Immobility
Tight cast or bandage
Related to venous compression from pregnant uterus
Maturational
Older Adult
Related to impaired venous return secondary to increased peripheral
resistance and decreased efficiency of valves

Author's Notes
Excess Fluid Volume is frequently used to describe pulmonary edema,
ascites, or renal failure. These are all collaborative problems that should
not be renamed as Excess Fluid Volume. Refer to http://thePoint.lww.com/
CarpenitoHB14e for collaborative problems related to renal failure, pulmonary
edema, and hepatic dysfunction. This diagnosis represents a situation
for which nurses can prescribe if the focus is on peripheral edema.
Nursing interventions center on teaching the client or family how to
minimize edema and protect tissue.

Goals
The client will exhibit decreased edema (specify site), as evidenced
by the following indicators:
• Relate causative factors.
• Relate methods of preventing edema.

Interventions
Identify Contributing and Causative Factors
Refer to Related Factors.
Reduce or Eliminate Causative and Contributing Factors
Improper Diet
• Assess dietary intake and habits that may contribute to fluid
retention.
• Be specific; record daily and weekly intake of food and fluids.
• Assess weekly diet for inadequate protein or excessive sodium
intake.
• Discuss likes and dislikes of foods that provide protein.
• Teach the client to plan a weekly menu that provides protein
at an affordable price.
• Teach the client to decrease salt intake.
• Read labels for sodium content.
• Avoid convenience and canned and frozen foods.
• Cook without salt; use spices (lemon, basil, tarragon, mint)
to add flavor.
• Use vinegar in place of salt to flavor soups, stews, etc.
(e.g., 2 to 3 teaspoons of vinegar per 4 to 6 quarts, according
to taste).
• Ascertain whether the client may use salt substitute (caution
that he or she must use the exact substitute prescribed).
Dependent Venous Pooling
• Assess for evidence of dependent venous pooling or venous
stasis.
• Encourage alternating periods of horizontal rest (legs elevated)
with vertical activity (standing); this may be contraindicated in
congestive heart failure.
• Keep the edematous extremity elevated above the level of
the heart whenever possible (unless contraindicated by heart
failure).
• Keep the edematous arms elevated on two pillows or with IV
pole sling.
• Elevate the legs whenever possible, using pillows under them
(avoid pressure points, especially behind the knees).
• Discourage leg and ankle crossing.
• Reduce constriction of vessels.
• Assess clothing for proper fit and constrictive areas.
• Instruct the client to avoid panty girdles/garters, knee-high
stockings, and leg crossing and to practice elevating the legs
when possible.
• Consider using antiembolism stockings or Ace bandages;
measure
the legs carefully for stockings/support hose.*
• Measure circumference of the calf and thigh. Consider both
measurements when choosing stockings, matching measurements
with a size requirement chart that accompanies the
stockings.
• Apply stockings while lying down (e.g., in the morning before
arising).
• Check extremities frequently for adequate circulation and
evidence of constrictive areas.
Venous Pressure Points
• Assess for venous pressure points associated with casts, bandages,
and tight stockings.
• Observe circulation at edges of casts, bandages, and stockings.
• For casts, insert soft material to cushion pressure points at
the edges.
• Check circulation frequently.
• Shift body weight in the cast to redistribute weight within
(unless contraindicated).
• Encourage client to do this every 15 to 30 minutes while
awake to prevent venostasis.
• Encourage wiggling of fingers or toes and isometric exercise
of unaffected muscles within the cast.
• If the client cannot do this alone, assist him or her at least
hourly to shift body weight.
• See Impaired Physical Mobility.
Inadequate Lymphatic Drainage
• Keep the extremity elevated on pillows.
• If the edema is marked, the arm should be elevated but not
in adduction (this position may constrict the axilla).
• The elbow should be higher than the shoulder.
• The hand should be higher than the elbow.
• Measure blood pressure in the unaffected arm.
• Do not give injections or start IV fluids in the affected arm.
• Protect the affected limb from injury.
• Teach the client to avoid using strong detergents, carrying
heavy bags, holding cigarettes, injuring cuticles or hangnails,
reaching into hot ovens, wearing jewelry or a wristwatch, or
using Ace bandages.
• Advise the client to apply lanolin or a similar cream, often
daily, to prevent dry, flaky skin.
• Encourage the client to wear a Medic-Alert tag engraved with
Caution: lymphedema arm—no tests/no needle injections.
• Caution the client to visit a physician if the arm becomes red,
swollen, or unusually hard.
• After a mastectomy, encourage range-of-motion (ROM) exercises
and use of the affected arm to facilitate development of a
collateral lymphatic drainage system (explain that lymphedema
often decreases within 1 month, but that the client should
continue massaging, exercising, and elevating the arm for 3 to
4 months after surgery).
Immobility/Neurologic Deficit
• Plan passive or active ROM exercises for all extremities every
4 hours, including dorsiflexion of the foot to massage veins.
• Change the client’s position at least every 2 hours, using the
four positions (left side, right side, back, abdomen) if not
contraindicated
(see Impaired Skin Integrity).
• If the client must remain in high Fowler’s position, assess for
edema of buttocks and sacral area; help the client shift body
weight every 2 hours to prevent pressure on edematous tissue.
Protect Edematous Skin From Injury
• Inspect skin for redness and blanching.
• Reduce pressure on skin areas; pad chairs; use knee-high stockings
and footstools.
• Prevent dry skin.
• Use soap sparingly.
• Rinse off soap completely.
• Use a lotion to moisten skin.
• See Impaired Skin Integrity for additional information about
preventing injury.
Initiate Health Teaching and Referrals, as Indicated
• Give clear verbal and written instructions for all medications:
what, when, how often, why, side effects; pay special attention
to drugs that directly influence fluid balance (e.g., diuretics,
steroids).
• Write down instructions for diet, activity, and use of Ace bandages,
stockings, and so forth.
• Have the client demonstrate the instructions.
• With severe fluctuations in edema, have the client weigh himself
or herself every morning and before bedtime daily; instruct
the client to keep a written record of weights. For less severe
illness, the client may need to weigh him or herself only once
daily and record the weight.
• Caution the client to call a physician for excessive edema/
weight gain (greater than 2 lb/day) or increased shortness of
breath at night or upon exertion. Explain that these signs may
indicate early heart problems and may require medication to
prevent them from worsening.
• Consider home care or visiting nurses referral to follow at
home.
• Provide literature concerning low-salt diets; consult with a
dietitian if necessary.
Maternal Interventions
• Explain the cause of edema of ankles and fingers.
• Advise the client to limit salt intake moderately (e.g., eliminate
processed meats, chips) and to maintain water intake of 8 to
10 glasses daily unless contraindicated.
• Consult with an advanced practice nurse or physician if client
has elevated blood pressure, proteinuria, facial puffiness, sacral
or pitting edema, or weight gain of more than 2 lb in 1 week.
• Advise the client to avoid reclining on her back, sitting for
prolonged periods without elevating feet, or standing for
prolonged
periods (Davis, 1996).
• Instruct the client to lie on the left side for short periods
several
times a day and to take a warm tub bath daily.

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