Nursing Care Plan for Fluid Volume Excess
Definition: The state in which an individual experiences increased fluid retention and edema.
- Weight gain that occurs during a 24- to 48-hour period
- Dependent pitting edema
- Ascites in severe cases
- Fluid crackles on lung auscultation
- Exertional dyspnea
- Oliguria or anuria
- Engorged neck veins
- Decrease in urinary osmolality as renal failure progresses
- Central venous pressure (CVP) > 15cm of H2O
- Pulmonary artery wedge pressure (PAWP) 20-25 mmHg
- Weight returns to baseline
- Edema or ascites is absent or reduced to baseline
- Lungs are clear to auscultation
- Exertional dyspnea is absent
- Blood pressure returns to baseline
- Heart rate returns to baseline
- Neck veins are flat
- Mucous membranes are moist
Nursing Interventions and Rationale
- Continue to monitor the assessment parameters listed under defining characteristics.
- Promote skin integrity of edematous areas by frequent repositioning and elevation of areas where possible. Avoid massaging pressure points or reddened areas of skin because this results in further tissue trauma.
- Plan patient care to provide rest periods to not heighten exertional dyspnea.
- Weigh patient daily at same time in same clothing, preferably with the same scale.
- Instruct patient about the correlation between fluid intake and weight gain, using commonly understood fluid measurements such as ingesting 4 cups (1000 ml) of fluid results in approximate 2-pound weight gain in the anuric patient.