Friday, November 26, 2010

Excess Fluid Volume

Excess Fluid Volume

NANDA Definition
Excess fluid volume is the increased in isotonic fluid retention.

Discussion of the Problem
Fluid volume excess (FVE), or hypervolemia, refers to an isotonic expansion of the ECF caused by the abnormal retention of water and sodium in approximately the same proportions in which they normally exits in the ECF. It is always secondary to an increase in the total body sodium content, which, in turn leads to an increase in total body water. This fluid excess usually results from compromised regulatory mechanisms for sodium and water as seen in the following conditions:  congestive heart failure (CHF), kidney failure, and liver failure. Other medical conditions that could contribute to excess fluid volume are as follows: hemodialysis, peritoneal dialysis and myocardial infarction. In addition, it may also be caused by excessive intake of sodium from foods, intravenous (IV) solutions, medications, or diagnostic contrast dyes. The restorative goal is to treat directly the cause. If the fluid excess is related to too much administration of sodium-containing fluids, discontinuing the infusion may be all that is required. When it comes with symptomatic treatments, administering diuretics and restricting fluids and sodium are required.

Nursing Interventions Classification (NIC)
  • Fluid Management
  • Fluid Monitoring

Nursing Outcomes Classification (NOC)
  • Fluid Balance

Goal and Objective
  • Patient will maintain sufficient fluid volume and electrolyte balance as manifested by vital signs within normal limits, clear lung sounds, pulmonary congestion not present on x-ray, and resolution of edema.

Subjective and Objective Data
  • Abnormal breath sounds: crackles (rales)
  • Azotemia
  • Bounding pulses
  • Change in electrolytes
  • Change in mental status (lethargy or confusion)
  • Change in respiratory pattern
  • Decreased hemoglobin or hematocrit
  • Edema
  • Increased blood pressure
  • Increased central venous pressure (CVP)
  • Increased pulmonary artery pressure (PAP)
  • Intake greater than output
  • Jugular vein distension
  • Oliguria
  • Pulmonary congestion on x-ray
  • Restlessness and anxiety
  • Shortness of breath; orthopnea
  • Specific gravity changes
  • Third heart sound (S3)
  • Weight gain

Related Factors
  • Decreased cardiac output; chronic or acute heart disease
  • Excessive fluid intake
  • Excessive sodium intake
  • Head injury
  • Hormonal disturbances
  • Liver disease
  • Low protein intake or malnutrition
  • Renal insufficiency or failure
  • Severe stress
  • Steroid therapy

Assessment (Dx)
  • Assess urine output in reaction to diuretic therapy. Concentration is on checking the reaction to the diuretics, instead of the actual quantity voided. At home, it is unrealistic to expect patients to quantify each void. Thus, recording two voids versus six voids after a diuretic medication may give more helpful information. NOTE: Fluid volume excess in the abdomen may hinder with absorption of oral diuretic medications. Medications may require to be administered intravenously by a nurse in the home or outpatient setting.

  • Assess weight in relation to nutritional status. In some heart failure patients, weight may be a poor gauge of fluid volume condition. Poor nutrition and diminished appetite over time lead to a reduction in weight, which may come with by fluid retention even though the net weight stays unchanged.

  • Auscultate for a third sound, and check for bounding peripheral pulses. These are signs of fluid overload.

  • Auscultate for crackles in lungs, alterations in respiratory pattern, shortness of breath, and orthopnea. These are initial signs of pulmonary congestion.

  • Check and document vital signs. Sinus tachycardia and elevated blood pressure are seen in initial stages. Geriatric patients have diminished reaction to catecholamines; therefore their reaction to fluid overload may be blunted, with less increse in heart rate.

  • Check chest x-ray reports. As interstitial edema builds up, the x-rays show cloudy white lung fields.

  • Evaluate necessitate for an indwelling urinary catheter. Management concentrates on diuresis of excess fluid.

  • Evaluate or teach patient to monitor weight daily with same scale and if possible at the same time of day. Instruction enables precise measurement and assits to follow trends.

  • Get patient history to determine the possible cause of the fluid disturbance. This can assist to direct managements. May consist of elevated fluids or sodium intake, or compromised regulatory mechanisms.

  • Monitor hemodynamic status including CVP, PAP, and PCWP (if available) if hospitalized. This direct measurement serves as best possible guide for therapy.

  • Note for existence of edema by palpating over tibia, ankles, feet, and sacrum. Pitting edema is marked by a depression that sustains after one’s finger is pressed over an edematous area and then removed. Grade edema from trace to 4. Measurement of an extremity with a measuring tape is one more technique of following edema.

  • Observe for a major weight change (2 pounds) in 1 day.

  • Observe for distended neck veins and ascites. Check abdominal girth to follow any ascites precisely.

  • Observe for excessive response to diuretics: 2-pound loss in 1 day, hypotension, weakness, blood urea nitrogen (BUN) elevated out of proportion to serum creatinine level.

  • Observe for signs of hypovolemia during therapy. Observing avoids complications related with therapy.

  • Observe input and output closely. Even though general fluid intake may be sufficient, shifting of fluid out of the intravascular to the extravascular spaces may lead to dehydration. The risk of this incident augments when diuretics are ordered. Patients may utilize diaries for home assessment.

  • Review daily log or chart for recorded intake if patient is on fluid restriction

Therapeutic Interventions (Tx)
  • Give innovative methods for monitoring fluid allotment at home. This gives a visual guide for how much fluid is still allowed all through the day.

  • Give or educate patient to take diuretics as ordered. Diuretic therapy may comprise several various types of agents for maximal therapy, depending on the acuteness or chronicity of the problem. Compliance is frequently hard for patients trying to sustain a normal lifestyle for chronic patients.

  • For acute patients:
Ø  Apply saline lock on IV line. This keeps patency but reduces fluid delivered to patient in a 24-hour period.
Ø  Give IV fluids via infusion pump, if probable. This guarantees precise delivery of IV fluids.
Ø  Help with repositioning every 2 hours if patient is not mobile. This avoids fluid buildup in dependent areas.
Ø  Work together with the pharmacist to maximally concentrate IVs and medications. This reduces unneeded fluids.

  • Institute or instruct patient regarding fluid restrictions as necessary. This assists decrease extracellular volume. For some patients, fluids may require to be restricted to 1000 ml per day.

  • Instruct necessitate for use of antiembolic stockings or bandages as ordered. These help improve venous return and reduce fluid accumulation in the extremities.

  • Instruct patient to avoid drugs that may cause fluid retention, such as over-the-counter non-steroidal anti-inflammatory agents (NSAIDs), certain vasodilators, and steroids.

  • Lessen constriction of vessels. This avoids venous pooling.

  • Limit sodium intake as ordered. Sodium diets of 2 to 3 g are typically ordered.

  • Raise edematous extremities. This enhances venous returns and, in turn, reduces edema.

Educative (Edx)
  • Educate causes of fluid volume excess and/or excess intake to patient or caregiver.

  • Give details or strengthen rationale and anticipated effect of management program.

  • Give explanation about the significance of keeping appropriate nutrition and hydration, and diet modifications.

  • Give information as required regarding the individual’s medical diagnosis.

  • Recognize signs and symptoms of fluid volume excess.

  • Recognize symptoms to be reported.

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