Nurseslabs » excess fluid volume

Excess Fluid Volume — Liver Cirrhosis Nursing Care Plans

Nurseslabs — Tue, 01 May 2012 15:15:03 +0000

NURSING DIAGNOSIS: Fluid Volume excess

May be related to

Compromised regulatory mechanism (e.g., syndrome of inappropriate antidiuretic hormone [SIADH], decreased plasma proteins, malnutrition)
Excess sodium/fluid intake

Possibly evidenced by

Edema, anasarca, weight gain
Intake greater than output, oliguria, changes in urine specific gravity
Dyspnea, adventitious breath sounds, pleural effusion
BP changes, altered CVP
JVD, positive hepatojugular reflex
Altered electrolyte levels
Change in mental status

Desired Outcomes

Demonstrate stabilized fluid volume, with balanced I&O, stable weight, vital signs within patient’s normal range, and absence of edema.

Nursing Interventions & Rationale

Nursing Interventions	Rationale
Measure I&O, noting positive balance (intake in excess of output). Weigh daily, and note gain more than 0.5 kg/day.	Reflects circulating volume status, developing/resolution of fluid shifts, and response to therapy. Positive balance/weight gain often reflects continuing fluid retention. Note: Decreased circulating volume (fluid shifts) may directly affect renal function/urine output, resulting in hepatorenal syndrome.
Monitor BP (and CVP if available). Note JVD/abdominal vein distension.	BP elevations are usually associated with fluid volume excess but may not occur because of fluid shifts out of the vascular space. Distension of external jugular and abdominal veins is associated with vascular congestion.
Assess respiratory status, noting increased respiratory rate, dyspnea.	Indicative of pulmonary congestion/edema.
Auscultate lungs, noting diminished/absent breath sounds and developing adventitious sounds (e.g., crackles).	Increasing pulmonary congestion may result in consolidation, impaired gas exchange, and complications, e.g., pulmonary edema.
Monitor for cardiac dysrhythmias. Auscultate heart sounds, noting development of S₃/S₄ gallop rhythm.	May be caused by HF, decreased coronary arterial perfusion, and electrolyte imbalance.
Assess degree of peripheral/dependent edema.	Fluids shift into tissues as a result of sodium and water retention, decreased albumin, and increased antidiuretic hormone (ADH).
Measure abdominal girth.	Reflects accumulation of fluid (ascites) resulting from loss of plasma proteins/fluid into peritoneal space. Note:Excessive fluid accumulation can reduce circulating volume, creating a deficit (signs of dehydration).
Encourage bedrest when ascites is present.	May promote recumbency-induced diuresis.
Provide frequent mouth care; occasional ice chips (if NPO).	Decreases sensation of thirst.
Monitor serum albumin and electrolytes (particularly potassium and sodium).	Decreased serum albumin affects plasma colloid osmotic pressure, resulting in edema formation. Reduced renal blood flow accompanied by elevated ADH and aldosterone levels and the use of diuretics (to reduce total body water) may cause various electrolyte shifts/imbalances.
Monitor serial chest x-rays.	Vascular congestion, pulmonary edema, and pleural effusions frequently occur.
Restrict sodium and fluids as indicated.	Sodium may be restricted to minimize fluid retention in extravascular spaces. Fluid restriction may be necessary to correct/prevent dilutional hyponatremia.
Administer salt-free albumin/plasma expanders as indicated.	Albumin may be used to increase the colloid osmotic pressure in the vascular compartment (pulling fluid into vascular space), thereby increasing effective circulating volume and decreasing formation of ascites.
Administer medications as indicated: Diuretics, e.g., spironolactone (Aldactone), furosemide (Lasix); Potassium; Positive inotropic drugs and arterial vasodilators.	Used with caution to control edema and ascites, block effect of aldosterone, and increase water excretion while sparing potassium when conservative therapy with bedrest and sodium restriction does not alleviate problem. Serum and cellular potassium are usually depleted because of liver disease and urinary losses. Given to increase cardiac output/improve renal blood flow and function, thereby reducing excess fluid.

Excess Fluid Volume — Liver Cirrhosis Nursing Care Plans Original source at: Nurseslabs

10 Congestive Heart Failure Nursing Care Plans

Nurseslabs — Tue, 24 Jan 2012 17:32:53 +0000

Heart failure (HF) or Congestive Heart Failure (CHF) is a physiologic state in which he heart cannot pump enough blood to meet the metabolic needs of the body. Heart failure results from changes in systolic or diastolic function of the left ventricle. The heart fails when, because of intrinsic disease or structural it cannot handle a normal blood volume or, in absence of disease, cannot tolerate a sudden expansion in blood volume. Heart failure is not a disease itself; instead, the term refers to a clinical syndrome characterized by manifestations of volume overload, inadequate tissue perfusion, and poor exercise tolerance. Whatever the cause, pump failure results in hypoperfusion of tissues, followed by pulmonary and systemic venous congestion.

Because heart failure causes vascular congestion, it is often called congestive heart failure, although most cardiac specialist no longer use this term. Other terms used to denote heart failure include chronic heart failure, cardiac decompensation, cardiac insufficiency and ventricular failure (Joyce M. Black, 2008).

Here are 10 Congestive Heart Failure Nursing Care Plans

1. Decreased Cardiac Output - Congestive Heart Failure Nursing Care Plans

The heart fails to pump enough blood to meet the metabolic needs of the body. The blood flow that supplies the heart is also decreased thus decrease in cardiac output occurs, blood then is insufficient and making it difficult to circulate the blood to all parts of the body thus may cause altered heart rate and rhythm, weakness and paleness

NDx: Decreased cardiac output r/t altered heart rate and rhythm AEB bradycardia

Assessment

Planning

Nursing Interventions

Rationale

Evaluation

Subjective:(none)

Objectives:

The patient manifested the following:

with pale conjunctiva, nail beds and buccal mucosa
irregular rhythm of pulse
bradycardic
pulse rate of 34 beats/min
generalized weakness

Short Term:After 3-4 hours of nursing interventions, the patient will participate in activities that reduce the workload of the heart.

Long Term:

After 2-3 days of nursing interventions, the patient will be able to display hemodynamic stability.

Assess for abnormal heart and lung sounds.
Monitor blood pressure and pulse
Assess mental status and level of consciousness.
Assess patient’s skin temperature and peripheral pulses.
Monitor results of laboratory and diagnostic tests.
Monitor oxygen saturation and ABGs.
Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs.
Implement strategies to treat fluid and electrolyte imbalances.
Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for toxicity.
Encourage periods of rest and assist with all activities.
Assist the patient in assuming a high Fowler’s position.
Teach patient the pathophysiology of disease, medications
Reposition patient every 2 hours
Instruct patient to get adequate bed rest and sleep
Instruct the SO not to leave the client unattended
Allows detection of left-sided heart failure that may occur with chronic renal failure patients due to fluid volume excess as the diseased kidneys are unable to excrete water.

Patients with renal failure are most often hypertensive, which is attributable to excess fluid and the initiation of the rennin-angiotensin mechanism.
The accumulation of waste products in the bloodstream impairs oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness.
Decreased perfusion and oxygenation of tissues secondary to anemia and pump ineffectiveness may lead to decreased in temperature and peripheral pulses that are diminished and difficult to palpate.
Results of the test provide clues to the status of the disease and response to treatments.
Provides information regarding the heart’s ability to perfuse distal tissues with oxygenated blood
Makes more oxygen available for gas exchange, assisting to alleviate signs of hypoxia and subsequent activity intolerance.
Decreases the risk for development of cardiac output due to imbalances.
Digitalis has a positive isotropic effect on the myocardium that strengthens contractility, thus improving cardiac output.
Reduces cardiac workload and minimizes myocardial oxygen consumption.
Allows for better chest expansion, thereby improving pulmonary capacity.
Provides the patient with needed information for management of disease and for compliance.
To prevent occurrence of bed sores
To promote relaxation to the body
To ensure safety and reduce risk for falls that may lead to injury

Short Term:After nursing interventions, the patient shall have participated in activities that reduce the workload of the heart.

Long Term:

After 2-3 days of nursing interventions, the patient shall have been able to display hemodynamic stability.

10 Congestive Heart Failure Nursing Care Plans Original source at: Nurseslabs

5 Chronic Renal Failure Nursing Care Plans

Nurseslabs — Wed, 21 Dec 2011 17:07:58 +0000

Chronic Renal Failure (CRF) is a progressive reduction of functioning renal tissue such that the remaining kidney mass can no longer maintain the body’s internal environment. Here are 5 Chronic Renal Failure Nursing Care Plans.

CRF can develop insidiously over many years, or it may result from an episode of a cure renal failure from which the client has not recovered.

The nursing goal for client’s with CRF is to prevent further complications and supportive care. Client education is also critical as this is a chronic disease and thus requires long-term treatment.

Read below our 5 Chronic Renal Failure Nursing Care Plans

1. Fluid Volume Excess - Chronic Renal Failure Nursing Care Plans

Renal disorder impairs glomerular filtration that resulted to fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces. Since fluids are not reabsorbed at the venous end, fluid volume overloads the lymph system and stays in the interstitial spaces leading the patient to have edema, weight gain, pulmonary congestion and HPN at the same time due to decrease GFR, nephron hyperthrophized leading to decrease ability of the kidney to concentrate urine and impaired excretion of fluid thus leading to oliguria/anuria.

Fluid- Volume- Excess- CRF

5 Chronic Renal Failure Nursing Care Plans Original source at: Nurseslabs