Fluid Volume Excess (FVE), or hypervolemia, refers to an isotonic expansion of the ECF due to an increase in total body sodium content and an increase in total body water. This fluid overload usually occurs from compromised regulatory mechanisms for sodium and water as seen commonly in heart failure (CHF), kidney failure, and liver failure. Excessive intake of sodium from foods, medications, IV solutions, or diagnostic dyes is also considered the cause of FVE. Other medical conditions that could contribute to FVE are hemodialysis, peritoneal dialysis, and myocardial infarction. Restriction of sodium and water intake is vital for the treatment of hypervolemia in order to return the extracellular compartment to normal. Ultrafiltration or dialysis may be required for acute cases.
Here are some factors that may cause fluid volume excess:
- Compromised regulatory mechanisms
- Decreased cardiac output; chronic or acute heart disease
- Excessive fluid intake
- Excessive sodium intake
- Head injury
- Hormonal disturbances
- Liver disease
- Low protein intake
- Renal insufficiency
- Severe stress
- Steroid therapy
Signs and Symptoms
Fluid volume excess is characterized by the following signs and symptoms:
- Abnormal breath sounds: crackles
- Altered electrolytes
- BP changes
- Change in mental status
- Change in respiratory pattern
- Decreased Hgb or Hct
- Increased central venous pressure (CVP)
- Increased pulmonary artery diastolic pressure
- Intake exceeds output
- Jugular vein distention
- Specific gravity changes
- Shortness of breath; orthopnea/dyspnea
- Third heart sound (S3)
Goals and Outcomes
The following are the common goals and expected outcomes for fluid volume excess:
- The patient will be normovolemic as evidenced by urine output greater than or equal to 30 mL/hr.
- The patient will have a balanced intake and output and a stable weight.
- The patient will maintain HR of 60 to 100 beats/min.
- The patient will achieve clear lung sounds as manifested by the absence of pulmonary crackles.
- The patient will verbalize awareness of causative factors and behaviors essential to correct fluid excess.
- The patient will explain measures that can be taken to treat or prevent fluid volume excess.
- The patient will describe symptoms that indicate the need to consult with a healthcare provider.
Nursing Assessment and Rationales
Assessment is required in order to distinguish possible problems that may have lead to fluid volume excess well as identify any incident that may occur during nursing care.
1. Review the patient’s history to determine the probable cause of the fluid imbalance.
Such information can assist to direct management. History may include increased fluids or sodium intake.
2. Monitor weight regularly using the same scale and preferably at the same time of day wearing the same amount of clothing.
Sudden weight gain may mean fluid retention. Different scales and clothing may show false weight inconsistencies.
3. Monitor input and output closely.
Dehydration may be the result of fluid shifting even if overall fluid intake is adequate.
4. Assess weight in relation to nutritional status.
In some patients with heart failure, weight may be a poor indicator of fluid volume status. Poor nutrition and decreased appetite over time result in a decrease in weight, which may be accompanied by fluid retention even though the net weight remains unchanged.
5. Record intake if the patient is on fluid restriction.
Patients should be reminded to include items that are liquid at room temperatures such as gelatin, sherbet, soup, and frozen juice pops.
6. Monitor and note BP and HR.
Sinus tachycardia and increased BP are evident in the early stages.
7. Review chest x-ray reports.
The x-ray studies show cloudy white lung fields as interstitial edema accumulates.
8. Assess urine output in response to diuretic therapy.
Recording two voids versus six voids after a diuretic medication may provide more useful information. Medications may be given intravenously because FVE in the abdomen may interfere with the absorption of oral diuretic medications.
9. Note the presence of edema by palpating over the tibia, ankles, feet, and sacrum.
Edema occurs when fluid accumulates in the extravascular spaces. Dependent areas more readily exhibit signs of edema formation. Edema is graded from trace (indicating barely perceptible) to 4 (severe edema). Pitting edema is manifested by a depression that remains after one’s finger is pressed over an edematous area and then removed. Measurement of an extremity with a measuring tape is another method of the following edema.
10. Assess for crackles in the lungs, changes in respiratory pattern, shortness of breath, and orthopnea.
These signs are caused by an accumulation of fluid in the lungs.
11. Assess for bounding peripheral pulses and S3.
These assessment findings are signs of fluid overload.
12. Check for distended neck veins and ascites. Monitor abdominal girth to follow any ascites accurately.
Distended neck veins are caused by elevated CVP. Ascites occur when fluid accumulates in extravascular spaces.
13. Review serum electrolytes, urine osmolality, and urine-specific gravity.
All are indicators of fluid status and guide therapy.
14. Check for excessive response to diuretics.
Significantly increased response to diuretics may lead to a fluid deficit.
15. Monitor fluid intake.
This enhances compliance with the regimen.
Nursing Interventions and Rationales
The following are the therapeutic nursing interventions for Fluid Volume Excess:
1. Instruct patient, caregiver, and family members regarding fluid restrictions, as appropriate.
Information and knowledge about the condition are vital to patients who will be co-managing fluids.
2. Limit sodium intake as prescribed.
Restriction of sodium aids in decreasing fluid retention
3. Take diuretics as prescribed.
Diuretics aid in the excretion of excess body fluids.
4. Elevate edematous extremities, and handle with care.
Elevation increases venous return to the heart and, in turn, decreases edema. Edematous skin is more susceptible to injury.
5. Consider the need for an external or indwelling urinary catheter.
Treatment focuses on the diuresis of excess fluid. Urinary catheters provide a more accurate measurement of the response to diuretics.
6. Consider interventions related to specific etiological factors (e.g., inotropic medications for heart failure, paracentesis for liver disease).
Knowledge of etiological factors gives direction for subsequent interventions.
7. For acute cases of Fluid Volume Excess:
- 7.1. Cooperate with the pharmacist to maximally concentrate IV fluids and medications.
Concentration decreases unnecessary fluids.
- 7.2. Anticipate admission to an acute care setting for hemofiltration or ultrafiltration.
These therapies are very efficient techniques to draw off extra fluid.
- 7.3. Administer IV fluids through an infusion pump, if possible.
Pumps guarantee precise delivery of IV fluids.
- 7.4. Apply a heparin lock device.
This device maintains IV access and patency but decreases fluid delivered to the patient in a 24-hour period.
- 7.5. Place the patient in a semi-Fowler’s or high-Fowler’s position.
Raising the head of the bed provides comfort in breathing.
- 7.6. Aid with repositioning every 2 hours if the patient is not mobile.
Repositioning prevents fluid accumulation in dependent areas.
8. Educate patient and family members regarding fluid volume excess and its causes.
Information is key to managing problems.
9. Explain the rationale and intended effect of the treatment program.
Follow-up care will be the patient’s or caregiver’s responsibility. Information is necessary to make correct choices in the future.
10. Explain the need to use anti-embolic stockings or bandages, as ordered.
These aids help promote venous return and minimize fluid accumulation in the extremities.
11. Educate the patient and family members on the importance of proper nutrition, hydration, and diet modification.
Knowledge heightens compliance with the treatment plan.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues and on electrolytes and acid-base balance.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses is reviewed and approved by the NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis…. subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
References and Sources
Recommended external links and further reading for Fluid Volume Excess nursing diagnosis:
- Fernandes, M. I. D. C. D., Medeiros, A. B. D. A., Macedo, B. M. D., Vitorino, A. B. F., Lopes, M. V. D. O., & Lira, A. L. B. D. C. (2014). Prevalence of nursing diagnosis of fluid volume excess in patients undergoing hemodialysis. Revista da Escola de Enfermagem da USP, 48(3), 446-453.
2 thoughts on “Fluid Volume Excess Nursing Care Plan”
Thank you so much for preparing this resource. It is very helpful.
Thanks for this article. It is helpful