Fluid Volume Excess (Hypervolemia) Nursing Diagnosis & Care Plan

Gain comprehensive knowledge about hypervolemia and fluid volume excess through this guide, which focuses on nursing care plans and nursing diagnosis. Explore the causes, signs, and symptoms associated with hypervolemia and acquire practical insights into effective nursing interventions and care plans to address this condition.

What is Fluid Volume Excess?

Approximately 60% of a typical adult’s body weight consists of fluid. Body fluid is located in two fluid compartments: the intracellular space (fluid in the cells) and the extracellular space (fluid outside the cells). Approximately two-thirds of body fluid is in the intracellular fluid (ICF) compartment and is located primarily in the skeletal mass. Approximately one-third is in the extracellular fluid (ECF) compartment. The ECF compartment is further divided into the intravascular, interstitial, and transcellular fluid spaces:

• Intravascular space. This is the fluid within the blood vessels and contains plasma, the effective circulating volume. Approximately three liters of the average six liters of blood volume in adults is made up of plasma, and the remaining three liters are made up of erythrocytes, leukocytes, and thrombocytes.
• Interstitial space. This space contains the fluid that surrounds the cell, such as lymph, and totals about 11 to 12 liters in an adult.
• Transcellular space. This is the smallest division of the ECF compartment and contains one liter. Examples are cerebrospinal, pericardial, synovial, intraocular, and pleural fluids, sweat, and digestive secretions.

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 fluid volume excess 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.

Hypervolemia refers to an isotonic volume expansion of the extracellular fluid (ECF) caused by the abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ECF.

The terms hypervolemia and fluid overload are often used interchangeably, but they do not have the same meaning. Fluid overload may vaguely refer to excess total body water content associated with edema. The term hypervolemia is sufficient to indicate an excess in circulating blood volume and, if present, needs to be properly documented before a strategy of fluid restriction and/or diuretics is applied (Vincent & Pinsky, 2018).

Causes

Here are some factors that may cause fluid volume excess and hypervolemia:

• 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
• Malnutrition
• Renal insufficiency
• Severe stress
• Steroid therapy

Nursing Care Plans and Management

To effectively manage fluid volume excess, nurses play a vital role in developing and implementing care plans tailored to each client’s need. Nursing care plans aim to identify underlying causes of fluid volume excess, alleviate symptoms, prevent complications, and promote optimal client outcomes.

Nursing Problem Priorities

The following are the nursing priorities for clients diagnosed with fluid volume excess:

1. Assessment and monitoring of fluid and electrolytes. The first step in managing fluid volume excess is conducting a comprehensive assessment of the client’s condition.
2. Edema formation. Because edema is a common manifestation of FVE, clients need to recognize its symptoms and understand its importance.
3. Electrolyte imbalances. There is a very narrow target range for normal electrolyte values, and slight abnormalities can have devastating consequences. Therefore, it is crucial to understand normal electrolyte ranges, causes of electrolyte imbalances, their signs and symptoms, and appropriate treatments.
4. Client and caregiver education. Nurses are the immediate primary educators of clients and their caregivers. Client education must include information about their condition, signs and symptoms to watch for, adherence to prescribed medications, and lifestyle modifications.

Nursing Assessment

Assessment is required in order to distinguish possible problems that may have led to fluid volume excess well as identify any incident that may occur during nursing care.

Fluid volume excess is characterized by the following signs and symptoms:

• Abnormal breath sounds: crackles
• Altered electrolytes
• Anxiety
• Azotemia
• BP changes
• Change in mental status
• Change in respiratory pattern
• Decreased Hgb or Hct
• Edema
• Increased central venous pressure (CVP)
• Increased pulmonary artery diastolic pressure
• Intake exceeds output
• Jugular vein distention
• Oliguria
• Restlessness
• Specific gravity changes
• Shortness of breath; orthopnea/dyspnea
• Tachycardia
• Third heart sound (S₃)

Nursing Diagnosis

After thorough assessment, nursing diagnoses are formulated to address the challenges of fluid volume excess, guided by the nurse’s clinical judgment and understanding of the patient’s unique condition. While nursing diagnoses help organize care, their use may vary across clinical settings. Ultimately, the nurse’s expertise and judgment shape the care plan to prioritize each patient’s needs. Here are examples of nursing diagnoses that may be useful for common concerns associated with excess fluid volume:

• Fluid Volume Excess related to increased fluid retention as evidenced by edema, weight gain, and distended neck veins secondary to renal failure.
• Fluid Volume Excess related to excessive sodium intake as evidenced by peripheral edema, elevated blood pressure, and weight gain secondary to heart failure.
• Fluid Volume Excess related to excessive intravenous fluid administration as evidenced by hypertension, peripheral edema, and jugular vein distention secondary to post-operative care.
• Fluid Volume Excess related to third spacing of fluids as evidenced by abdominal distension, decreased urinary output, and edema secondary to severe burns.
• Fluid Volume Excess related to excessive fluid intake as evidenced by hypertension, edema, polydipsia and weight gain secondary to diabetes mellitus.
• Fluid Volume Excess related to decreased renal function as evidenced by edema, hypertension, and oliguria secondary to chronic kidney disease.
• Fluid Volume Excess related to blood transfusions as evidenced by edema, elevated blood pressure, and fluid retention secondary to massive blood transfusion.

Nursing Goals

The following are the common goals and expected outcomes for fluid volume excess:

• The client will be normovolemic as evidenced by urine output greater than or equal to 30 mL/hr.
• The client will have a balanced intake and output and a stable weight.
• The client will maintain a heart rate of 60 to 100 beats/min.
• The client will achieve clear lung sounds as manifested by the absence of pulmonary crackles.
• The client will verbalize awareness of causative factors and behaviors essential to correct fluid excess.
• The client will explain measures that can be taken to treat or prevent fluid volume excess.
• The client will describe symptoms that indicate the need to consult with a healthcare provider.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for clients diagnosed with fluid volume excess may include:

1. Assessing and Monitoring Fluids and Electrolytes

It is important to detect fluid volume excess (FVE) before the condition becomes severe. A thorough assessment provides valuable information about a client’s current fluid, electrolyte, and acid-base balances, as well as risk factors for developing imbalances.

Monitor vital signs routinely, especially blood pressure and heart rate.
Assess for manifestations such as tachycardia, hypertension, and tachypnea, which can indicate fluid volume excess and guide appropriate fluid management interventions. Sinus tachycardia and increased blood pressure are early indicators of fluid volume excess, prompting further assessment and interventions to prevent complications associated with elevated intravascular volume.

Perform daily weight measurements and observe for sudden weight gain.
A weight gain of 1 kilogram (2.2 pounds) is equivalent to a gain of approximately one liter of fluid and can indicate fluid retention and prompt the need for further assessment and interventions to prevent complications associated with fluid overload. Regularly monitor weight using the same scale, at the same time of day, and with consistent clothing. Standardized measurement techniques ensure an accurate assessment of changes in fluid status over time.

Assess weight in relation to nutritional status.
Recognizing that in some clients with heart failure, weight may not accurately reflect fluid volume status due to poor nutrition and decreased appetite, necessitating a comprehensive assessment of fluid balance and nutritional intake to guide appropriate interventions. There is increasing evidence that fluid volume overload may contribute to malnutrition in chronic kidney disease clients that may contribute to protein-energy wasting (Fouque et al., 2021). 

Assess for signs of fluid overload, including neck and peripheral vein distention, and dyspnea.
These signs indicate fluid overload and can be used to assess the client’s condition and response to treatment. Neck vein distention is a sign of increased central venous pressure, which can be caused by heart failure or pulmonary hypertension, while peripheral vein distention and pitting edema indicate fluid accumulation in the limbs. Dyspnea is a common symptom of hypervolemia and can be caused by pulmonary congestion or edema. Monitoring and noting these signs are essential in guiding nursing interventions, promoting optimal client outcomes, and preventing complications such as heart failure and pulmonary edema.

Auscultate lung and heart sounds to detect adventitious sounds (crackles) and extra heart sounds (S3).
This may indicate the presence of fluid excess and the potential development of pulmonary edema, prompting the need for interventions to prevent respiratory compromise. Breath sounds are assessed at regular intervals in at-risk clients, particularly if parenteral fluids are being given. Crackles can signify fluid volume excess and are often auscultated first in the lower posterior lung fields (Ernstmeyer & Christman, 2021).

Monitor intake and output closely, noting any decreases in urinary output and positive fluid balance.
This can suggest decreased renal perfusion, cardiac insufficiency, or fluid shifts contributing to fluid volume excess, guiding interventions such as diuretic therapy and fluid restriction. Fluid shifting can contribute to dehydration even if overall fluid intake appears adequate, prompting the need for adjustments in fluid administration and monitoring of hydration status.

Assess for the presence and location of edema formation.
Recognizing that edema can be either a cause or a result of various pathological conditions, and evaluating its severity and distribution helps determine the effectiveness of fluid management interventions and guides further treatment decisions. Tight, edematous, shiny skin indicates fluid volume excess (Ernstmeyer & Christman, 2021).

Monitor laboratory studies, including sodium, potassium, BUN, and arterial blood gases (ABGs), as indicated.
This helps to evaluate electrolyte imbalances, renal function, and acid-base status, providing insights into the underlying causes of fluid volume excess and informing appropriate interventions. BUN and creatinine levels are used to evaluate kidney function, with increased levels indicating worsening renal function. ABGs are used to closely monitor critically ill clients, such as clients with diabetic ketoacidosis or in severe respiratory distress (Ernstmeyer & Christman, 2021).

Review the client’s history to identify the probable cause of fluid imbalance.
This may include increased fluids or sodium intake, enabling tailored interventions and client education to address the specific factors contributing to fluid volume excess. Subjective data is helpful in determining normal pattern identification and risk identification. A history of kidney disease or heart failure places the client at risk for fluid volume excess. Recognizing these risks helps the nurse prepare for complications that may arise and allows them to recognize subtle cues as problems develop (Ernstmeyer & Christman, 2021).

Review chest x-ray reports to identify cloudy white lung fields indicative of interstitial edema accumulation.
Providing objective evidence of fluid overload and guiding interventions to manage pulmonary congestion. Chest radiography is the examination of choice in clients diagnosed with noncardiogenic pulmonary edema. Most clients with NPE are seriously ill and immobile, and there may be transportation problems regarding CT scans and MRI units. Conventional chest X-ray is readily and universally available, and it has the added advantage of portability (Khan et al., 2018).

Assess urine output in response to diuretic therapy.
Comparing the number and amount of urine volume before and after medication administration to evaluate the effectiveness of diuretics and adjust dosages as necessary to promote diuresis and relieve fluid volume excess.  Diuretic treatment calls for careful assessment of ECF volume, urine output, electrolyte levels in plasma and urine, body weight, acid-base status, serum glucose, and BP regularly with particular emphasis on clients with cardiovascular, hepatic, renal, or metabolic disorders and in older adults (Arumugham & Shahin, 2023).

Palpate for pitting edema in areas such as the tibia, ankles, feet, and sacrum.
Noting the presence and degree of pitting edema as well as changes in extremity measurements using a measuring tape marked in millimeters, providing objective results for the assessment of peripheral edema, as well as pitting edema. Pitting edema is assessed by pressing a finger into the affected part, creating a pit or indentation that is evaluated on a scale of 1+ (minimal) to 4+ (severe).

Monitor the central venous pressure as indicated and if available.
Often, a CVP line is inserted into the subclavian or jugular vein and is advanced until the tip of the catheter rests near the junction of the superior vena cava and the right atrium. The CVP is used to assess preload in the right side of the heart. The CVP value assists in monitoring the client’s response to fluid replacement.

Assess the client’s mental status routinely.
New mental status changes such as confusion or decreased level of consciousness can indicate fluid, electrolyte, or acid-base imbalance, especially hypo or hypernatremia (Ernstmeyer & Christman, 2021).

Monitor urine osmolality and specific gravity.
Urine osmolarity measures the concentration of particles in the urine. A decreased serum osmolarity means the blood is more dilute than normal and may indicate a fluid volume excess. Urine-specific gravity is a urine test that commonly measures hydration status by measuring the concentration of particles in the urine. A urine specific gravity below 1.010 indicates dilute urine, which can occur with excessive fluid intake (Ernstmeyer & Christman, 2021).

Monitor an infant’s urine output by counting and weighing diapers.
When monitoring urine output in infants, parents are often asked about the number of wet diapers in a day. Nurses may also weigh diapers for hospitalized infants for a more accurate measurement of urine output (Ernstmeyer & Christman, 2021).

Measure fluid overload using bioimpedance spectroscopy (BIS).
BIS is a noninvasive, inexpensive, and portable method that has been used for body composition analysis. It determines the electrical impedance or opposition to the flow of an electric current through body tissues, which can then be used to estimate body composition, including total body water, intracellular volume, and extracellular volume (Bansal, 2017).

2. Managing Edema Formation

Edema can occur as a result of increased capillary fluid pressure, decreased capillary oncotic pressure, or increased interstitial oncotic pressure, causing expansion of the interstitial fluid compartment. The goal of treatment is to preserve or restore the circulating intravascular fluid volume.

Provide alternatives to fluid intake for clients on fluid restriction.
Providing reminders to include liquid items that are room temperature such as gelatin, sherbet, soup, and frozen juice pops, ensuring compliance with prescribed fluid restrictions and preventing excessive fluid intake. Also, caution the client on a sodium-restricted diet to avoid water softeners that add sodium to water in exchange for other ions, such as calcium.

Encourage adequate bed rest.
Limited cardiac reserves result in fatigue and activity intolerance. Rest, particularly lying down, favors diuresis and reduction of edema. The mechanism is related to diminished venous pooling and the subsequent increase in effective circulating blood volume and renal perfusion.

Turn or reposition, and provide skin care at regular intervals.
Frequent turning decreases pressure and friction on edematous tissue, which is more prone to breakdown than normal tissue. Additionally, turning the client helps stimulate blood circulation in different areas of the body. By changing positions, gravity can assist in the movement of fluid and reduce stagnant blood flow.

Elevate edematous extremities, and handle them with care.
Elevation increases venous return to the heart and, in turn, decreases edema. Edematous skin is more susceptible to injury. Leg, ankle, and foot edema can be improved by elevating the legs above heart level for 30 minutes three or four times per day. Elevating the legs may be sufficient to reduce or eliminate edema for people with mild venous disease, but more severe cases require other measures (Sterns, 2023).

Monitor the infusion rate of parenteral fluids closely; use an infusion pump, as necessary.
Rapid fluid bolus or prolonged excessive administration potentiates volume overload and the risk of cardiac decompensation. Management of fluid volume excess is directed at the causes, and if related to excessive administration of sodium-containing fluids, discontinuing the infusion may be all that is needed.

Administer oral fluids with caution. Do a 24-hour schedule fluid intake if fluids are restricted.
Fluid restrictions, as well as extracellular shifts, can aggravate the drying of mucous membranes, and the client may desire more fluids that are prudent. Depending on its source, water may contain as little as 1 mg or more than 1500 mg of sodium per quart. Clients need to use distilled water if the local water supply is very high in sodium. Bottled water can have a sodium content that ranges from 0 to 1200 mg/liter.

Administer small volumes of hypertonic sodium solution parenterally.
If neurologic symptoms are severe, or in clients with traumatic brain injury, it may be necessary to administer small volumes of a hypertonic sodium solution with the goal of alleviating cerebral edema. Incorrect use of these fluids is extremely dangerous because one liter of 3% sodium chloride solution contains 513 mEq of sodium and one liter of 5% sodium chloride solution contains 855 mEq of sodium.

Administer diuretics as indicated: loop diuretics such as furosemide, potassium-sparing diuretics such as spironolactone, and thiazide diuretics such as hydrochlorothiazide.
To achieve the excretion of excess fluid, either a single thiazide diuretic or a combination of agents may be selected, such as thiazide and spironolactone. The combination can be particularly helpful when two drugs have different sites of action, allowing more effective control of fluid excess. Diuretics are prescribed when dietary restriction of sodium alone is insufficient to reduce edema by inhibiting the reabsorption of sodium and water by the kidneys. The choice of diuretic is based on the severity of the hypervolemic state, the degree of impairment of renal function, and the potency of the diuretic.

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. Between one-quarter and one-half of clients hospitalized for heart failure undergoes indwelling urinary catheterization. The rationale for urinary catheterization in this population sometimes includes managing hypervolemia or improving comfort during diuretic treatment. However, the risks of urinary tract infections and traumatic complications are well-known (John et al., 2022).

Promote the use of compression stockings.
Effective compression stockings apply the greatest amount of pressure at the ankle and gradually decrease the pressure up the leg. These stockings are available with varying degrees of compression. Stockings with small amounts of compression can be purchased at pharmacies and surgical supply stores without a prescription. In moderate to severe edema, prescription stockings are required (Sterns, 2023).

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. Paracentesis can be performed if needed to reduce the need for a high dose of diuretics and avoid electrolyte imbalance (Goyal et al., 2023).

Prepare the client for dialysis.
Hypernatremia in the setting of volume overload may require dialysis. If renal function is so severely impaired that pharmacologic agents cannot act efficiently, other modalities are considered to remove sodium and fluid from the body. Hemodialysis or peritoneal dialysis may be used to remove nitrogenous wastes and control potassium and acid-base balance, and to remove sodium and fluid.

Promote a low-sodium diet and salt substitutes.
Treatment of fluid volume excess usually involves a dietary restriction of sodium. An average daily diet not restricted in sodium contains 6 to 15 g of salt, whereas low-sodium diets can range from a mild restriction to as little as 25o mg of sodium per day, depending on the client’s needs. Lemon juice, onions, and garlic are excellent substitute flavorings, although some clients prefer salt substitutes. Most salt substitutes contain potassium and must therefore be used cautiously by clients taking potassium-sparing diuretics.

Encourage intake of protein-rich foods.
Protein intake may be increased in clients who are malnourished or who have low serum protein levels in an effort to increase capillary oncotic pressure and pull fluid out of the tissues into vessels for excretion by the kidneys.

For acute cases of hypervolemia

Cooperate with the pharmacist to maximally concentrate IV fluids and medications.
Concentration decreases unnecessary fluids. For clients with hypernatremia, treatment consists of the gradual lowering of the serum sodium level by infusion of a hypotonic electrolyte solution or an isotonic nonsaline solution, D5W is indicated when water needs to be replaced without sodium.

Anticipate admission to an acute care setting for hemofiltration or ultrafiltration.
These therapies are very efficient techniques to draw off extra fluid. If renal function is so severely impaired that pharmacologic agents cannot act efficiently, other modalities such as dialysis are considered to remove sodium and fluid from the body. Hemodialysis or peritoneal dialysis may be used to remove nitrogenous wastes and control potassium and acid-base balance, and to remove sodium and fluid.

Administer IV fluids through an infusion pump, if possible. Apply a heparin lock device.
A heplock maintains IV access and patency but decreases fluid delivered to the client in a 24-hour period. Infusion pumps guarantee precise delivery of IV fluids. With chronic hypernatremia, the established practice is to correct more slowly due to the risks of brain edema during treatment. The brain adjusts to and mitigates chronic hypernatremia by increasing the intracellular content of organic osmolytes. The concern is that if extracellular tonicity is rapidly decreased, water will move into the brain cells, producing cerebral edema (Lukitsch & Batuman, 2023).

Place the client in a semi-Fowler’s or high-Fowler’s position.
Raising the head of the bed provides comfort in breathing. If dyspnea or orthopnea is present, the client is placed in a semi-Fowler position to promote lung expansion.

Aid with repositioning every two hours if the client is not mobile.
Repositioning prevents fluid accumulation in dependent areas. The client is also turned and repositioned at regular intervals because edematous tissue is more prone to skin breakdown than normal tissue.

For clients with congestive heart failure

Monitor the client’s fluid intake, both oral and parenteral.
If the diet includes fluid restriction, the nurse can assist the client to plan fluid intake throughout the day while respecting the client’s dietary preferences. If the client is receiving IV fluids and medications, the amount of fluid needs to be monitored closely, and the primary provider can be consulted about double concentrating the amount of medication in the same volume of fluid to decrease the fluid volume given.

Alternate the client’s schedule of activities and rest periods.
A typical program for a client with heart failure might include a daily walking regimen, with the duration increased over a 6-week p[eriod. The primary provider, the nurse, and the client should collaborate to develop a schedule that promotes pacing and prioritization of activities. The schedule should alternate activities with periods of rest and avoid having two significant energy-consuming activities occur on the same day or in immediate succession.

Promote intake of diuretics in the morning.
Oral diuretics should be given early in the morning so that diuresis does not interfere with the client’s nighttime rest. Discussing the timing of medication administration is especially important for older adults who may have urinary urgency or incontinence. A single dose of diuretic may cause the client to excrete a large volume of fluid shortly after its administration.

Place the client in a position that facilitates breathing.
The client is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the client may sit in a recliner. In these positions, the venous return to the heart is reduced, pulmonary congestion is reduced, and pressure on the diaphragm is minimized.

Administer diuretics as prescribed.
Diuretics are prescribed to remove excess ECF by increasing the rate of urine produced in clients with signs and symptoms of fluid overload. Heart failure guidelines advocate using the smallest dose of diuretic necessary to control fluid volume. Loop, thiazide, and aldosterone-blocking diuretics may be prescribed for clients diagnosed with heart failure.

Avoid excessive fluid intake and promote a low-sodium diet.
Following a low-sodium (no more than 2 g per day) diet and avoiding excessive fluid intake are usually recommended, although studies differ regarding the effectiveness of sodium restriction. Decreasing dietary sodium intake reduces fluid retention and the symptoms of peripheral and pulmonary congestion. Any change in diet should consider good nutrition as well as the client’s likes, dislikes, and cultural food patterns.

Prepare the client for ultrafiltration.
Ultrafiltration is an alternative intervention for clients with severe fluid overload. It is reserved for clients with advanced heart failure who are resistant to diuretic therapy. Liters of excess fluid and plasma are removed slowly from the client’s intravascular circulating volume over a number of hours.

For clients with pulmonary edema

Place the client in an upright position.
Pulmonary edema in its early stages can be managed by implementing position changes. Placing the client in an upright position with the feet and legs dependent or dangling reduces the left ventricular workload. This also has the immediate effect of decreasing venous return, decreasing right ventricular stroke volume, and decreasing lung congestion.

Provide emotional support and reassurance to the client.
As the ability to breathe decreases, the client’s fear and anxiety rise proportionately, making the condition more severe. Reassuring the client and providing skillful anticipatory nursing care are integral parts of the therapy. The nurse may give the client simple, concise information in a reassuring voice about what is being done to treat the condition and the expected results.

Ensure accessibility of a bathroom or placing a commode near the client.
The client receiving diuretic therapy may excrete a large amount of urine within minutes after a potent diuretic is given. A bedside commode may be used to decrease the energy required by the client and to reduce the resultant increase in cardiac workload by getting on and off a bedpan.

Assist in providing ventilatory support.
For some clients, endotracheal intubation and mechanical ventilation are required. The ventilator can provide positive end-expiratory pressure, which is effective in reducing venous return, decreasing fluid movement from the pulmonary capillaries to the alveoli, and improving oxygenation.

Administer diuretics as indicated.
Diuretics promote the excretion of sodium and water by the kidneys. Furosemide or another loop diuretic is given by IV push or as a continuous infusion to produce a rapid diuretic effect. The blood pressure must be closely monitored as the urine output increases because it is possible for the client to become hypotensive as intravascular volume decreases.

Administer vasodilators as prescribed.
Vasodilators such as IV nitroglycerin or nitroprusside may enhance symptom relief in pulmonary edema. Their use is contraindicated in clients who are hypotensive. Blood pressure is continually assessed in clients receiving IV vasodilator infusions.

For clients with end-stage renal disease

Regular fluid intake carefully.
Usually, the fluid allowance per day is 500 to 600 mL more than the previous day’s 24-hour urine output. The client’s fluid intake may also be limited to a prescribed volume. The fluid restriction will be determined on the basis of urine output, weight, and response to therapy.

Provide or encourage frequent oral hygiene.
Oral hygiene minimizes the dryness of oral mucous membranes. Additionally, an ammonia odor to the breath caused by uremia can reduce the client’s appetite. Oral hygiene may lessen the discomfort of uremic fetor.

Promote salt restriction in the diet strictly.
Reduction in salt intake may slow the progression of diabetic CKD, at least in part by lowering blood pressure. A randomized, controlled trial found that moderate dietary sodium reduction (approximately 2500 mg/day of Na+) added to angiotensin-converting enzyme (ACE) inhibition is more effective in reducing proteinuria and blood pressure in nondiabetic clients with modest CKD (Arora & Batuman, 2023).

Prepare the client for dialysis.
Acute or urgent dialysis is indicated when there is a high and increasing level of serum potassium, fluid overload, or impending pulmonary edema. Chronic or maintenance dialysis is indicated in advanced CKD and ESKD with the fluid overload that is not responsive to diuretics and fluid restriction.

3. Restoring Electrolyte Balance

In addition to monitoring laboratory work for results indicating fluid imbalance, electrolytes, specifically sodium, potassium, calcium, phosphorus, and magnesium, should be monitored and managed closely for clients at risk. Electrolyte imbalances may also occur from side effects of diuretics.

Replace potassium losses, as indicated.
A potassium deficit may occur, especially if the client is receiving a potassium-wasting diuretic. This can cause lethal cardiac dysrhythmias if untreated. If hypokalemia cannot be prevented by conventional measures such as increased intake in the daily diet or by oral potassium supplements for deficiencies, then it is treated cautiously with IV replacement therapy.

Provide a balanced protein, low-sodium diet. Restrict fluids, as indicated.
If serum proteins are low because of malnutrition or gastrointestinal (GI) losses, intake of dietary proteins can enhance colloidal osmotic gradients and promote a return of fluid to the vascular space. Restriction of sodium or water decreases extracellular fluid retention. An average daily diet not restricted in sodium contains 6 to 15 g of salt, whereas low-sodium diets can range from a mild restriction to as little as 250 mg of sodium per day, depending on the client’s needs.

Promote a limited sodium intake as prescribed.
Restriction of sodium aids in decreasing fluid retention. A mild sodium-restricted diet allows only light salting of food (about half the usual amount) in cooking and at the table, and no addition of salt to commercially prepared foods that are already seasoned. It is the sodium salt (sodium chloride) rather than sodium itself that contributes to edema.

Instruct the client to avoid water supplements.
Excess water supplements are avoided in clients receiving isotonic or hypotonic enteral feedings, particularly if abnormal sodium loss occurs or water is being abnormally retained. Actual fluid needs are determined by evaluating fluid intake and output, urine specific gravity, and serum sodium levels.

Review medications that can cause electrolyte imbalances.
The nurse should conduct careful medication reconciliation and review medications with the client or caregiver. Assess for medications that may cause fluid and electrolyte imbalances. Diuretics can provide a wide range of electrolyte imbalances based on the type of diuretic. Thiazides inhibit sodium reabsorption and can lead to the loss of sodium, chloride, potassium, and a slight decline in calcium levels (Kear, 2017).

4. Preventing Complications

If too much blood or intravenous solution is infused too quickly, hypervolemia can occur. This condition can be aggravated in clients who already have increased circulatory volume.

Encourage deep breathing and coughing exercises.
Pulmonary fluid shifts potentiate respiratory complications. Deep breathing and incentive spirometry are indicated for all clients to minimize or prevent atelectasis and improve ventilation. Additionally, it helps reduce the anxiety of the client having dyspnea.

Maintain semi-Fowler’s position if dyspnea or ascites is present.
Gravity improves lung expansion by lowering the diaphragm and shifting fluid to the lower abdominal cavity. For clients with ascites, lying flat can increase the pressure on the abdomen, which can further impair breathing and exacerbate symptoms. Elevating the upper body in a semi-Fowler position helps reduce the pressure on the diaphragm.

Provide safety measures as indicated such as putting the bed in a low position and using side rails.
Fluid shifts may cause cerebral edema and changes in mentation, especially in the geriatric population. Implement fall prevention measures such as ensuring a clutter-free environment, using non-slip mats, and providing assistive devices, such as handrails and bed rails, to maintain the client’s safety.

Prepare for and assist with dialysis or ultrafiltration, if indicated.
This may be done to rapidly reduce fluid overload, especially in the presence of severe cardiac or renal failure. Ultrafiltration is a method of fluid removal that is particularly useful in clients with renal dysfunction and expected diuretic resistance. Use of ultrafiltration in clients with decompensated heart failure and worsening renal function compared to conventional stepwise pharmacotherapy is associated with similar diuresis but more impaired renal function (Sovari & Sharma, 2020).

Prevent fluid overload caused by excessive intravenous infusion.
Overloading the circulatory system with excessive IV fluids causes increased blood pressure and central venous pressure. Its treatment includes decreasing the IV rate, monitoring vital signs frequently, and placing the client in a high-Fowler position. This complication can be avoided by using an infusion pump and by carefully monitoring all infusions.

Place a central venous pressure line as indicated.
Several readings are obtained to determine a range in CVP, and fluid replacement is continued to achieve a CVP between 8 and 12 mm Hg. interpreting blood volume on the basis of CVP readings alone has been recently challenged in literature; therefore, CVP readings should be used in conjunction with other assessment variables to assess blood volume.

Administer blood and blood products slowly as prescribed.
If too much blood is infused too quickly, hypervolemia can occur. This condition can be aggravated in clients who already have increased circulatory volume. Packed RBCs are safer to use than whole blood. If the administration rate is sufficiently slow, circulatory overload may be prevented. For clients who are at risk for, or already in, circulatory overload, diuretics are given prior to the transfusion or between units of PRBCs.

Monitor the client closely after the blood transfusion.
Transfusion-associated circulatory overload (TACO) can develop as late as six hours after transfusion. therefore, the client may need close monitoring after the transfusion is completed, particularly those who are at higher risk for developing this complication, such as older adults, those with a positive fluid balance prior to transfusion, clients with renal dysfunction, and clients with left vascular dysfunction.

5. Client and Caregiver Education

Educating the client and the caregiver about their condition empower them to actively participate in their care and promotes long-term management of fluid volume excess.

Educate the client and family members regarding fluid volume excess and its causes.
Information is key to managing problems. Edema occurs when there is a change in the capillary membrane, increasing the formation of interstitial fluid or decreasing the removal of interstitial fluid. Sodium retention is a frequent cause of the increased ECF volume. Burns and infection are examples of conditions associated with increased interstitial fluid volume.

Instruct the client, caregiver, and family members regarding fluid restrictions, as appropriate.
Information and knowledge about the condition are vital to clients who will be co-managing fluids. By restricting fluids as indicated by the healthcare provider, the volume of fluid in the body is reduced, which can help decrease edema. The amount of fluid entering the body is also reduced, helping restore a more balanced fluid status.

Reinforce the importance of taking diuretics as prescribed.
Diuretics aid in the excretion of excess body fluids. The most common side effect of any diuretic is mild hypovolemia, which can lead to transient dehydration and increased thirst. When there is overtreatment of diuretics, this could lead to severe hypovolemia, causing hypotension, dizziness, and syncope (Arumugham & Shahin, 2023).

Explain the rationale and intended effect of the treatment program.
Follow-up care will be the client’s or caregiver’s responsibility. Information is necessary to make correct choices in the future. The goal of treatment is to preserve or restore the circulating intravascular fluid volume. Thus, in addition to treating the cause of the edema, other treatments may include diuretic therapy, restriction of fluids and sodium, the elevation of the extremities, application of anti-embolism stockings, paracentesis, dialysis, and continuous renal replacement therapy.

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. Stockings are available in several heights, including knee-high, thigh-high, and pantyhose. Knee-high stockings are sufficient for most clients. Some stockings can cause skin irritation or pain, although proper measurement and fitting of the stockings can reduce the risk of discomfort (Sterns, 2023).

Educate the client and family members on the importance of proper nutrition, hydration, and diet modification.
Knowledge heightens compliance with the treatment plan. Clients should be instructed to read food labels carefully to determine salt content. Because about half of the ingested sodium is in the form of seasoning, seasoning substitutes can play a major role in decreasing sodium intake.

Educate the client with heart failure about the importance of adherence to the prescribed regimen.
Therapeutic regimens for heart failure are complex and require the client and family to make significant lifestyle changes. The inability to adhere to dietary and pharmacologic recommendations leads to episodes of acute decompensated heart failure and hospitalization. Nonadherence with diet and fluid restrictions and medications causes many hospital readmissions.

Provide information about community and government resources for client support.
Because of the high cost of hospitalization for heart failure, the Center for Medicare and Medicaid Services (CMS) initiated a program that reduces reimbursement to hospitals with a high 30-day readmission rate. Other options include home healthcare services, transitional care programs, and telehealth management programs.

Create an educational plan for a client who is about to be discharged.
The use of the teach-back technique to assess the client’s comprehension of the instructions can increase teaching effectiveness and prevent rehospitalization. The creation of an educational packet also facilitates effective client teaching. A basic home education plan for the client can be provided, along with a written copy of instructions.

Ensure the effectiveness of the discharge plan.
A number of evidence-based components are known to increase the effectiveness of a discharge plan. This includes comprehensive, client-centered instructions, scheduling follow-up visits with primary care providers within seven days of discharge, and following up by telephone within three days of discharge.

Instruct the client on ways to decrease leg swelling during long travels.
Sitting for prolonged periods, such as during air travel, can cause swelling of the lower extremities. The nurse may instruct the client to stand up and walk around every hour or two, wear loose-fitting, comfortable clothing, and consider wearing knee-high compression stockings. The client may also flex and extend the ankles and knees periodically, avoid crossing the legs, and change positions frequently while seated (Sterns, 2023,).

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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See also

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

Recommended external links and further reading for Fluid Volume Excess:

• Arora, P., & Batuman, V. (2023, May 26). Chronic Kidney Disease (CKD) Treatment & Management: Approach Considerations, Delaying or Halting Progression of Chronic Kidney Disease, Treating Pathologic Manifestations of Chronic Kidney Disease. Medscape Reference.
• Arumugham, V. B., & Shahin, M. H. (2023, May 29). Therapeutic Uses of Diuretic Agents – StatPearls. NCBI.
• Bansal, N. (2017, June 22). Measuring Fluid Overload and Mortality Risk in ESRD Patients. Medscape.
• Ernstmeyer, K., & Christman, E. (2021). Nursing Fundamentals. Open Resources for Nursing.
• Fouque, D., Kopple, J. D., Massry, S. G., & Kalantar-Zadeh, K. (Eds.). (2021). Nutritional Management of Renal Disease. Elsevier Science.
• Goyal, A., Cusick, A. S., & Bhutta, B. S. (2023, February 9). Peripheral Edema – StatPearls. NCBI.
• Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-surgical Nursing. Wolters Kluwer.
• John, G., Arcens, M., Berra, G., Garin, N., Carballo, D., Carballo, S., & Stirnemann, J. (2022). Risks and benefits of urinary catheterisation during inpatient diuretic therapy for acute heart failure: a retrospective, non-inferiority, cohort study. BMJ Open, 12(8).
• Kear, T. M. (2017). Fluid and Electrolyte Management Across the Age Continuum. Nephrology Nursing Journal, 44(6).
• Khan, A. N., Kasthuri, R. S., Macdonald, S., & Irion, K. L. (2018, August 8). Noncardiogenic Pulmonary Edema Imaging: Practice Essentials, Radiography, Computed Tomography. Medscape Reference.
• Lukitsch, I., & Batuman, V. (2023, January 3). Hypernatremia: Practice Essentials, Pathophysiology, Etiology. Medscape Reference.
• Sovari, A. A., & Sharma, G. K. (2020, July 23). Cardiogenic Pulmonary Edema: Background, Etiology, Prognosis. Medscape Reference.
• Sterns, R. H. (2023). Patient education: Edema (swelling) (Beyond the Basics). UpToDate.
• Vincent, J.-L., & Pinsky, M. R. (2018). We should avoid the term “fluid overload”. Critical Care, 22.
• 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.