Hypervolemia & Hypovolemia (Fluid Imbalances) Nursing Care Plans

Hypervolemia: Excess Fluid Volume

Hypervolemia can occur due to excess fluid or sodium intake, which overwhelms the body’s regulatory mechanisms and leads to an accumulation of fluid in the extracellular space. Compromised regulatory mechanisms, such as impaired kidney function or hormonal imbalances, can also contribute to hypervolemia by reducing the body’s ability to excrete excess fluid and maintain fluid balance.

Nursing Diagnosis

• Excess Fluid Volume

May be related to

• Excess fluid or sodium intake.
• Compromised regulatory mechanism.

Possibly evidenced by

• Ascites.
• Aphasia, muscle twitching, tremors, seizures.
• Bounding pulses.
• Changes in the level of consciousness (lethargy, disorientation, confusion to coma).
• Crackles.
• Distended neck and peripheral veins.
• Edema variable from dependent
• Elevated central venous pressure.
• Extra heart sounds S₃.
• Hypertension.
• Productive cough.
• Shortness of breath.
• Sudden weight gain, often in excess of 5% of total body weight.
• Tachypnea with or without dyspnea, orthopnea.
• Tachycardia (usually present); bradycardia (a late sign of cardiac decompensation).

Desired Outcomes

• The client will verbalize understanding of individual dietary and fluid restrictions.
• The client will demonstrate behaviors to monitor fluid status and prevent or limit recurrence.
• The client will demonstrate stable fluid volume as evidenced by stable vital signs, balanced intake and output, stable weight, and absence of signs of edema.

Nursing Assessment and Rationales

Thorough nursing assessment is crucial in identifying the underlying causes of hypervolemia, monitoring the patient’s fluid status, and implementing appropriate nursing interventions to promote optimal health outcomes.

1. Monitor vital signs as well as central venous pressure, if available.
Tachycardia and hypertension are common manifestations. Tachypnea is usually present with or without dyspnea. Elevated CVP may be noted before dyspnea and adventitious breath sounds occur. Hypertension may be a primary disorder or occur secondary to other associated conditions such as heart failure.

2. Weigh clients daily. Observe for sudden weight gain.
One liter of fluid retention equals a weight gain of 1 kilogram (2.2 pounds). Daily weight measurement is essential in hypervolemia nursing care plans to detect minor changes in weight and prevent complications, and sudden weight gain should be observed as it may indicate fluid overload, requiring immediate nursing intervention.

3. Note the presence of neck and peripheral vein distention, along with pitting edema, and dyspnea.
These signs indicate fluid overload and can be used to assess the patient’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 in hypervolemia and can be caused by pulmonary congestion or edema. Monitoring and noting these signs is essential in guiding nursing interventions, promoting optimal patient outcomes, and preventing complications such as heart failure and pulmonary edema.

4. Auscultate lung and heart sounds.
Adventitious sounds (crackles) and extra heart sounds (S₃) are indicative of fluid excess, possibly returning in the rapid development of pulmonary edema.

5. Monitor intake and output. Note decreased urinary output and positive fluid balance on 24-hour calculations.
Decreased renal perfusion, cardiac insufficiency, and fluid shifts may cause decreased urinary output and edema formation.

6. Assess for the presence and location of edema formation.
Edema can be either a cause or a result of various pathological conditions reflecting four competing forces: blood hydrostatic and osmotic pressures and interstitial fluid hydrostatic and osmotic pressures. The dynamic interaction of these four forces allows fluid to shift from one body compartment to another. Edema may be generalized or localized in dependent areas. Older clients may develop dependent edema with relatively little excess fluid.

7. Monitor laboratory studies, such as sodium, potassium, BUN, and arterial blood gases (ABGs), as indicated.
Extracellular fluid shifts, sodium and water restriction, and renal function all affect serum sodium levels. Potassium deficit may occur with kidney dysfunction or diuretic therapy. BUN may be increased as a result of renal dysfunction. ABGs may reflect metabolic acidosis.

Nursing Interventions and Rationales

Nursing interventions are crucial for managing hypervolemia by improving fluid balance, preventing complications, and promoting health, and may include monitoring fluid, administering diuretics, and managing underlying conditions.

1. Monitor infusion rate of parenteral fluids closely; May use infusion pump, as necessary.
Rapid fluid bolus or prolonged excessive administration potentiates volume overload and the risk of cardiac decompensation.

2. 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.

3. Encourage adequate bed rest.
Limited cardiac reserves result in fatigue and activity intolerance. Rest, particularly lying down, favors diuresis and reduction of edema.

4. Encourage deep breathing and coughing exercises.
Pulmonary fluid shifts potentiate respiratory complications.

5. Turn or reposition, and provide skin care at regular intervals.
Decreases pressure and friction on edematous tissue, which is more prone to breakdown than normal tissue.

6. 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.

7. Provide safety measures as indicated such as putting the bed in a low position, providing soft restraints, and using side rails.
Fluid shifts may cause cerebral edema and changes in mentation, especially in the geriatric population.

8. 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.

9. 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.

10. Administer diuretics as indicated: loop diuretics such as furosemide (Lasix), potassium-sparing diuretics such as spironolactone (Aldactone), and Thiazide diuretics such as hydrochlorothiazide (Microzide).
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.

11. Prepare for and assist with dialysis or ultrafiltration, if indicated.
May be done to rapidly reduce fluid overload, especially in the presence of severe cardiac or renal failure.