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Buy the Full Version Reward Your CuriosityEverything you want to read. Anytime. Anywhere. Any device. No Commitment. Cancel anytime. Excess Fluid Volume Nursing Care Plans Diagnosis and InterventionsFluid Volume Excess NCLEX Review and Nursing Care Plans Fluid volume excess also known as hypervolemia, refers to the excessive accumulation of fluid in the extracellular fluid compartment. It may occur due to a variety of factors. Excess fluid volume is mainly associated with sodium regulation. A normal fluid volume is important in the balanced functioning of cells and sodium helps make this happen. Sodium is a major extracellular electrolyte. It maintains fluid balance through the concept of tonicity. The tonicity of a solution is related to whether the fluid will influence the cells or not. A solution that does not change the volume of the cell is called isotonic. While a hypotonic solution causes cells to swell, a hypertonic solution on the other hand makes cells shrink. Sodium moves around intracellularly and extracellularly to keep body fluids isotonic and not affect cells and their function. Restricting sodium and fluid intake is one of the effective treatment options to regain “normovolemia” or balanced fluid volume in the body. If left untreated, fluid volume excess can put a strain on the major organs in the body such as the heart, liver, and kidneys. Excess Fluid Volume Nursing Care Plan 1Heart Failure Nursing Diagnosis: Fluid Volume Excess related to compromised regulatory mechanism secondary to heart failure as evidenced by the presence of crackles and shortness of breath Desired Outcome: The patient will regain a balanced fluid volume as evidenced by ease of breathing and clear lung sounds.
Excess Fluid Volume Nursing Care Plan 2Chronic Kidney Disease (CKD) Nursing Diagnosis: Fluid Volume Excess related to renal insufficiency secondary to CKD as evidenced by bilateral leg edema, as well as a positive balance in the fluid balance chart. Desired Outcome: The patient will understand measures to maintain normovolemia in the presence of CKD.
Excess Fluid Volume Nursing Care Plan 3Hypertension Nursing Diagnosis: Fluid Volume Excess related to high sodium intake and chronic hypertension as evidenced by a serum sodium level of 149 mEQ/L and blood pressure of 180/98 mmHg Desired Outcome: The patient will restore normal fluid balance through interventions to normalize sodium level and blood pressure.
Excess Fluid Volume Nursing Care Plan 4Acute Respiratory Distress Syndrome (ARDS) Nursing Diagnosis: Fluid Volume Excess related to compromised respiratory mechanisms secondary to ARDS as evidenced by crackles upon auscultation, shortness of breath, restlessness, anxiety, and altered serum sodium levels Desired Outcome: The patient will restore normal fluid balance through interventions to normalize sodium level, reduce fluid retention in the lungs, and prevent pulmonary edema.
Excess Fluid Volume Nursing Care Plan 5Lupus: Long-term Steroid Therapy Nursing Diagnosis: Fluid Volume Excess related to long-term steroid therapy secondary to lupus as evidenced by bilateral leg edema, increased weight, and blood pressure of 160/100 mmHg Desired Outcome: The patient will achieve optimal normal fluid balance.
Nursing ReferencesAckley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon Disclaimer:Please follow your facilities guidelines and policies and procedures. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. |