Fluid Overload Nursing Diagnosis and Nursing Care Plans

Fluid Overload Nursing Care Plans Diagnosis and Interventions

Fluid Overload NCLEX Review and Nursing Care Plans

Fluid overload, also called hypervolemia, is a medical condition in which the body has too much water. While the body needs a certain amount of fluid to function properly, too much fluid can be harmful to one’s health.

Heart failure, kidney failure, cirrhosis, and pregnancy are only a few of the disorders that might cause it.

Signs and Symptoms of Fluid Overload

• Edema. The feet, ankles, legs, arms, wrists, and face are the most prevalent sites for edema or swelling. When a person presses on the area of swelling with the thumb and it makes an indentation, it is termed pitting edema. This condition might be a sign of a significant medical problem.
• Discomfort. Abdominal cramps, headaches, and stomach bloating are some of the discomforts that can be felt in the body.
• Hypertension. The excess fluid in the body causes the heart to work harder, causing blood pressure to rise.
• Shortness of breath and/or chest pain. Excess fluid entering the lungs causes shortness of breath, limiting the capacity to breathe properly. Chest pain could indicate pulmonary edema or fluid in the lungs.
• Cardiovascular problems. Because excess fluid can speed up or slow the heart rhythm, damage the heart muscles, and expand the size of the heart, it can cause heart problems.
• Weight gain. This is the most common symptom of fluid overload. Before they notice swelling in their legs or abdomen, most people gain 8 to 15 pounds.

Causes of Fluid Overload

In most cases, fluid overload is the outcome of an underlying health issue. Mild cases, on the other hand, can develop after eating foods high in sodium or during hormone imbalances, and normally resolve entirely on their own if there are no underlying health issues.

If detected early, fluid overload is usually manageable, but the underlying cause of it should be treated to prevent a recurrence.

Fluid overload is frequently caused by kidney problems. This is because the kidneys normally maintain the body’s salt and fluid levels in check. They raise the overall sodium content of the body by retaining salt, which increases the fluid volume.

The most typical causes of fluid overload are as follows:

• Heart failure, specifically right ventricular failure. When the heart muscle is weak or injured, it cannot pump blood as efficiently as it should. As a result, the kidneys are not getting enough blood to work properly. The body then retains fluid and salt to restore equilibrium, which causes fluid overload.
• Cirrhosis. It is commonly caused by excessive alcohol intake or hepatitis. Cirrhosis is the development of scar tissue on the liver caused by liver disease. Scar tissue inhibits the liver’s ability to function properly, causing fluid to accumulate in the abdomen.
• Kidney Failure. Kidney failure is frequently caused by diabetes and other metabolic illnesses. When the kidneys are not operating properly, fluid can build up in the body.
• Nephrotic syndrome. It is a condition in which the kidneys’ tiny blood vessels are damaged, resulting in excessive protein excretion in the urine. These blood vessels filter waste and excess water from the blood, and when they are damaged, the body is unable to eliminate the excess fluid.
• Other conditions. Other conditions, such as pregnancy, alter a woman’s hormonal balance and causes fluid retention. Premenstrual edema, or swelling that happens before a woman’s menstrual cycle, is another condition that can induce fluid overload.
• Intravenous (IV) Fluids. When someone is dehydrated or unable to consume enough fluids, such as after surgery, IV fluids can save a life. Too much IV fluid, on the other hand, can cause fluid overload, especially if other medical problems are present.
• Certain medications. Birth control pills, hormone replacement therapy, and other hormonal drugs that cause the body to retain too much salt and fluid can induce fluid overload. Mild fluid overload can also be caused by some antidepressants, blood pressure medicines, and nonsteroidal anti-inflammatory drugs (NSAIDs).
• Excessive salt consumption. According to a study, the average American eats 3,400 mg of salt per day, far more than the recommended maximum of 2,300 mg. When people eat too much sodium, the body retains water, causing moderate bloating and fluid overload. For generally healthy individuals, one salty meal is unlikely to cause difficulties. But excessive salt consumption can be fatal in small children, the elderly, and individuals with underlying health concerns.

Diagnosis of Fluid Overload

The following are methods commonly used to diagnose fluid overload:

• Medical History – there are a number of disorders that induce signs and symptoms similar to fluid overload, and they must be ruled out. Lung and heart issues, venous or lymphatic circulation problems, illnesses that cause low protein levels in the blood (hypoproteinemia), liver disease, and thyroid dysfunction are all examples of these conditions.
• Physical exam – if a person suspects or is exhibiting the signs of fluid overload, a physician should be consulted to confirm the diagnosis. A physical examination will be conducted by the doctor initially. Weight gain and swelling are two of the most common symptoms of fluid overload. Depending on whether an individual was sitting, reclining, or standing before the visit, one or more areas of the body may appear swollen.
• Blood tests – a blood test to monitor sodium levels and other electrolytes (biochemistry) is also likely to be performed by the physician. While total sodium levels in the body would rise as a result of fluid overload, sodium levels in blood tests may be high, normal, or low. A urine sodium test can aid establish whether fluid overload is caused by the kidneys or by something else. The urinary sodium level is frequently greater than 20 milliequivalents per liter (mEq/L) in kidney failure, but less than 10 mEq/L in heart failure, cirrhosis, and nephrotic syndrome.
• Imaging tests – several diagnostic tests, such as an electrocardiogram (ECG), an echocardiogram (ultrasound scanning of the heart), a chest X-ray, and other blood tests to check kidney function, blood count, liver function, and blood gases, may be recommended to rule out other conditions that resemble fluid overload or to determine the extent of complications if they have already occurred.

Complications of Fluid Overload

• Congestive heart failure (CHF) or pericarditis
• Poor wound healing
• Tissue breakdown
• Impaired bowel function
• Pulmonary edema

Treatment of Fluid Overload

Fluid overload treatment varies from person to person and is dependent on the underlying cause of the condition. It is usually treated with the following medical interventions:

1. Diuretics. Medications that aid in the removal of excess fluid from the body.
2. Dialysis. A procedure in which the blood is filtered through a machine and is usually done in extreme cases.
3. Paracentesis. A procedure in which a tiny tube is used to remove fluid from the abdomen.
4. Limiting salt consumption. When a person consumes too much salt, the body retains additional sodium, increasing the volume of fluid outside of the cells in the body. This increase in fluid allows the body to keep its sodium and fluid retention while excreting more sodium in the urine.
5. Weighing oneself every day. One way to assess if the condition is getting worse or need to adjust the medications to reduce extra fluid in the body is to weigh oneself every day.
6. Lifestyle modifications. Smoking cessation, maintaining a healthy weight, avoiding alcohol and caffeine, eating a well-balanced diet, getting enough sleep, and stress management are all examples of lifestyle changes.

Fluid Overload Nursing Diagnosis

Fluid Overload Nursing Care Plan 1

Nursing Diagnosis: Fluid Volume Excess related to excessive fluid and sodium intake, and renal insufficiency as evidenced by edema, oliguria, shortness of breath, increased heart rate, elevated blood pressure, and electrolytes imbalances.

Desired Outcome: The patient will maintain a normal volume of fluid in the body as evidenced by urine output greater than or equal to 30 mL/hour, balanced intake and output, and vital signs within normal limits.

Fluid Overload Nursing Care Plan 2

Ineffective Breathing Pattern

Nursing Diagnosis: Ineffective Breathing Pattern secondary to fluid overload as evidenced by productive cough, shortness of breath, weakness, and pink frothy sputum.

The patient’s breathing pattern will be efficient without inducing tiredness.

Fluid Overload Nursing Care Plan 3

Nursing Diagnosis: Impaired comfort secondary to fluid overload as evidenced by facial grimace, restlessness, and verbal reports of headache, abdominal cramps, and stomachache.

Desired Outcome: The patient’s level of discomfort will be reduced and the patient will demonstrate effective ways to alleviate discomforts caused by fluid overload.

Fluid Overload Nursing Care Plan 4

Anxiety

Nursing Diagnosis: Anxiety related to underlying pathophysiological process and changes in health condition secondary to fluid overload as evidenced by restlessness, expressed concern about lifestyle modifications, and fear of probable complications.

Desired Outcome: The patient will express anxiety awareness, identify tolerable anxiety levels, and display appropriate coping mechanisms.

Fluid Overload Nursing Care Plan 5

Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output related to alterations in rate, rhythm, and electrical conduction secondary to fluid overload as evidenced by increased heart rate, changes in blood pressure, decreased urine output, extra heart sounds, edema, and shortness of breath.

The patient will demonstrate adequate cardiac output as evidenced by vital signs within acceptable ranges, decreased episodes of shortness of breath, and adequate urinary output.

Nursing References

Ackley, 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. (2018). 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, 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 intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

Anna Curran. RN-BC, BSN, PHN, CMSRN I am a Critical Care ER nurse. I have been in this field for over 30 years. I also began teaching BSN and LVN students and found that by writing additional study guides helped their knowledge base, especially when it was time to take the NCLEX examinations.