Domain 2. Nutrition
Class 5. Hydration
Diagnostic Code: 00026
Nanda label: Excess fluid volume
Diagnostic focus: Fluid volume
Nursing diagnosis is among the most important skills nurses learn and use throughout their career. It involves the assessment of a patient’s physical and mental state, using both subjective and objective factors, to arrive at an appropriate diagnosis. The nurse then develops a staging plan for the assessment and care of the patient, working with other professionals in a team effort. In this article, we’ll dive into nursing diagnosis excess fluid volume – something many patients, particularly those with comorbid conditions, could experience in the clinical setting.
NANDA Nursing Diagnosis Definition
TheNational Alliance of Nursing Diagnosis (NANDA) defines excess fluid volume as “a state in which measurable and observable increases in the volume of extracellular– and/or intravascular fluids have occurred.” Fluid imbalance and excessive fluid administration are the most common causes of an increase in the body’s fluid balance.
Common subjectives include feelings of restlessness, fatigue, and sweating. Other subjectives may include a rapid heart rate and breathing, increased thirst, weak or absent peripheral pulse, dark yellow urine, and skin turgor. Objectives may include weight gain, decreased urine output, and edema.
A variety of factors can be linked to an excessive fluid volume issue, including underlying medical conditions such as cardiac or renal problems, electrolyte imbalances, inadequate fluid intake, medications, or fluid overload due to overexcretion or fluid shifts. Regardless of the cause, it is important that healthcare professionals competent differentiate between preexisting and new fluid loss and take adequate steps to address whatever is causing the disorder.
Associated conditions associated with excess fluid volume include heart failure, pulmonary edema, shock, and electrolyte disturbances. All of these conditions can have serious implications for the patient’s health in the short and long run.
Suggestions of Use
Healthcare professionals can help manage a patient’s excess fluid volume issue by optimizing nutrition, offering adequate hydration, discontinuing processes that may contribute to this condition, implementing diuretic protocols, and providing psychoeducation.
Suggested alternative NANDA Nursing Diagnosis
Nursing care for excess fluid volume should start with identifying whether fluid has accumulated in the extracellular space, intraperitoneal cavity, or pleural cavity. Once the location of the fluid is determined, the most appropriate alternative NANDA nursing diagnosis can then be applied. For example, if the accumulation is in the extracellular space, ‘Fluid Volume Deficit’ should be considered; if it is in the intraperitoneal cavity, ‘Ineffective Tissue Perfusion related to Fluid Overload’; and if it is in the pleural cavity, ‘Fluid Overload related to Pleural effusion’ should be used.
It is important to note that all of the above mentioned diagnosis are symptom-based and hence, require proper evaluation and thorough assessment to be accompanied before being implemented in practice. Additionally, lipid replacement therapy and hemodialysis may also be employed in certain scenarios.
Not applicable outcomes (NOCs) can help to ensure that the nurse practitioner takes appropriate action to control fluid status. The following NOCs may prove useful when working with a patient experiencing excess fluid volume: Body Fluid Balance, Fluid & Electrolyte Regulation, Fluid Intake, Fluid Output Self-Care, Activity Tolerance, Fluid Volume, Fluid Movement and Clearance, Nutritional Status and Water Balance. Each of these outcomes assesses how well the patient is managing their individual fluid requirements and can be modified over time based on the patient’s progress.
Evaluation Objectives and Criteria
Consequently, the goals for the evaluation of the effectiveness of nursing interventions for excess fluid volume include: (1) stabilization of the individual’s fluid balance; (2) prevention or reduction of edema, if present; and (3) appropriate and timely action taken by the healthcare professional when necessary.
Interventions related to the management of a patient’s excess fluid volume should be developed by the healthcare provider in accordance with the patient’s condition and specific requirements. Possible interventions include monitoring outcomes closely, engaging in a nutritional evaluation, administering fluids in a safe manner and at adequate rates, evaluating needs for diuretics, engaging in continual therapeutic assessment, keeping records of all interventions and the outcomes, evaluating possible complications, and providing psychoeducation.
Given the complexity of the situation and extent of potential side effects, nursing activities for the management of a patient with an excess fluid volume issue must be monitored closely. Such activities may include communication with the patient and caregivers, documenting vital signs such as weight, respiratory rate and blood pressure, maintenance of uninterrupted IV access, individualized diet plans, recordkeeping, and education.
Excess fluid volume is a complex clinical case requiring careful evaluation and purposeful clinical decision-making. Healthcare professionals must be proactive in managing the issue and employ different techniques to reach an effective and sustainable resolution. With appropriate assessment and multidisciplinary approaches, this condition must not be disregarded or overlooked.
Frequently Asked Questions
- What is excess fluid volume? Excess fluid volume is a state in which observable increases in the volume of extracellular-and/or intravascular fluids have occurred.
- What are the defining characteristics of excess fluid volume? Common subjectives include feelings of restlessness, fatigue, and sweating. Objectives may include weight gain, decreased urine output, and edema.
- What kind of associated conditions may present with excess fluid volume? Heart failure, pulmonary edema, shock, and electrolyte disturbances are some of the associated conditions associated with excess fluid volume
- What can healthcare professionals do to manage a patient’s excess fluid volume? Healthcare professionals can help manage a patient’s excess fluid volume issue by optimizing nutrition, offering adequate hydration, discontinuing processes that may contribute to this condition, implementing diuretic protocols, and providing psychoeducation.
- What nursing activities should be included in excess fluid volume management? Nursing activities for the management of a patient with excess fluid volume issue should include communication with the patient and caregivers, documenting vital signs, maintaining uninterrupted IV access, individualized diet plans, recordkeeping, and education.