Excess Fluid Volume

ADS
Increased isotonic fluid retention

Defining Characteristics:
  • Jugular vein distention; 
  • decreased hemoglobin and hematocrit; 
  • weight gain over short period; 
  • changes in respiratory pattern, dyspnea or shortness of breath; 
  • orthopnea; 
  • abnormal breath sounds (rales or crackles); 
  • pulmonary congestion; 
  • pleural effusion; 
  • intake exceeds output; 
  • S3 heart sound; 
  • change in mental status; 
  • restlessness; 
  • anxiety; 
  • blood pressure changes; 
  • pulmonary artery pressure changes; 
  • increased central venous pressure; 
  • oliguria; 
  • azotemia; 
  • specific gravity changes; 
  • altered electrolytes; 
  • edema, may progress to anascara; 
  • positive hepatojugular reflex

Related Factors:
  • Compromised regulatory mechanism; 
  • excess fluid intake; 
  • excess sodium intake

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Electrolyte and Acid-Base Balance
  • Fluid Balance
  • Hydration
Client Outcomes
  • Remains free of edema, effusion, anascara; weight appropriate for client
  • Maintains clear lung sounds; no evidence of dyspnea or orthopnea
  • Remains free of jugular vein distention, positive hepatojugular reflex, and gallop heart rhythm
  • Maintains normal central venous pressure, pulmonary capillary wedge pressure, cardiac output, and vital signs
  • Maintains urine output within 500 ml of intake and normal urine osmolality and specific gravity
  • Remains free of restlessness, anxiety, or confusion
  • Explains measures that can be taken to treat or prevent excess fluid volume, especially fluid and dietary restrictions and medications
  • Describes symptoms that indicate the need to consult with health care provider
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Fluid Management
  • Fluid Monitoring

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