00026 Excess fluid volume

Domain 2: nutrition
Class 5: hydration
Diagnostic Code: 00026
Nanda label: excess volume of liquids
Diagnostic focus: liquid volume
Approved 1982 • Revised 1996, 2013, 2017, 2020 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda’s nursing diagnosis « excess volume of liquids » is defined as: excessive fluid retention.

Definite characteristics

  • Abnormal respiratory sounds
  • Alteration of blood pressure
  • Alteration of mental state
  • Alteration of pulmonary blood pressure
  • Alteration of the respiratory pattern
  • Alteration of the specific density of urine
  • Anxiety
  • Azotemia
  • Decrease in serum hematocrit levels
  • Decrease in serum hemoglobin levels
  • edema
  • Hepatomegaly
  • Increased central venous pressure
  • Superior contributions to losses
  • Jugular Ingurgitation
  • Oliguria
  • Pleural spill
  • positive hepatoyugular reflex
  • Presence of heart noise S 3
  • Psychomotor agitation
  • Pulmonary congestion
  • Weight increase in a short period of time

Related factors

  • Excessive fluid intake
  • Excessive sodium intake
  • INEFICA MANAGEMENT OF MEDICATION

Associated problems

  • Deviations that affect the elimination of liquids
  • Pharmacological preparations

Suggestions of use

  • This label should not be used for states that the nursing professional cannot prevent or treat (for example, not use excess fluid volume to describe renal failure or pulmonary edema, since they belong to medical diagnoses). The main type of excess of the volume of liquids that the nursing professional can treat independently is the dependent peripheral edema, whose symptoms can be reduced by the elevation of the patient affected members.
  • Edema (an excessive symptom of liquid volume) is an important risk factor for the deterioration of skin integrity, which is resolved by educating the patient and taking protection measures. If the patient requires medical intervention to solve excess fluids, a collaboration problem should be used, such as that of a possible complication of renal failure: generalized edema. The excess of the volume of liquids could also cause problems, such as the possible complication due to the volume of liquids: pulmonary edema.
  • Incorrect: excess of the volume of liquids related to the decrease in cardiac expenditure
  • Correct: possible complication of decreased cardiac output: excess of the volume of liquids
  • Correct: possible complication of heart failure: pulmonary edema
  • Correct: Risk of deterioration of skin integrity related to excess volume of liquids, manifested by generalized edema

Suggested alternative diagnostics

  • cardiac spending, decrease in
  • Cutaneous integrity, risk of deterioration of
  • Inephic peripheral tissue perfusion
  • Volume of liquids, risk of imbalance of

NOC Results

  • Liquid balance: liquid balance in intracellular and extracellular spaces of the body
  • Renal functioning: blood filtration and elimination of metabolic waste products through urine formation
  • Severity of liquid overload: severity of excess fluids in intracellular and extracellular spaces of the body

Evaluation objectives and criteria

  • The excess of the volume of liquids is eliminated, as evidenced by the liquid balance, the minimal severity of the liquid overload and the indicators of adequate renal functioning:
  • The liquid balance is not compromised (by excess), as evidenced by the following indicators (specify from 1 to 5: seriously, substantially, moderately, slightly or not compromised):
    • Balance between intake and discharge in 24 hours
    • Body weight stability
    • Specific urine gravity
  • The liquid balance is not compromised (by excess), as evidenced by the following indicators (specify from 1 to 5: severe, substantial, moderate, light or none)
    • Ascitis, distension of the veins of the neck and peripheral edema
    • Anomalous respiratory noises

Other examples

The patient will be able to:

  • Verbally manifest your understanding of dietary and liquid restrictions
  • Verbally express your understanding of prescription medications
  • Maintain vital constants in normal limits for the patient
  • Do not suffer lack of breath
  • Have the hematocrit within normal limits

NIC Interventions

  • Urinary elimination management: Maintenance of an optimal urine elimination pattern
  • Hypervolemia management: Reduction of the volume of extracellular or intracellular fluid and prevention of complications in a patient with liquid overload
  • Liquid management: improvement of liquid balance and prevention of the resulting complications from abnormal or undesirable liquid concentrations
  • Management of liquids and electrolytes: regulation and prevention of complications derived from the alteration of liquid and electrolyte concentrations
  • Electrolyte surveillance: Patient data collection and analysis to regulate electrolyte balance
  • Liquid surveillance: Patient data collection and analysis to regulate liquid balance

Nursing Activities

Valuations

  • Specify the location and degree of peripheral, sacred and periorbital edema on a scale of 1+ to 4+
  • Evaluate pulmonary or cardiovascular complications as indicated by the increase in dyspnea, the increase in the pulse, the elevation of blood pressure, the existence of abnormal heart sounds or anomalous pulmonary sounds
  • Evaluate the limb or part of the body that suffers edema to verify the deterioration of circulation and cutaneous integrity
  • Evaluate the effects of medications (for example, spheroid, diuretics, lithium) on edema
  • Regularly control the abdominal contour or members
  • (NIC) Liquid management:
    • Weigh the patient daily and control their evolution
    • Maintain a precise record of intake and spending
    • Control the relevant laboratory results for fluid retention (for example, increased specific gravity, increased blood ureic nitrogen, hematocrit reduction, increase in urine osmolarity levels)
  • Monitor the indications of overload or fluid retention (for example, crepitants, PVC or elevated pulmonary capillary plot pressure, edema, distension of the veins of the neck and ascites), as required

Patient and family education

  • Teach the patient the causes and solutions of edema, dietary restrictions and use, dosage and side effects of prescription medications
  • (NIC) Liquid management: instruct the patient about the strict diet state, if necessary

Collaboration activities

  • Administer dialysis, if indicated
  • Consult with the primary care provider on the use of means against embolisms or bandages Ace
  • Consult with the dietitian to provide an adequate protein diet and reduced sodium
  • (NIC) Liquid management:
    • Consult the doctor if the signs and symptoms of excess volume of liquids persist or worsen
    • Administer prescription diuretics, as indicated

Others

  • Change the position every _________
  • Raise the limbs to increase the venous return
  • Maintain and assign the patient fluid restrictions
  • (NIC) Liquid management: distribute fluid intake for 24 hours, as indicated

At home

  • Help the patient and the family to integrate dietary and exercise restrictions into their lifestyle
  • Evaluate compliance with medical treatments and the use of medicines
  • Help the family recognize the signs and symptoms of worsening the excessive levels of liquid volume and knowing when to call the primary care provider and the emergency service of the town
    • Ask the patient to weigh every day on the same scale; Notify the doctor any weight change greater than 1.5 kg in 24 hours
    • Determine if there are factors that could interfere with the patient’s ability or motivation to comply with fluid and diets restrictions

Babies and Children

  • Calculate the daily liquid maintenance needs of the child based on weight. An amount of liquids equal to or greater than the one that has been lost

has been replaced

  • To measure the production of fluids in babies, diapers should be counted or weighed. A gram of wet diaper equals 1 mi of urine

 

Older people

  • The elderly are especially sensitive to the excess volume of liquids; Risk factors should be carefully monitored