Definition of the NANDA label
Excess fluid volume is the state in which there is increased retention of isotonic body fluids and edema.
Surplus intake and/or retention of fluid.
The risk factors, NOC and NIC of the NANDA diagnosis “Excess fluid volume” are detailed below.
- Edema that can progress to anasarca.
- Electrolyte imbalance.
- Variations in blood pressure and pulmonary artery pressure.
- Increased central venous pressure.
- Weight gain in a short period of time, fluid intake is higher than elimination.
- Pleural effusion, dyspnea and orthopnea.
- Changes in breathing pattern.
- Auscultation of abnormal breath sounds (crackles and rales).
- Auscultation of the third heart sound (S3).
- Pulmonary congestion.
- Decreased hemoglobin and hematocrit.
- Distension of the jugular.
- Positive hepatojugular reflex.
- Oliguria, changes in urine density and azotemia.
- Agitation and anxiety.
- Alteration of regulatory mechanisms (production of aldosterone, production of antidiuretic hormone, renin-angiotensin system).
- Excess fluid intake.
- Excess sodium intake.
- Compromised regulatory mechanism
- Electrolyte and acid-base balance.
- Water balance.
- Neurological state.
- Manage the acid-base concentration.
- Electrolyte management.
- Fluid and electrolyte management.
- Manage hypervolemia.
- Liquid handling.
- Liquid monitoring.
- Bladder catheterization.
- Neurological monitoring.
- Monitor vital signs.
Other NANDA diagnoses:
00173 Risk for acute confusion
00062 Risk for caregiver role strain
00171 Readiness for enhanced religiosity
00061 Caregiver role strain
00160 Willingness to improve fluid volume balance
00029 Decreased cardiac output
00048 Impaired dentition
00120 Situational low self-esteem
00042 Risk for latex allergy reaction
00121 Disturbed personal identity