00026 Excess fluid volume

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00026 Excess fluid volume

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.

Defining characteristics

  • 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.

Related factors

  • Alteration of regulatory mechanisms (production of aldosterone, production of antidiuretic hormone, renin-angiotensin system).
  • Excess fluid intake.
  • Excess sodium intake.

Associated condition

  • Compromised regulatory mechanism

NOC

  • Electrolyte and acid-base balance.
  • Water balance.
  • Hydration.
  • Neurological state.

NIC

  • Manage the acid-base concentration.
  • Electrolyte management.
  • Fluid and electrolyte management.
  • Manage hypervolemia.
  • Liquid handling.
  • Liquid monitoring.
  • Bladder catheterization.
  • Neurological monitoring.
  • Monitor vital signs.
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