![]() Hematocrit will also decrease with an excess of circulating blood volume. Serum osmolality will be decreased with overhydration. With excess fluid volume, electrolytes may be diluted causing low sodium ( hyponatremia). Patients with liver cirrhosis may develop ascites, which is an accumulation of fluid in the abdominal cavity.Ī bounding peripheral pulse is a sign of fluid overload. A sudden weight gain also indicates fluid retention. Pitting edema to the body, such as in the arms, hands, legs, and feet is a sign of fluid in the tissues. Lung sounds that can be described as “wet” or crackles can indicate increased pulmonary congestion. Increased heart rate, blood pressure, and respiratory rate can indicate an increase in fluid volume. Monitoring sources of intake (oral, IV) and comparing to the patient’s output (if a urinary catheter is inserted) will help prevent fluid overload. Assess for potential causes of excess fluid volume.Ĭhronic conditions such as heart failure, kidney failure, and cirrhosis can easily lead to fluid overload. Nursing Assessment for Excess Fluid Volumeġ. Patient verbalizes how to monitor for excess fluid volume.Patient verbalizes understanding of the importance of fluid restrictions.Patient will present with clear breath sounds and a normal respiratory rate.Patient will display no signs of edema or sudden weight gain.Patient will display normal fluid volume as evidenced by balanced intake and output.Adventitious breath sounds (rales or crackles).Shortness of breath (orthopnea, dyspnea, increased respiratory rate).Signs and Symptoms (As evidenced by) Subjective: (Patient reports) Excess fluid intake either orally or intravenous.Syndrome of inappropriate antidiuretic hormone (SIADH).Causes of Excess Fluid Volume (Related to) Nurses must intervene through ongoing assessment and monitoring, diet and fluid restrictions, patient education, and medication administration to prevent and treat excess fluid. Nurses need to understand the role of diseases and their effect on fluid as well as the complications of excess fluid volume. More concerning fluid overload occurs due to underlying disease processes such as liver cirrhosis, kidney failure, and congestive heart failure. Minor fluid retention can occur when eating salty foods. Water follows sodium in the body, so if there is too much sodium, there will also be too much water. Fluid overload occurs when the body can’t get rid of fluid or holds onto it (retention) usually caused by excess sodium. Hypervolemia is when the body has too much fluid. Excess fluid volume, fluid overload, and fluid or water retention are all phrases to describe the medical term, hypervolemia. ![]()
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