Nursing Care Plans

Nursing Care Plan For Nursing Diagnosis: Excess fluid volume

Definition of the Nursing Diagnosis Excess Fluid Volume:

The retention of water and sodium because of increased Aldosterone level.

Defining Characteristics:

• Rate of respiration is increased.
• Swelling of body parts.
• Hemoglobin level will be decreased.
• Changes in heart sounds.
• Imbalance of electrolytes.
• State of confusion.
• Shortness of breath.

Related factors:

• Disorders of liver.
• Dysfunction of kidneys.
• Cancers.
• High intake of sodium diet.
• Excessive fluid intake.

Nursing Outcomes:

• Blood pressure within normal limits.
• Pulse must be in normal limits.
• S3 heart sound should be absent.
• Level of sodium towards normal limits.
• Shortness of breath should be decreased.
• Normal mental condition.

Nursing Interventions and Rationale:

• Assessment of patient’s health and general condition.
  • Rationale: For basic knowledge of disease.
• Monitoring of vital signs of patient.
  • Rationale: Provide information about treatment plan.
• Inhibition of fluid intake by the patient.
  • Rationale: Prevent further retention of fluid in patient’s body.
• Position of patient must be change after time interval.
  • Rationale: To prevent pressure sores.
• Evaluation of patient mental status.
  • Rationale: To assess cerebral edema.
• Observe any edema on patient’s body.
  • Rationale: Indicates retention of fluid in patient’s body.
• Administer drugs to excrete excessive fluid.
  • Rationale: To excrete excess of fluids in patient’s body.