Excess fluid volume, fluid overload, and fluid or water retention are all phrases to describe the medical term, hypervolemia. Hypervolemia is when the body has too much fluid. Fluid overload occurs when the body can’t get rid of fluid or holds onto it (retention). The most common causes of true hypervolemia include underlying disease processes such as liver cirrhosis, kidney failure, and congestive heart failure. Mild hypervolemia can occur as a part of normal hormonal fluctuations or by eating too much salt. Without underlying disease, the body’s normal compensatory mechanisms will excrete the excess fluid.
Nurses need to understand the role of diseases and their effect on fluid as well as the complications of excess fluid volume. Nurses must intervene through ongoing assessment and monitoring, diet and fluid restrictions, patient education, and medication administration to prevent and treat excess fluid.
In this article:
- Causes (Related to)
- Signs and Symptoms (As evidenced by)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Causes (Related to)
The following are the common causes of excess fluid volume:
- Malnutrition
- Syndrome of inappropriate antidiuretic hormone (SIADH)
- Excess fluid intake either orally or intravenous
- Excess sodium intake
- Steroid use
- Hormonal imbalance
- Kidney failure
- Heart failure
- Liver failure
Signs and Symptoms (As evidenced by)
The following are the common signs and symptoms of excess fluid volume. They are categorized into subjective and objective data based on patient reports and assessment by the nurse.
Subjective (Patient reports)
- Difficulty breathing
- Anxiety
- Weight gain or swelling
Objective (Nurse assesses)
- Shortness of breath (orthopnea, dyspnea, increased respiratory rate)
- Adventitious breath sounds (rales or crackles)
- Abnormal electrolyte levels
- High blood pressure
- Edema
- Change in mental status
- Restlessness
- Decreased hemoglobin or hematocrit
- Increased central venous pressure
- Jugular vein distention
- Oliguria
- Tachycardia
- Pulmonary congestion/edema
Expected Outcomes
The following are the common nursing care planning goals and expected outcomes for excess fluid volume:
- Patient will display normal fluid volume as evidenced by balanced intake and output.
- Patient will display no signs of edema or sudden weight gain.
- Patient will present with clear breath sounds and a normal respiratory rate.
- Patient verbalizes understanding of the importance of fluid restrictions if ordered.
- Patient verbalizes how to monitor for excess fluid volume.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to excess fluid volume.
1. Assess for potential causes of excess fluid volume.
Chronic conditions such as heart failure, kidney failure, and cirrhosis can easily lead to fluid overload.
2. Monitor intake and output.
Monitoring sources of intake (oral, IV) and comparing to the patient’s output (if a urinary catheter is inserted) will help prevent fluid overload.
3. Monitor vital signs.
Sudden changes in heart rate, increased blood pressure, and respiratory rate can indicate an increase in fluid volume.
4. Monitor lung sounds.
Lung sounds that can be described as “wet” or crackles can indicate increased pulmonary congestion.
5. Assess for edema and weight gain.
Pitting edema to the body, such as in the arms, hands, legs, feet or sacrum is a sign of fluid in the tissues. A sudden weight gain also indicates fluid retention. Patients with liver cirrhosis may develop ascites, which is an accumulation of fluid in the abdominal cavity.
6. Palpate pulses.
A bounding peripheral pulse is a sign of fluid overload.
7. Monitor lab values.
With excess fluid volume, electrolytes may be diluted causing low sodium (hyponatremia). Serum osmolality will be decreased with overhydration. Hematocrit will also decrease with an excess of circulating blood volume. BUN measures kidney function and will decrease with too much fluid.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you’ll learn more about possible nursing interventions for a patient with excess fluid volume.
1. Enforce fluid restrictions and educate on the importance.
If a fluid restriction is ordered, the nurse should educate the patient and their family on the reason for better adherence. Fluid restrictions prevent the patient from taking in too much extra fluid.
2. Record accurate intake and output.
Along with enforcing fluid restrictions, monitoring and recording accurate I&O is vital. All intake from IV fluids, water taken with medications, and meal intake need to be documented so it can be compared to the patient’s urine output.
3. Record daily weights.
A patient at risk for fluid overload should have their weight monitored daily. This should be done at the same time each day using the same scale or bed scale. If at home, the patient should weigh themselves at the same time (preferably in the morning before eating and dressing).
4. Educate the patient and family on signs of fluid gain.
Swelling in extremities, shortness of breath, needing to sleep sitting up (orthopnea), weight gain of 2 pounds in 24 hours or 5 pounds in a week, and observed mental status changes are signs of fluid retention and overload.
5. Administer diuretics.
Diuretics rid the body of excess sodium and water in the body. This can relieve high blood pressure, edema, and shortness of breath.
6. Review dietary restrictions.
Patients may be on a low or restricted sodium diet. Monitor for appropriate meals, provide salt substitutes and educate on diet changes such as reading food labels, restricting fast or frozen foods and eliminating table salt.
7. Consult with a dietician.
If patients cannot maintain proper diets or restrictions they may require further teaching and interventions from a registered dietician.
8. Provide mouth care.
Fluid restrictions can be uncomfortable and result in a dry mouth and poor oral hygiene. Offer the patient mouth swabs and frequent oral care to reduce discomfort.
9. Assist with procedures such as paracentesis or dialysis.
Patients with liver failure may require the removal of fluid from their abdomen (ascites) via a paracentesis to relieve pressure and other symptoms. Dialysis removes waste and excess fluid from patients with kidney failure.
10. Reposition and provide skin care.
Place patients in Semi-Fowlers or High-Fowler’s position as tolerated to assist with breathing. Reposition every 2 hours to and elevate extremities to promote circulation. Patients with edema are at a high risk of skin breakdown.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for excess fluid volume.
Care Plan #1
Diagnostic statement:
Excess fluid volume related to inadequate lymphatic drainage secondary to mastectomy as evidenced by edema.
Expected outcomes:
- Patient will be free of edema.
- Patient will verbalize understanding of measures to treat and prevent post-mastectomy lymphedema.
Assessment:
1. Monitor the skin for edema.
Edema occurs when fluid accumulates in the extravascular spaces. It is graded from trace (barely perceptible) to four (severe edema) or measured using a tape measure.
2. Assess for signs and symptoms of infection (i.e., fever, weakness, local inflammation).
The limb with lymphedema is at increased risk of developing cellulitis or skin infection that may become severe to necessitate hospitalization.
Interventions:
1. Take care of the edematous limb by using compression devices and elevating the affected extremity above the heart.
These measures help improve blood flow by moving the extra fluid back to the heart.
2. Avoid medical procedures such as venipuncture or blood pressure taking on the affected arm as much as possible. Do these procedures preferably on the contralateral arm. Medical procedures may still be done on the affected arm as a last resort.
Lymphedema is an increased risk for trauma and infection. Hence, maintaining skin integrity is of utmost importance. However, contrary to previous studies, recent researchers claimed that there is little evidence to prove that conducting medical procedures on the affected arm will increase the risk of breast cancer-related lymphedema in patients who underwent a unilateral mastectomy. However, more high-quality research is needed before these precautionary measures are discarded. The nurse should follow their institutional guidelines.
3. Encourage or assist the patient in performing ROM exercises.
Exercise helps in improving lymphatic drainage, thus reducing the severity of lymphedema.
4. Educate on measures to prevent trauma or injury to the affected area:
- Wash the skin daily with mild soap to keep the skin clean.
- Avoid cutting cuticles or picking at the skin around the nails of the affected limb.
- Moisturize skin with lotion to avoid skin cracks and dryness.
- When shaving, use an electric razor instead of a blade.
- Never forget to wear sunscreen while outside.
- Contact a healthcare provider if a cut, bite, or scrape occurs on the affected limb.
Although lymphedema is usually benign and non-life-threatening, the condition can persist for a few months, interfering with ADL performance and affecting the quality of life. These measures will help to protect the affected limb from injury and infection that may cause more complicated problems.
Nursing Care Plan #2
Diagnostic statement:
Excess fluid volume related to low protein intake as evidenced by edema.
Expected outcomes:
- Patient will be free of symptoms of malnutrition such as hypoglycemia, hypothermia, dehydration, electrolyte imbalance and micronutrient deficiencies.
- If the patient is a child, once they have been stabilized a plan should be implemented to achieve appropriate growth for their life stage.
- Patient will address the underlying cause of malnutrition.
Assessment:
1. Obtain diet history contributing to fluid retention.
Protein malnutrition causes edema. Proteins maintain fluid homeostasis by keeping the fluid within the intravascular space. Assessing the patient’s usual foods or dietary habits while noting protein intake will help the nurse plan a more appropriate diet for the patient.
2. Assess for complications of malnutrition.
If malnutrition is severe, it will lead to electrolyte imbalances, immune system stunting, liver cirrhosis and pancreas atrophy.
Interventions:
1. Treat hypoglycemia and dehydration.
Special formulas to slowly restore blood sugar and hydration are given initially in cases of extreme malnutrition. It is key to cautiously start correcting malnutrition because there is the risk of causing refeeding syndrome. Refeeding syndrome can be a life threatening complication.
2. Treat electrolyte imbalance.
Usually electrolyte imbalances are corrected using an electrolyte formula. However, if they are severe, medical intervention may be necessary.
3. Provide and educate about a balanced meal plan.
A balanced meal plan with adequate macro and micronutrients is necessary to reverse malnutrition and excessive fluid volume.
4. Collaborate with a dietitian as needed.
Dietitians are the experts in providing nutritional assessments and interventions. A multidisciplinary approach to combat malnutrition is essential for making an individualized meal plan that replenishes nutrient deficiencies.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Cleveland Clinic. (2023). Kwashiorkor. https://my.clevelandclinic.org/health/diseases/23099-kwashiorkor
- Daily Weights. (n.d.). American Association of Heart Failure Nurses. https://www.aahfn.org/mpage/dailyweights
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
- Fluid Excess/Intoxication. (n.d.). Physiopedia. https://www.physio-pedia.com/Fluid_Excess/Intoxication
- Gillespie, T. C., Sayegh, H. E., Brunelle, C. L., Daniell, K. M., & Taghian, A. G. (2018). Breast cancer-related lymphedema: risk factors, precautionary measures, and treatments. Gland surgery, 7(4), 379–403. https://doi.org/10.21037/gs.2017.11.04
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Lewis, S. (2020, December 4). Hypervolemia (Fluid Overload). Healthgrades. https://www.healthgrades.com/right-care/symptoms-and-conditions/hypervolemia-fluid-overload
- Mayo Clinic. (2023). Edema. https://www.mayoclinic.org/diseases-conditions/edema/diagnosis-treatment/drc-20366532
- Mehrara, B. (2023). Patient education: Lymphedema after cancer surgery (beyond the basics). Uptodate. https://www.uptodate.com/contents/lymphedema-after-cancer-surgery-beyond-the-basics#H3705030
