NANDA Definition: Increased isotonic fluid retention
Fluid volume excess, or hypervolemia, occurs from an increase in total body sodium content and an increase in total body water. This fluid excess usually results from compromised regulatory mechanisms for sodium and water as seen in congestive heart failure (CHF), kidney failure, and liver failure. It may also be caused by excessive intake of sodium from foods, intravenous (IV) solutions, medications, or diagnostic contrast dyes. Hypervolemia may be an acute or chronic condition managed in the hospital, outpatient center, or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of fluid and sodium restriction, and the use of diuretics. For acute cases dialysis may be required.
Nursing Diagnosis Excess Fluid Volume
Excess Fluid Volume (Increased isotonic fluid retention) related to weak regulatory mechanism, excess fluid intake, excessive sodium intake. (weight gain, blood pressure changes, CVP increased, edema, Dypsneu, oliguria)
NOC : patients showed a balance of fluid volume
NIC :
- Fluid Management
- Nutrition management
- Respiratory management
