Excess Fluid Volume Nursing Diagnosis & Care Plan

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) usually caused by excess sodium. Water follows sodium in the body, so if there is too much sodium, there will also be too much water. Minor fluid retention can occur when eating salty foods. More concerning fluid overload occurs due to underlying disease processes such as liver cirrhosis, kidney failure, and congestive heart failure. 

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.

Causes of Excess Fluid Volume (Related to)

• Malnutrition 
• Burns 
• Syndrome of inappropriate antidiuretic hormone (SIADH) 
• Excess fluid intake either orally or intravenous 
• Excess sodium intake 
• Kidney failure 
• Heart failure 
• Liver failure 

Signs and Symptoms (As evidenced by)

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

• 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 
• Patient verbalizes how to monitor for excess fluid volume

Nursing Assessment for 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. 
Increased heart rate, 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, and feet 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 for 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. This also prevents skin breakdown.

References and Sources

1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
2. Lewis, S. (2020, December 4). Hypervolemia (Fluid Overload). Healthgrades. https://www.healthgrades.com/right-care/symptoms-and-conditions/hypervolemia-fluid-overload
3. Fluid Excess/Intoxication. (n.d.). Physiopedia. https://www.physio-pedia.com/Fluid_Excess/Intoxication
4. Daily Weights. (n.d.). American Association of Heart Failure Nurses. https://www.aahfn.org/mpage/dailyweights