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    Overhydration Nursing Care Plan: Wong, Karl Michael P

    Uploaded by

    Mikaela Wong
    1. The nursing care plan addresses excess fluid volume (overhydration) in a client presenting with edema in the lower extremities and jugular vein distention. 2. Interventions include monitoring location and extent of edema, intake and output, lab values, lung sounds, and jugular vein distention. Dietary sodium restriction and diuretic administration are also addressed if ordered. 3. The goal is for the client to be free of edema, maintain normal urine output and function, remain free of jugular distention, and have clear lung sounds within 1 hour of nursing interventions.

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    Overhydration Nursing Care Plan: Wong, Karl Michael P

    Uploaded by

    Mikaela Wong
    207 views8 pages
    1. The nursing care plan addresses excess fluid volume (overhydration) in a client presenting with edema in the lower extremities and jugular vein distention. 2. Interventions include monitoring location and extent of edema, intake and output, lab values, lung sounds, and jugular vein distention. Dietary sodium restriction and diuretic administration are also addressed if ordered. 3. The goal is for the client to be free of edema, maintain normal urine output and function, remain free of jugular distention, and have clear lung sounds within 1 hour of nursing interventions.

    Original Title

    NCP OVERHYDRATION

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    1. The nursing care plan addresses excess fluid volume (overhydration) in a client presenting with edema in the lower extremities and jugular vein distention. 2. Interventions include monitoring location and extent of edema, intake and output, lab values, lung sounds, and jugular vein distention. Dietary sodium restriction and diuretic administration are also addressed if ordered. 3. The goal is for the client to be free of edema, maintain normal urine output and function, remain free of jugular distention, and have clear lung sounds within 1 hour of nursing interventions.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    207 views8 pages

    Overhydration Nursing Care Plan: Wong, Karl Michael P

    Uploaded by

    Mikaela Wong
    1. The nursing care plan addresses excess fluid volume (overhydration) in a client presenting with edema in the lower extremities and jugular vein distention. 2. Interventions include monitoring location and extent of edema, intake and output, lab values, lung sounds, and jugular vein distention. Dietary sodium restriction and diuretic administration are also addressed if ordered. 3. The goal is for the client to be free of edema, maintain normal urine output and function, remain free of jugular distention, and have clear lung sounds within 1 hour of nursing interventions.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 8

    OVERHYDRATION

    Nursing care plan


    Wong, Karl Michael P.
    Assessment Nursing
    Diagnosis
     Subjective: Excess Fluid Volume related to renal
    “Bigla nalang nagmanas mga paa ko kaya insufficiency as evidenced by oliguria,
    nagpahospital na ako” as verbalized by the increase in weight over time and edema
    client

    Objective:
    (+) Grade 3 bilateral edema on ankles
    (+) slight effort on respiration; lung sounds
    clear
    (+) jugular distention
    Cold lower extremities
    UO: 25 ml/hr
    RR: 19
    PR: 131
    BP: 130/90
    Temp: 36.8
    Background Goal of Care
    Knowledge
    Excess fluid volume, or hypervolemia, refers Within 1 hour of nursing care, the patient is
    to an isotonic expansion of the ECF due to expected to:
    an increase in total body sodium content and  
    an increase in total body water. This fluid 1. Be free of edema
    overload usually occurs from compromised 2. Maintain urine output of 30 ml/hr with
    regulatory mechanisms for sodium and water normal urine osmolality and specific gravity
    as seen in congestive heart failure (CHF), 3. Remain free of jugular vein distention
    kidney failure, and liver failure. 4. Maintain current clear lung sounds; no
    evidence of dyspnea or orthopnea
    Nursing Rationale
    Interventions
    1. Monitor location and extent of edema 1. Edema occurs when fluid accumulates in
    using the 1+ to 4+ scale to quantify the extravascular spaces. Dependent areas
    edema. more readily exhibit signs of edema
    • Also measure the legs using a formation. Pitting edema is manifested by a
    millimeter tape in the same area. depression that remains after one’s finger is
    • Note differences in measurement pressed over an edematous area and then
    between extremities. removed.

    2. Accurately measuring intake and output


    2. Monitor intake and output is important for the client with fluid volume
    • Note trends reflecting decreasing urine overload
    output in relation to fluid intake.
    3. Monitor serum and urine osmolality, 3. In a client with fluid overload, an increase
    serum sodium, blood urea nitrogen dilution will usually be observed
    (BUN)/creatinine ratio, and hematocrit for  
    abnormalities.

    4. Acute pulmonary edema may be due to


    4. Auscultate lung sounds for crackles, increased permeability of the alveolar
    monitor respiration effort, and determine the capillary barrier
    presence and severity of orthopnea

    5. Increased intravascular volume results in


    5. With head of bed elevated 30 to 45 jugular vein distention, edema, crackles,
    degrees, monitor jugular veins for distention and S3 heart sound
    with the client in the
    upright position
    6. Provide a restricted-sodium diet as 6. Restricting the sodium in the diet will
    appropriate if ordered. favor the
    renal excretion of excess fluid. Take care to
    avoid hyponatremia, which can cause
    serious complications
    including nausea, seizures, coma, and
    death

    7. Administer prescribed diuretics as 7. Monitoring input and output is useful


    appropriate for monitoring effects of diuretic therapy
    • ensure adequate blood pressure
    before administration.
    • If diuretic is administered intravenously,
    note and record the blood pressure and
    urine output following the dose.
    8. Turn clients with dependent edema at 8. Severe edema predisposes clients to skin
    least every 2 hours. breakdown
    and pressure ulcers

    9. Consult with the health care provider if 9. Pulmonary edema requires prompt
    signs and symptoms of excess fluid volume treatment such as preload reducers,
    persist or worsen afterload reducers, and morphine to relieve
    anxiety
    Evaluation
     After 1 hour of nursing interventions, the goal was met as evidenced by:

    1. Client was free of edema


    2. Client maintained urine output of 30 ml/hr with normal urine osmolality and specific gravity
    3. Client remained free of jugular vein distention
    4. Client maintain current clear lung sounds; no evidence of dyspnea or orthopnea

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