UNKLAB NURSING PORTAL

Home » Nursing-Advanced Sub » Med-Sur Nursing » Cardio, GI & Respi » NCP Excess Fluid Volume — Heart Failure (CHF)

NCP Excess Fluid Volume — Heart Failure (CHF)

Image Courtesy: http://nurseslabs.com/

NURSING DIAGNOSIS

May be related to

  • Reduced glomerular filtration rate (decreased cardiac output)/increased antidiuretic hormone (ADH) production, and sodium/water retention
Possibly evidenced by

  • Orthopnea, S3 heart sound
  • Oliguria, edema, JVD, positive hepatojugular reflex
  • Weight gain
  • Hypertension
  • Respiratory distress, abnormal breath sounds

Desired Outcomes
Fluid Balance (NOC)

  • Demonstrate stabilized fluid volume with balanced intake and output, breath sounds clear/clearing, vital signs within acceptable range, stable weight, and absence of edema.
  • Verbalize understanding of individual dietary/fluid restrictions.

Nursing Interventions & Rationale

Nursing Interventions Rationale
 Monitor urine output, noting amount and color, as well as time of day when diuresis occurs.  Urine output may be scanty and concentrated (especially during the day) because of reduced renal perfusion. Recumbency favors diuresis; therefore, urine output may be increased at night/during bedrest.
 Monitor/calculate 24-hour intake and output (I&O) balance.  Diuretic therapy may result in sudden/excessive fluid loss (circulating hypovolemia), even though edema/ascites remains.
 Maintain chair or bedrest in semi-Fowler’s position during acute phase.  Recumbency increases glomerular filtration and decreases production of ADH, thereby enhancing diuresis.
 Establish fluid intake schedule if fluids are medically restricted, incorporating beverage preferences when possible. Give frequent mouth care/ice chips as part of fluid allotment.  Involving patient in therapy regimen may enhance sense of control and cooperation with restrictions.
 Weigh daily.  Documents changes in/resolution of edema in response to therapy. A gain of 5 lb represents approximately 2 L of fluid. Conversely, diuretics can result in rapid/excessive fluid shifts and weight loss.
 Assess for distended neck and peripheral vessels. Inspect dependent body areas for edema with/without pitting; note presence of generalized body edema (anasarca).  Excessive fluid retention may be manifested by venous engorgement and edema formation. Peripheral edema begins in feet/ankles (or dependent areas) and ascends as failure worsens. Pitting edema is generally obvious only after retention of at least 10 lb of fluid. Increased vascular congestion (associated with RHF) eventually results in systemic tissue edema.
 Change position frequently. Elevate feet when sitting. Inspect skin surface, keep dry, and provide padding as indicated.  Edema formation, slowed circulation, altered nutritional intake, and prolonged immobility/bedrest are cumulative stressors that affect skin integrity and require close supervision/preventive interventions.
 Auscultate breath sounds, noting decreased and/or adventitious sounds, e.g., crackles, wheezes. Note presence of increased dyspnea, tachypnea, orthopnea, paroxysmal nocturnal dyspnea, persistent cough.  Excess fluid volume often leads to pulmonary congestion. Symptoms of pulmonary edema may reflect acute left-sided HF. RHF’s respiratory symptoms (dyspnea, cough, orthopnea) may have slower onset but are more difficult to reverse.
 Investigate reports of sudden extreme dyspnea/air hunger, need to sit straight up, sensation of suffocation, feelings of panic or impending doom.  May indicate development of complications (pulmonary edema/embolus) and differs from orthopnea paroxysmal nocturnal dyspnea in that it develops much more rapidly and requires immediate intervention.
 Monitor BP and central venous pressure (CVP)  Hypertension and elevated CVP suggest fluid volume excess and may reflect developing/increasing pulmonary congestion, HF.
 Assess bowel sounds. Note complaints of anorexia, nausea, abdominal distension, constipation.  Visceral congestion (occurring in progressive HF) can alter gastric/intestinal function.
Provide small, frequent, easily digestible meals. Reduced gastric motility can adversely affect digestion and absorption. Small, frequent meals may enhance digestion/prevent abdominal discomfort.
Measure abdominal girth, as indicated. In progressive RHF, fluid may shift into the peritoneal space, causing increasing abdominal girth (ascites).
Encourage verbalization of feelings regarding limitations. Expression of feelings/concerns may decrease stress/anxiety, which is an energy drain that can contribute to feelings of fatigue.
Palpate abdomen. Note reports of right upper quadrant pain/tenderness. Advancing HF leads to venous congestion, resulting in abdominal distension, liver engorgement (hepatomegaly), and pain. This can alter liver function and impair/prolong drug metabolism.
Administer medications as indicated:
Diuretics, e.g., furosemide (Lasix), bumetanide (Bumex)Thiazides with potassium-sparing agents, e.g., spironolactone (Aldactone)Potassium supplements, e.g., K-Dur
Signs of potassium and sodium deficits that may occur because of fluid shifts and diuretic therapy.Increases rate of urine flow and may inhibit reabsorption of sodium/chloride in the renal tubules.Promotes diuresis without excessive potassium losses.Replaces potassium that is lost as a common side effect of diuretic therapy, which can adversely affect cardiac function.
Maintain fluid/sodium restrictions as indicated.  Reduces total body water/prevents fluid reaccumulation.
Consult with dietitian.  May be necessary to provide diet acceptable to patient that meets caloric needs within sodium restriction.
Monitor chest x-ray.  Reveals changes indicative of increase/resolution of pulmonary congestion.
Assist with rotating tourniquets/phlebotomy, dialysis, or ultrafiltration as indicated.  Although not frequently used, mechanical fluid removal rapidly reduces circulating volume, especially in pulmonary edema refractory to other therapies
 Source:
Advertisements