Excess Fluid Volume - Nanda Nursing Diagnosis

Nursing Care Plan Excess Fluid Volume


Circumstances where an individual experiencing or at risk of excess intracellular or interstitial fluid.

Related Factors :
Related to interference regulator mechanism
Renal failure, acute or chronic
Related to increased preload, decreased contractility, and decreased cardiac output
Mmyocardial infarction
Congestive heart failure
Left heart failure
Valve disease
Tachycardia / arrhythmia
Related to portal hypertension, low plasma colloid osmotic pressure, sodium retention
Liver Disease: Cirrhosis, Ascites, Cancer
Related to damage the venous backflow
Varikose vein
Peripheral vascular disease
Chronic phlebitis
Related to retention of sodium and water
Corticosteroid therapy
Situational (Personal, environmental)
Related to the input excess sodium / liquid
Related tonnes of low protein intake
Related to venostatis / collection venosa
Splint or cast powerful
Stand or Sit down for a long time
Related to compression of the veins by the uterus during pregnancy
Related to inadequate lymphatic drainage
Related to damage the venous backflow
Increased resistance and decreased efficiency of the valve

Major data
  • Eedema
  • Skin taut, shiny

Minor data
  • Input more than the output
  • Shortness of breath
  • Weight gain

Expected outcomes

Individuals will:
1. Reveal the causative factors and prevention methods edema
2. showed a reduction in peripheral and sacral edema.


1. Assess inputs diet and habits that can support fluid retention
2. Encourage individuals to reduce salt intake
3. Teach individuals to
a. Read labels for sodium content
b. Avoid foods that are enjoyable, canned, and frozen foods.
c. Cook without salt, and use spices to add flavor (lemon, basil, mint)
d. Use vinegar salt substitute to taste soup, stew, etc.
4. Assess the evidence venostatis on the subject.
5. Keep extremity edema experiencing high above the heart if possible (unless there are contraindications to heart failure)
6. Instruct individuals to avoid pants made from shirt / corset, knee-high pants and crossed his legs down and elevate the legs still exercise when possible.
7. For inadequate drainage:
a. Keep the limb elevated on a pillow
b. Measure blood pressure in the arm is not sore
c. Do not give injections or intravenous fluids enter a pain in the arm.
d. Protect sore arm from injury.
e. Encourage individuals to avoid strong detergents, carrying heavy bags, smoke, injuring the epidermis or pimples on the nails, reaching into a hot oven, using jewelry or watches, or use a headband.
f. Warn people to see a doctor if the arms become red, swollen, or other hardware of the ordinary.
8. Protect your arm edema from injury.
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