Assessment:

Objective Data:

1. Monitor vital signs, including blood pressure, heart rate, and respiratory rate, to identify signs of fluid overload.
2. Assess for edema, particularly in dependent areas such as the ankles, legs, and sacral region.
3. Observe for signs of respiratory distress, such as dyspnea, crackles, and increased respiratory effort.
4. Review laboratory results, including electrolyte levels and renal function tests, to assess kidney function and electrolyte balance.

Subjective Data:

1. Conduct a thorough health history, including any recent changes in fluid intake, medications, or medical conditions.
2. Inquire about the patient’s perception of swelling, shortness of breath, or other symptoms associated with fluid retention.
3. Assess the patient’s dietary habits, including sodium intake and fluid consumption.

Diagnosis:

• Fluid Volume Excess Related to [Specify the underlying cause, e.g., heart failure, renal failure].

Planning:

• The patient will achieve fluid balance with decreased edema, normalized vital signs, and improved respiratory status within the next week.

Interventions:

1. Monitor Fluid Intake and Output:
   • Accurately measure and record the patient’s fluid intake, including oral, intravenous, and enteral fluids.
   • Monitor urinary output, assessing color, concentration, and volume.
2. Daily Weights:
   • Implement daily weights at the same time each day, using the same scale and clothing.
   • Educate the patient about the significance of weight changes and when to report sudden increases.
3. Assessment of Edema:
   • Regularly assess for the presence of edema, noting its location, extent, and any changes.
   • Use a graded scale to document the severity of edema (e.g., 1+ to 4+).
4. Blood Pressure Monitoring:
   • Monitor blood pressure regularly, observing for hypertension, which may indicate fluid overload.
   • Collaborate with the healthcare provider to adjust antihypertensive medications if needed.
5. Respiratory Assessment:
   • Assess respiratory status, including lung sounds, respiratory rate, and signs of respiratory distress.
   • Monitor for orthopnea and paroxysmal nocturnal dyspnea.
6. Dietary Management:
   • Collaborate with the dietitian to develop a sodium-restricted diet tailored to the patient’s needs.
   • Educate the patient about the importance of adhering to dietary restrictions.
7. Intravenous Therapy Management:
   • Manage intravenous fluids cautiously, adjusting infusion rates based on the patient’s fluid status.
   • Monitor for signs of fluid overload during intravenous therapy.
8. Medication Management:
   • Administer diuretics as prescribed, monitoring for electrolyte imbalances.
   • Educate the patient about the purpose of diuretic therapy and potential side effects.
9. Elevate Legs and Encourage Ambulation:
   • Instruct the patient to elevate legs when sitting or lying down to facilitate fluid drainage.
   • Encourage regular ambulation to promote venous return and reduce dependent edema.
10. Education on Self-Care:
    • Provide education on self-monitoring techniques, including recognizing signs of worsening edema or fluid retention.
    • Teach the patient to adjust fluid intake based on individual needs and dietary restrictions.
11. Collaboration with Interdisciplinary Team:
    • Collaborate with physicians, nurses, dietitians, and pharmacists to optimize fluid and electrolyte balance.
    • Communicate regularly with the healthcare team to ensure a coordinated approach to care.
12. Patient and Family Education:
    • Educate the patient and family about the importance of medication adherence and follow-up appointments.
    • Provide written materials and resources for ongoing education.

Evaluation:

• Assess changes in vital signs, including blood pressure, heart rate, and respiratory rate.
• Evaluate reductions in edema through regular assessments and documentation.
• Review daily weights for trends indicating fluid balance.
• Monitor laboratory results for improvements in electrolyte levels and renal function.
• Collaborate with the patient to assess the effectiveness of dietary and lifestyle modifications.
• Adjust the care plan based on ongoing assessments and the patient’s response to interventions.