NCP Edema - Fluid Volume Excess NIC NOC

Definition: increased isotonic fluid retention

Defining characteristics:
  • Body weight increased in a short time
  • Excessive intake than output
  • Altered blood pressure, pulmonary artery pressure changes, increased CVP
  • Jugular venous distention
  • Changes in breathing pattern, dyspnoe / shortness of breath, orthopnoe, abnormal breath sounds (Rales or crackles), pulmonary congestion, pleural effusion
  • Decreased hemoglobin and hematocrit, electrolyte changes, particularly changes in density
  • Heart sound SIII
  • Reflex positive hepatojugular
  • Oliguria, azotemia
  • Mental position changes, nervousness, anxiety

Related Factor:
  • Weak regulatory mechanisms
  • Excessive fluid intake
  • Excessive sodium intake

NOC Labels:
  • Electrolit and acid base balance
  • Fluid balance
  • Hydration

Expected outcomes:
  • Free from edema, effusion, anasarca
  • The sound of breathing clean, no dyspnea / orthopnea
  • Free from jugular venous distention, reflexes hepatojugular (+)
  • Maintaining central venous pressure, pulmonary capillary wedge pressure, cardiac output and vital sign within normal limits
  • Free from fatigue, anxiety or confusion
  • Explaining the excess fluid indicator

NIC:


Fluid management
  • Weigh diapers / pads if needed
  • Maintain a record of intake and output accurately
  • Insert urinary catheter if necessary
  • Monitor lab results that correspond to fluid retention (BUN, Hmt, urine osmolality)
  • Hemodynamic Monitor position including CVP, MAP, PAP, and PCWP
  • Monitor vital sign
  • Monitor indications retention / excess fluid (cracles, CVP, edema, distended neck veins, ascites)
  • Assess the location and size of edema
  • Monitor the input of food / liquid and count daily calorie intake
  • Monitor portion of nutrients
  • Give diuretics as instructed
  • Limit fluid intake on the state of dilution hyponatremia with serum Na less than 130 mEq / l
  • Collaboration doctor if signs of excess fluid appears to deteriorate.

Fluid Monitoring
  • Determine history of the number and type of fluid intake and elimination
  • Determine the possible risk factors of fluid imbalance (Hyperthermia, diuretic therapy, renal disorders, heart failure, diaphoresis, liver dysfunction, etc.)
  • Monitor weight
  • Monitor serum and urine electrolytes
  • Monitor serum and urine osmilalitas
  • Monitor BP, HR, and RR
  • Monitor blood pressure and orthostatic changes in heart rhythm
  • Monitor invasive hemodynamic parameters
  • Record intake and output accurately
  • Monitor the neck distention, peripheral eodem and weight gain
  • Give drugs that can increase urine output
  • Monitor signs and symptoms of edema.

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