Nursing Care Plan

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Medical Diagnoses: Excess Fluid Volume, Compromised regulatory mechanism


Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale






No subjective data based on documents.








Atrial fibrillation w/ rapid ventricular response, left axis deviation, pulmonary disease pattern, inferior infarction

BP 145/86

HR 110; Rhythm Afib

Upon arrival to the ER, her VS were BP 178/110, HR 114

Hgb 10.2

Hct 29.6

She has a history of Type 2 diabetes mellitus, hypertension, coronary artery disease, chronic atrial fibrillation

Dorothy has no urinary output documented for the past 10 hours.

Intake includes 1100 ml of IV fluids and 3 cups of ice chips (~160 ml)

Strong hx of smoking and moderate life sytle.




Excess Fluid Volume







Long Term:

Client will remain free of edema, effusion, anasarca; weight appropriate for the client during hospital stay.

Monitor location and extent of edema; use a millimeter tape in the same area at the same time each day to measure edema in extremities. Generalized edema (e.g., in the upper extremities and eyelids) is associated with decreased oncotic pressure often as a result of nephrotic syndrome. Measuring the extremity with a millimeter tape is more accurate than using the 1 to 4 scale (Metheny, 2000). Heart failure and renal failure are usually associated with dependent edema because of increased hydrostatic pressure; dependent edema causes swelling in the legs and feet of ambulatory clients and the presacral region of clients on bed rest. EBN: Dependent edema was found to demonstrate the greatest sensitivity as a defining characteristic for excess fluid volume (Rios et al, 1991).

Monitor daily weight for sudden increases; use same scale and type of clothing at same time each day, preferably before breakfast. EB: Measurement of body weight change is a safe technique to assess hydration status (Armstrong, 2005). EB: Body weight could safely be used to monitor for fluid overload when administering hyperhydration with high-dose chemotherapy (Mank et al, 2003).

With head of bed elevated 30 to 45 degrees, monitor jugular veins for distention in the upright position; assess for positive hepatojugular reflex. Increased intravascular volume results in jugular vein distention, even in a client in the upright position, and a positive hepatojugular reflex (Kasper et al, 2005).

Turn clients with dependent edema frequently (i.e., at least every 2 hours). Edematous tissue is vulnerable to ischemia and pressure ulcers (Casey, 2004).

Teach client on diuretics to weigh self daily in the morning and notify the physician of a change in weight of 3 pounds or more (Karch, 2004).







Compromised regulatory mechanism







Short Term:

Client will maintain clear lung sounds, no evidence of dyspnea or orthopnea to be evaluated by the end of shift on xxxxx


Monitor vital signs; note decreasing blood pressure, tachycardia, and tachypnea. Monitor for gallop rhythms. If signs of heart failure are present, see the care plan for Decreased Cardiac output. Heart failure results in decreased cardiac output and decreased blood pressure. Tissue hypoxia stimulates increased heart and respiratory rates.

Monitor lung sounds for crackles, monitor respirations for effort, and determine the presence and severity of orthopnea. Pulmonary edema results from excessive shifting of fluid from the vascular space into the pulmonary interstitial space and alveoli. Pulmonary edema can interfere with the oxygen/carbon dioxide exchange at the alveolar-capillary membrane (Metheny, 2000), resulting in dyspnea and orthopnea.





decreased hematocrit; decreased hemoglobin

intake exceeds output change in mental status; changes in respiratory pattern;









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*I = Implementation.  Check those interventions/actions/orders that were implemented.

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