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:

NOC Labels:

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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