Possibly evidenced by
Orthopnea, S3 heart sound
Oliguria, edema, JVD, positive hepatojugular reflex
Weight gain
Hypertension
Respiratory distress, abnormal breath sounds
Desired Outcomes/Evaluation Criteria—Client Will
Fluid Overload Severity
Demonstrate stabilized fluid volume with balanced intake and output, breath sounds clear or clearing, vital signs within acceptable range, stable weight, and absence of edema.
Verbalize understanding of individual dietary and fluid restrictions.
Nursing care plan intervention with rationale:
1. Monitor urine output, noting amount and color, as well as time of day when diuresis occurs.
Rationale: Urine output may be scanty and concentrated (especially during the day) because of reduced renal perfusion. Recumbency favors diuresis; therefore, urine output may be increased at night or during bedrest.
2. Monitor 24-hour intake and output (I&O) balance.
Rationale: Diuretic therapy may result in sudden or excessive fluid loss, creating a circulating hypovolemia, even though edema and ascites remains in the client with advanced HF or CHF.
3. Maintain chair rest or bedrest in semi-Fowler’s position during acute phase.
Rationale: Recumbency increases glomerular filtration and decreases production of ADH, thereby enhancing diuresis.
4. Establish fluid intake schedule if fluids are medically restricted, incorporating beverage preferences when possible. Give frequent mouth care and ice chips as part of fluid allotment.
Rationale: Involving client in therapy regimen may enhance sense of control and cooperation with restrictions.
5. Weigh daily.
Rationale: Documents changes in or resolution of edema in response to therapy. A gain of 5 lb represents approximately 2 L of fluid. Conversely, diuretics can result in rapid and excessive
fluid shifts and weight loss.
6. Assess for distended neck and peripheral vessels. Inspect dependent body areas for edema with and without pitting; note presence of generalized body edema (anasarca).
Rationale: Excessive fluid retention may be manifested by venous engorgement and edema formation. Peripheral edema begins in feet and ankles, or dependent areas, and ascends as failure worsens. Pitting edema is generally obvious only after retention of at least 10 lb of fluid. Increased vascular congestion—associated with right-sided HF—eventually results in systemic tissue edema.
7. Change position frequently. Elevate feet when sitting. Inspect skin surface, keep dry, and provide padding, as indicated.
Rationale: Edema formation, slowed circulation, altered nutritional intake, and prolonged immobility or bedrest are cumulative stressors that affect skin integrity and require close supervision and preventive interventions.
8. Auscultate breath sounds, noting decreased and adventitious sounds, for example, crackles and wheezes. Note presence of increased dyspnea, tachypnea, orthopnea, paroxysmal nocturnal dyspnea, and persistent cough.
Rationale: Excess fluid volume often leads to pulmonary congestion. Symptoms of pulmonary edema may reflect acute leftsided HF. With right-sided HF, respiratory symptoms of dyspnea, cough, and orthopnea may have slower onset, but are more difficult to reverse. Note: Among clients with advanced HF, 60% experience significant dyspnea (Pantilat & Steimle, 2004), usually related to volume overload.
9. Investigate reports of sudden extreme dyspnea and air hunger, need to sit straight up, sensation of suffocation, feelings of panic or impending doom.
Rationale: May indicate development of complications, such as pulmonary edema or embolus, which differs from orthopnea or paroxysmal nocturnal dyspnea in that it develops much more rapidly and requires immediate intervention.
10. Monitor BP and central venous pressure (CVP) (if available).
Rationale: Hypertension and elevated CVP suggest fluid volume excess and may reflect developing or increasing pulmonary congestion, HF.
11. Assess bowel sounds. Note complaints of anorexia, nausea, abdominal distention, and constipation.
Rationale: Visceral congestion, occurring in progressive HF, can alter gastrointestinal function.
12. Provide small, frequent, easily digestible meals.
Rationale: Reduced gastric motility can adversely affect digestion and absorption. Small, frequent meals may enhance digestion and prevent abdominal discomfort.
13. Measure abdominal girth, as indicated.
Rationale: In progressive right-sided HF, fluid may shift into the peritoneal space, causing increasing abdominal girth (ascites).
14. Encourage verbalization of feelings regarding limitations.
Rationale: Expression of feelings or concerns may decrease stress and anxiety, which is an energy drain that can contribute to feelings of fatigue.
15. Palpate abdomen. Note reports of right upper-quadrant pain or tenderness.
Rationale: Advancing HF leads to venous congestion, resulting in abdominal distention, liver engorgement (hepatomegaly), and pain. This can alter liver function and impair or prolong
drug metabolism.
Other possible Nursing Diagnosis for Heart Failure:
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