Nursing diagnosis: risk for excess Fluid Volume
Risk factors may include
Rapid and excessive fluid intake—IV, blood, plasma expanders, saline given to support BP during dialysis
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Maintain “dry weight” within client’s normal range; be free of edema; and have clear breath sounds and serum sodium levels within normal limits.
Nursing intervention with rationale:
1. Measure all sources of I&O. Weigh routinely.
Rationale: Aids in evaluating fluid status, especially when compared with weight. Weight gain between treatments should not exceed 0.5 kg or approximately 1 lb/day.
2. Monitor BP and pulse.
Rationale: Hypertension and tachycardia between hemodialysis runs may result from fluid overload and heart failure (HF).
3. Note presence of peripheral or sacral edema, respiratory rales, dyspnea, orthopnea, distended neck veins, and electrocardiogram (ECG) changes indicative of ventricular hypertrophy.
Rationale: Fluid volume excess due to inefficient dialysis or repeated hypervolemia between dialysis treatments may cause or exacerbate HF, as indicated by signs and symptoms of respiratory and systemic venous congestion.
4. Note changes in mentation. (Refer to CP: Renal Dialysis; ND: risk for disturbed Thought Processes.)
Rationale: Fluid overload or hypervolemia may potentiate disequilibrium syndrome.
5. Monitor serum sodium levels. Restrict sodium intake, as indicated.
Rationale: High sodium levels are associated with fluid overload, edema, hypertension, and cardiac complications.
6. Restrict fluid intake as indicated, spacing allowed fluids throughout a 24-hour period.
Rationale: The intermittent nature of hemodialysis results in fluid retention and volume overload between procedures and may require fluid restriction. Spacing fluids helps reduce thirst.