Risk for Excess Fluid Volume | Nursing Care Plan for Peritoneal Dialysis

Nursing diagnosis: risk for excess Fluid Volume

Risk factors may include
Inadequate osmotic gradient of dialysate
Fluid retention—malpositioned, kinked or clotted catheter; bowel distention, peritonitis, scarring of peritoneum
Excessive oral (PO) or intravenous (IV) intake

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Fluid Balance
Demonstrate dialysate outflow exceeding or approximating infusion.
Experience no rapid weight gain, edema, or pulmonary congestion.

Nursing intervention with rationale:
1. Maintain a record of inflow and outflow volumes and cumulative fluid balance.
Rationale: In most cases, the amount drained should equal or exceed the amount instilled. A positive balance with more fluid in than out indicates need for further evaluation.

2. Record serial weights, compare with intake and output (I&O) balance. Weigh client when abdomen is empty of dialysate providing a consistent reference point.
Rationale: Serial body weights are an accurate indicator of fluid volume status. A positive fluid balance with an increase in weight indicates fluid retention.

3. Assess patency of catheter, noting difficulty in draining. Note presence of fibrin strings or plugs.
Rationale: Slowing of flow rate or presence of fibrin suggests partial catheter occlusion requiring further evaluation or possible intervention.

4. Check tubing for kinks; note placement of bags. Anchor catheter so that adequate inflow and outflow is achieved.
Rationale: Improper functioning of equipment may result in retained fluid in abdomen and insufficient clearance of toxins.

5. Turn from side to side, elevate the head of the bed, and apply gentle pressure to the abdomen.
Rationale: May enhance outflow of fluid when catheter is malpositioned or obstructed by the omentum.

6. Note abdominal distention associated with decreased bowel sounds, changes in stool consistency, and reports of constipation.
Rationale: Bowel distention or constipation may impede outflow of effluent. (Refer to CP: Renal Dialysis; ND: risk for Constipation.)

7. Monitor blood pressure (BP) and pulse, noting hypertension, bounding pulses, neck vein distention, and peripheral edema; measure central venous pressure (CVP), if available.
Rationale: Elevations indicate hypervolemia. Assess heart and breath sounds, noting S3 and crackles and rhonchi. Fluid overload may potentiate heart failure (HF) or pulmonary edema.

8. Evaluate development of tachypnea, dyspnea, and increased respiratory effort. Drain dialysate and notify physician.
Rationale: Abdominal distention or diaphragmatic elevation may cause respiratory distress.

9. Assess for headache, muscle cramps, mental confusion, and disorientation.
Rationale: Symptoms suggest hyponatremia or water intoxication.

10. Add heparin to initial dialysis runs; assist with irrigation of catheter with heparinized saline.
Rationale: May be useful in preventing fibrin clot formation, which can obstruct peritoneal catheter.