Thursday, April 19, 2012

Nursing Interventions for Fluid Volume Excess

Excess Fluid Volume

Definition:

Circumstances where an individual experiencing or at risk of excess intracellular or interstitial fluid.

Major data
  • edema
  • tighten skin, shiny
Minor data
  • more inputs than outputs
  • shortness of breath
  • weight gain
Expected outcomes are:

Individuals will:
  1. Reveal the causative factors and prevention methods edema.
  2. showed a decrease of peripheral and sacral edema.

Nursing Interventions for Fluid Volume Excess

1. Assess input and diet habits that can support the retention of fluids

2. Encourage individuals to reduce salt intake

3. Teach individuals to
  • Read labels for sodium content
  • Avoid foods that are fun, canned, and frozen foods.
  • Cook without using salt and spices to add flavor (lemon, basil, mint)
  • Use vinegar to taste salt substitute soup, stew, etc.
4. Review of the evidence depends on the venostatis.

5. Keep the limb is edematous as high above the heart if possible (unless there are contraindications by heart failure)

6. Instruct the individual to avoid made ​​of jersey pants / girdle, knee-high pants, and crossed the lower leg and remained elevated leg exercises whenever possible.

7. To inadequate drainage:
  • Keep the limb elevated on pillows
  • Measure blood pressure in the arm that does not hurt
  • Do not give injections or intravenous fluids to enter the arms are sore.
  • Protect your arm is sore, from injury.
  • Encourage individuals to avoid strong detergents, carrying heavy bags, smoke, injuring the epidermis or nodule on the nail, reaching into a hot oven, use a jewelry or watches, or using a headband.
  • Warn people to see a doctor if the arms become red, swollen, or other hardware of the ordinary.
8. Protect the arm edema, from injury.

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