This online nursing care plan below includes the following conditions: Fluid Volume Excess, Fluid Overload, Congestive Heart Failure, Pulmonary Edema, Ascites, Edema, and Fluid and Electrolyte Imbalance.
What are nursing care plans? How do you develop a nursing care plan? What nursing care plan book do you recommend helping you develop a nursing care plan?
This care plan is listed to give an example of how a Nurse [LPN or RN] may plan to treat a patient with those conditions.
Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.
Care Plans are often developed in different formats. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.
Nursing Care Plan for: Fluid Volume Excess, Fluid Overload, Congestive Heart Failure, Pulmonary Edema, Ascites, Edema, and Fluid and Electrolyte Imbalance.
If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.
Scenario:
A 74 year old male presents to the ER with complaints of swelling in legs and feet, shortness of breath with any type of activity, non-radiating chest pain, increase cough, and the inability to sleep laying down at night. Pt states he has felt bad since Tuesday and today is Friday. He also states he has gained 7 pounds since he last weight on Tuesday. Pt currently weighs 210 lbs. Pt states he usually weighs around 200-203 lbs. During history collection from pt, pt becomes short of breath and has to stop talking to catch his breath. Pt states that he takes Lasix 60mg PO BID but has not taken any since Monday because he wasn’t able to go to the pharmacy due to the snowstorm last week. Pt also takes Lisinopril 2.5 mg PO BID, Coreg 6.25mg PO Daily, Coumadin 5mg PO Daily [has a history of Atrial fibrillation], Potassium PO 20meq BID, and Multivitamin 1 Tab PO Daily. Vital Signs: BP 155/93, HR 95, O2 Sat 90% on 4L nasal cannula, Temp. 98.6. On assessment, 3+ pitting edema noted in lower extremities, bilateral crackles noted through out lung fields, hands and abdomen are swollen, and slight jugular distention noted. Lab and Diagnostic work shows: BNAT 1824, K+5.0, Creatinine 1.8, BUN 21, chest x-ray preliminary results show possible bilateral pleural effusions, and echo-cardiogram results show ejection fraction of 35%.
Nursing Diagnosis:
Fluid volume overload related to decreased cardiac output as evidence by ejection fraction of 35%, edema in lower extremities, jugular distention, bilateral crackles, weight gain, BNAT 1824, and pleural effusions noted in lungs bilaterally.Subjective Data:
Complaints of shortness of breath on any type of activity, non-radiating chest pain, increase cough, and the inability to sleep laying down at night, gained 7 pounds since last weight on Tuesday, takes Lasix 60mg PO BID but has not taken any since Monday because he wasn’t able to go to the pharmacy due to the snowstorm last week.Objective Data:
Lisinopril 2.5 mg PO BID, Coreg 6.25mg PO Daily, Coumadin 5mg PO Daily [has a history of Atrial fibrillation], Potassium PO 20meq BID, and Multivitamin 1 Tab PO Daily. Vital Signs: BP 155/93, HR 95, O2 Sat 90% on 4L nasal cannula, Temp. 98.6, 3+ pitting edema noted in lower extremites, bilateral crackles noted through out lung fields, hands and abdomen are swollen, and slight jugular distention noted. Lab and Diagnostic work shows: BNAT 1824, K+5.0, Creatinine 1.8, BUN 21, chest x-ray preliminary results show possible bilateral pleural effusions, and echo-cardiogram results show ejection fraction of 35%.Nursing Outcomes:
-Pt’s O2 Saturation will be between 90-100% as evidence by nursing documentation during hospitalization.-Pt will weigh 200 lbs by discharge.-Pt will have no evidence of edema in lower extremities within 48 hours of hospitalization.
Nursing Interventions:
-Pt will be titrated on Oxygen via nasal cannula to keep O2 Sat. between 92-100% per MD order.-Pt will be given Lasix 60mg IV BID per MD order and will be weighed daily.– Pt will be placed on a 1500 ml fluid restricted diet per MD order and Intake and Output will be monitor and calculated after each shift.
The nursing process is used continuously when caring for individuals who have fluid, electrolyte, or acid-base imbalances, or at risk for developing them, because their condition can change rapidly. This systematic approach to nursing care ensures that subtle cues or changes are not overlooked and that appropriate outcomes and interventions are implemented according to the patient’s current condition.
Assessment
A thorough assessment provides valuable information about a patient’s current fluid, electrolyte, and acid-base balance, as well as risk factors for developing imbalances. Performing a chart review or focused health history is a good place to start collecting data, with any identified gaps or discrepancies verified during the physical assessment. It is also important to consider pertinent life span or cultural considerations that impact a patient’s fluid and electrolyte status.
Subjective Assessment
Subjective assessment data is information obtained from the patient as a primary source or family members or friends as a secondary source. This information must be obtained by interviewing the patient or someone accompanying the patient. Some of this information can be obtained through a chart review, but should be verified with the patient or family member for accuracy.
Subjective data to obtain includes age; history of chronic disease, surgeries, or traumas; dietary intake; activity level; prescribed medications and compliance with taking medications; pain; and bowel and bladder functioning. Subjective assessment data is helpful to determine normal pattern identification and risk identification. For example, a history of kidney disease or heart failure places the patient at risk for fluid volume excess, whereas diuretic use places the patient at risk for fluid volume deficit and electrolyte and acid-base imbalances. A history of diabetes mellitus also places a patient at risk for fluid, electrolyte, and acid-base imbalances. Recognizing these risks helps nurses be prepared for complications that may arise and allows the nurse to recognize subtle cues as problems develop.
Objective Assessment
Objective assessment data is information that the nurse directly observes. This data is obtained through a physical examination using inspection, auscultation, and palpation. A complete head-to-toe assessment should be performed to avoid missing clues to the patient’s condition.
Focused assessments such as trends in weight, 24-hour intake and output, vital signs, pulses, lung sounds, skin, and mental status are used to determine fluid balance, electrolyte, and acid-base status.
- Accurate daily weights can provide important clues to fluid balance. Weights must be taken on the same scale, at the same time of day, with the patient wearing similar clothing in order to be accurate. A one kilogram change in weight in 24 hours is considered significant because this represents a one liter fluid gain or loss and should be reported to the provider.
- Accurate measurement of 24-hour intake and output helps validate weight findings. Averaged urine output of less than 30 mL/hour or 0.5mL/hr/kg of concentrated urine should be reported to the provider.
- Vital signs should be analyzed. An elevated blood pressure and bounding pulses are often seen with fluid volume excess. Decreased blood pressure with an elevated heart rate and a weak or thready pulse are hallmark signs of fluid volume deficit. Systolic blood pressure less than 100 mm Hg in adults, unless other parameters are provided, should be reported to the health care provider.
- Lung crackles can signify fluid volume excess and are often first auscultated in the lower posterior lung fields.
- Tight, edematous, shiny skin indicates fluid volume excess. See Figure 15.15 for an image of edema. Conversely, skin tenting, dry mucous membranes, or dry skin indicate fluid volume deficit.
- New mental status changes such as confusion or decreased level of consciousness can indicate fluid, electrolyte, or acid-base imbalance, especially hypo- or hypernatremia, acid-base imbalances, or fluid volume deficit.
- Cardiac arrhythmias can be seen with acid-base imbalances and electrolyte imbalances, especially with hypo- or hyperkalemia and alkalosis. See Table 15.6a for a comparison of expected and unexpected findings and those that require notification of a health care provider.
Table 15.6a Expected Findings Versus Unexpected Findings Indicating a Fluid Imbalance
Assessment Expected FindingsUnexpected Findings Indicating Excessive Fluid Volume
*Bolded items are critical conditions that require immediate health care provider notification.
Unexpected Findings Indicating Deficient Fluid Volume Vital signsBlood pressure, heart rate, and oxygen saturation levels within normal limitsElevated blood pressure, increased respiratory rate, or decreased oxygen saturationDecreased blood pressure or elevated heart rateNeurologicalAlert and orientedHeadacheHeadache, confusion, decreased level of consciousness, dizziness, or weaknessCardiacNormal heart rate and rhythm, capillary refill 20 mm Hg or a decrease in diastolic blood pressure > 10 mm Hg, or if the patient reports feeling light-headed or dizzy, is considered abnormal. Orthostatic hypotension should be reported to the provider and safety measures implemented to prevent falls.- Monitor mental status, vital signs, and heart rhythm at least every 8 hours or more frequently as needed. Electrolyte imbalances can cause confusion, cardiac dysrhythmias, muscle weakness, edema, and respiratory failure.
- Review associated laboratory results and report abnormal findings to the provider.
- Review the patient’s medical record for possible causes of altered electrolyte levels, such as diuretics, kidney disease, gastrointestinal fluid loss, drainage from wounds or burns, and excessive perspiration. Address potential causes with the provider.
- Administer PO and IV electrolyte supplements as ordered for deficiencies.
- Limit dietary intake of specific electrolyte excesses.
- Administer electrolyte-binding medications, such as Kayexalate for hyperkalemia, as prescribed.
- Administer IV fluids to promote renal excretion of excess electrolyte levels, as prescribed.
- Educate the patient and family members about dietary choices corresponding to the specific electrolyte imbalance. Provide information about monitoring for potential electrolyte imbalances at home resulting from their medications.
Read more about medications affecting fluid and electrolyte balance, such as diuretics, in the “Cardiovascular and Renal System” chapter in Open RN Nursing Pharmacology.
Read about intravenous fluids used to treat Fluid Volume Deficit in the “IV Therapy Management” chapter in Open RN Nursing Skills.
Implement Interventions Safely
Patients with fluid and electrolyte imbalances can quickly move from one imbalance to another based on treatments received. It is vital to reassess a patient before implementing interventions to ensure current status warrants the prescribed intervention. For example, a patient admitted with Fluid Volume Deficit received intravenous fluids [IV] over the past 24 hours. When the nurse prepares to administer the next bag of IV fluids, she notices the patient has developed pitting edema in his lower extremities. She listens to his lungs and discovers crackles. The nurse notifies the prescribing provider, and the order for intravenous fluids is discontinued and a new order for diuretic medication is received.
Therefore, assessments for new or worsening imbalances should be performed prior to implementing interventions:
- Monitor daily weights for sudden changes. A weight change of greater than 1 kg in 24 hours [using the same scale and type of clothing] should be reported to the provider.
- Monitor location and extent of edema using the 1+ to 4+ scale to quantify edema.
- Monitor intake and output over a 24-hour period; note trends of decreasing urine output in relation to fluid intake indicating potential development of Fluid Volume Excess.
- Monitor lab work such as serum osmolarity, serum sodium, BUN, and hematocrit for abnormalities. [For example, a patient receiving IV fluids may develop Fluid Volume Excess, resulting in decreased levels of serum osmolarity, serum sodium, BUN, and hematocrit. Conversely, a patient receiving IV diuretics can quickly become dehydrated, resulting in elevated levels of serum osmolarity, serum sodium, BUN, and hematocrit.]
- For patients receiving intravenous fluids, monitor for the development of excessive fluid volume. Monitor lung sounds for crackles and ask about the presence of dyspnea. Report new abnormal findings to the provider.
- For patients receiving diuretic therapy, monitor for fluid volume deficit and electrolyte imbalances such as hypokalemia and hyponatremia.
Implement fall precautions for patients with orthostatic hypotension, restlessness, anxiety, or confusion related to fluid imbalances.
Evaluation
The effectiveness of interventions implemented to maintain fluid balance must be continuously evaluated. Evaluation helps the nurse determine whether goals and outcomes are met and if interventions are still appropriate for the patient. If outcomes and goals are met, the plan of care can likely be discontinued. If outcomes and goals are not met, they may need to be revised. It is also possible that interventions may need to be added or revised to help the patient meet their goals and outcomes. Table 15.6e provides a list of assessment findings indicating imbalances are improved.
Table 15.6e Evaluating for Improvement of Imbalances
ImbalanceSigns and Symptoms of ImprovementFluid Volume ExcessDecreased crackles, decreased edema, decreased shortness of breath, and/or improved jugular venous distentionFluid Volume DeficitIncreased blood pressure, decreased heart rate, normal skin turgor, and/or moist mucous membranesElectrolyte ImbalancesElectrolyte levels return to normal and/or absence of signs or symptoms of deficit or excessAcid-Base ImbalanceABGs return to normal or baseline, resolution of vomiting or diarrhea, and/or no respiratory distress