Isotonic Fluid Case Study

Decent Essays
Excess Fluid Volume: Increased isotonic fluid retention
Nursing Diagnosis
• Fluid Volume, excess
May be related to
• Reduced glomerular filtration rate (decreased cardiac output)/increased antidiuretic hormone (ADH) production, and sodium/water retention
Possibly evidenced by
• Orthopnea, S3 heart sound
• Oliguria, edema, JVD, positive hepatojugular reflex
• Weight gain
• Respiratory distress, abnormal breath sounds
Desired Outcomes
• Demonstrate stabilized fluid volume with balanced intake and output, breath sounds clear/clearing, vital signs within acceptable range, stable weight, and absence of edema.
• Verbalize understanding of individual dietary/fluid restrictions.
Nursing Interventions Rationale
Monitor urine output, noting amount and color, as well as time of
…show more content…
May indicate development of complications (pulmonary edema and/or embolus) and differs from orthopnea paroxysmal nocturnal dyspnea in that it develops much more rapidly and requires immediate intervention.
Monitor BP and central venous pressure (CVP) Hypertension and elevated CVP suggest fluid volume excess and may reflect developing pulmonary congestion, HF.
Assess bowel sounds. Note complaints of anorexia, nausea, abdominal distension, constipation. Visceral congestion (occurring in progressive HF) can alter intestinal function.
Provide small, frequent, easily digestible meals. Reduced gastric motility can adversely affect digestion and absorption. Small, frequent meals may enhance digestion/ prevent abdominal discomfort.
Measure abdominal girth, as indicated. In progressive RHF, fluid may shift into the peritoneal space, causing increasing abdominal girth (ascites).
Encourage verbalization of feelings regarding limitations. Expression of feelings may decrease anxiety, which is an energy drain that can contribute to feelings of
Get Access