Primary Nursing Diagnosis

Fluid volume excess related to retention of free water

OUTCOMES. Fluid balance; Hydration; Circulation status; Cardiac pump effectiveness

INTERVENTIONS. Fluid monitoring; Fluid/electrolyte management; Circulatory care; Vital signs monitoring; Medication management

Independent

If the patient is at risk for airway compromise because of low serum sodium levels or seizure activity, maintaining a patent airway is the primary nursing concern. Insert an oral or nasal airway ifthe patient is able to maintain her or his own breathing, or prepare the patient for endotracheal intubation if it is needed. If the patient is able to maintain airway and breathing, consider positioning the patient so that the head of the bed is either flat or elevated no more than 10 degrees. This position enhances venous return and increases left atria filling pressure, which, in turn, reduce the release of ADH.

Explore with the patient methods to maintain the fluid restriction. If thirst and a dry mouth cause discomfort, try alternatives such as hard candy (if the patient is awake and alert) or chewing gum. Allocate some of the restricted fluids for ice chips to be used throughout the day at the patient's discretion. Work with the patient to determine the amount of fluid to be sent on each tray so that fluid intake is spread equitably throughout the day. If the patient is receiving fluids in IV piggyback medications, consider those volumes as part of the 24-hour intake. Work with the pharmacy to concentrate all medications in the lowest volume that is safe for the patient.

Promote range-of-motion exercises for patients who are bedridden, and turn and reposition them every 2 hours to limit the complications of immobility. Maintain side rails in the up position to prevent injury if the patient has a decreased mental status. Initiate seizure precautions to ensure the patient's safety.

• Physical findings: Status of airway, assessment of CNS, fluid volume status (presence of edema, skin turgor, intake and output), serum sodium level

• Response to fluid restriction, diuretics, and other medications

• Presence of complications: Changes in lung or cardiac sounds; changes in level of consciousness; seizures

Be sure the patient or significant others understand the medication regimen, including the dosage, route, action, adverse effects, and need for follow-up laboratory tests (ADH level, serum sodium and potassium, blood urea nitrogen and creatinine, urine and serum osmolality). Instruct the patient to report changes in voiding patterns, level of consciousness, presence of edema, symptoms of hyponatremia, reduced neurological functioning, nausea and vomiting, and muscle cramping. If the patient is going home on fluid restriction, be sure to discuss methods of limiting fluid intake and encourage the patient to weigh himself or herself daily to monitor for fluid retention.

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