Fluid Volume Excess

Fluid
Volume Excess

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_)
Decreased cardiac output
(_) Low protein intake
(_) Liver disease

(_) Inflammatory process
(_) Steroid therapy

(_)
Medications:_______________________
(_) Excess fluid intake
(_) Sodium intake more than adequate
(_) Other:_____________________________

____________________________________
____________________________________

 

As
evidenced by:
[Check
those that apply]
Major:

(
Must be
present
)
(_)
Edema
(_) Taught, shiny skin

 

Date &
Sign.
Plan and Outcome
[Check
those that apply]
Target
Date:
Nursing Interventions
[Check
those that apply]
Date

Achieved:

  The
patient will:

(_)
Have decreased edema in extremities.

(_) Other:

  (_)
Reduce or eliminate causative contributing
factors:_________
________________________

(_) Assess location and severity of
edema q ____ hours.

(_) Measure intake and
output.

(_) Measure edematous
extremity(ies) or abdominal girth q __.

(_) Daily weights each
____ am/pm using same scale.

(_) Elevate _______
extremity(ies) ____ degrees.

(_) Passive/active
range of motion exercises of _______ q ___ hours.

(_) Avoid constrictive
clothing.

(_) Explore with
patient potential etiological factors for edema and
provide health teaching.

(_)
Other:________________
________________________

________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature