Fluid Volume Excess
Fluid Volume Excess
(_)Actual (_) Potential
| (_)
Decreased cardiac output (_) Low protein intake (_) Liver disease (_) Inflammatory process (_) Steroid therapy |
(_)
Medications:_______________________ (_) Excess fluid intake (_) Sodium intake more than adequate (_) Other:_____________________________ ____________________________________ ____________________________________ |
| 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
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