How To Prevent Fluid Overload
Def: The state in which an individual experiences increased fluid retention and edema
Associated factors:
Excessive fluid intake Decreased cardiac output; chronic or acute heart
Excessive sodium intake disease
Renal insufficiency or failure Head injury
Steroid therapy Liver disease
Low protein intake or malnutrition Severe stress
Hormonal disturbances
Evidence of fluid overload:
Weight gain Increased blood pressure
Edema Increased central venous pressure (CVP)
Bounding pulses Increased pulmonary artery pressure (PAP)
Shortness of breath; orthopnea Jugular vein distention
Pulmonary congestion on x-ray Change in mental status (lethargy or confusion)
Abnormal breath sounds: crackles (rales) Oliguria
Change in respiratory pattern Specific gravity changes
Third heart sound S3 Azotemia
Intake greater than output Change in electrolytes
Decreased hemoglobin or hematocrit Restlessness and anxiety
Ongoing Assessment
(1) Obtain patient history to ascertain the probable cause of the fluid disturbance.
Which can help to guide interventions. May include increased fluids or sodium intake, or compromised
regulatory mechanisms.
(2) Assess or instruct patient to monitor weight daily and consistently, with same scale and preferably
at the same time of day.
To facilitate accurate measurement and to follow trends.
(3) Monitor for a significant weight change (1 kg) in one day.
(4) Evaluate weight in relation to nutritional status.
In some heart failure patients, weight may be a poor indicator of fluid volume status. Poor nutrition and
decreased appetite over time result in a decrease in weight, which may be accompanied by fluid
retention even though the net weight remains unchanged.
(5) If patient is on fluid restriction, review daily log or chart for recorded intake.
Patients should be reminded to include items that are liquid at room temperature such as Jello, sherbet,
and popsicles.
(6) Monitor and document vital signs.
Sinus tachycardia and increased blood pressure are seen in early stages. Elderly patients have reduced
response to catecholamines; thus their response to fluid overload may be blunted, with less rise in heart
rate.
(7) Monitor for distended neck veins and ascites. Monitor abdominal girth to follow any ascites
accurately.
(8) Auscultate for a third sound, and assess for bounding peripheral pulses.
These are signs of fluid overload.
(9) Assess for crackles in lungs, changes in respiratory pattern, shortness of breath, and orthopnea.
For early recognition of pulmonary congestion.
(10) Assess for presence of edema by palpating over tibia, ankles, feet, and sacrum.
Pitting edema is manifested by a depression that remains after one's finger is pressed over an edematous
area and then removed. Grade edema trace, indicating barely perceptible, to 4, which indicates severe
edema. Measurement of an extremity with a measuring tape is another method of following edema.
(11) Monitor chest x-ray reports.
As interstitial edema accumulates, the x-rays show cloudy white lung fields.
(12) Monitor input and output closely.
Although overall fluid intake may be adequate, shifting of fluid out of the intravascular to the
extravascular spaces may result in dehydration. The risk of this occurring increases when diuretics are
given. Patients may use diaries for home assessment.
(13) Evaluate urine output in response to diuretic therapy.
Focus is on monitoring the response to the diuretics, rather than the actual amount voided. At home, it is
unrealistic to expect patients to measure each void. Therefore recording two voids versus six voids after a
diuretic medication may provide more useful information. NOTE: Fluid volume excess in the abdomen
may interfere with absorption of oral diuretic medications. Medications may need to be given
intravenously by a nurse in the home or outpatient setting.
(14) Monitor for excessive response to diuretics: 1 kg loss in 1 day, hypotension, weakness, blood urea
nitrogen (BUN) elevated out of proportion to serum creatinine level.
(15) Monitor serum electrolytes, urine osmolality, and urine-specific gravity.
(16) Assess the need for an indwelling urinary catheter.
Treatment focuses on diuresis of excess fluid.
(17) During therapy, monitor for signs of hypovolemia.
To prevent complications associated with therapy.
(18) If hospitalized, monitor hemodynamic status including CVP, PAP, and PCWP, if available.
This direct measurement serves as optimal guide for therapy
Therapeutic Interventions
(1) Institute/instruct patient regarding fluid restrictions as appropriate.
To help reduce extracellular volume. For some patients, fluids may need to be restricted to 100 ml per
day.
(2) Provide innovative techniques for monitoring fluid allotment at home. For example, suggest that
patient measure out and pour into a large pitcher the prescribed daily fluid allowance (e.g., 1000 ml).
Then, every time patient drinks some fluid he or she is to remove that amount from the pitcher.
This provides a visual guide for how much fluid is still allowed throughout the day.
(3) Restrict sodium intake as prescribed.
Sodium diets of 2 to 3 gm are usually prescribed.
(4) Administer or instruct patient to take diuretics as prescribed.
Diuretic therapy may include several different types of agents for optimal therapy, depending on the
acuteness or chronicity of the problem. For chronic patients, compliance is often difficult for patients
trying to maintain a normal lifestyle.
(5) Instruct patient to avoid medications that may cause fluid retention, such as over-the-counter
nonsteroidal antiinflammatory agents, certain vasodilators, and steroids.
(6) Elevate edematous extremities.
To increase venous return and, in turn, decrease edema.
(7) Reduce constriction of vessels (use appropriate garments, avoid crossing of legs or ankles).
To prevent venous pooling.
(8) Instruct in need for antiembolic stockings or bandages as ordered.
To help promote venous return and to minimize fluid accumulation in the extremities.
(9) Provide interventions related to specific etiologic factors (i.e., inotropic medications for heart
failure, paracentesis for liver disease, and others).
For acute patients:
(10) Consider admission to acute care setting for hemofiltration or ultrafiltration.
This is a very effective method to draw off excess fluid.
(11) Collaborate with the pharmacist to maximally concentrate IVs and medications.
To decrease unnecessary fluids.
(12) Apply heparin lock on IV line.
To maintain patency but to decrease fluid delivered to patient in a 24-hour period.
(13) Administer IV fluids through infusion pump, if possible.
To ensure accurate delivery of IV fluids.
(14) Provide adequate activity or position changes as able.
To prevent fluid accumulation in dependent areas.
(15) Assist with repositioning every 2 hours if patient is not mobile.