About
Excessive fluids within and between body tissues.
Assess
Full bounding pulses, hypertension, pulmonary edema ( crackles in the lungs), dyspnea, increased shallow respirations; urine output, electrolytes, daily weight, peripheral edema.
Complications
Pulmonary edema; congestive heart failure
Diagnosis
- Excess fluid volume related to inability to maintain fluid balance
- Risk for impaired gas exchange related to excess fluids in lungs
- Risk for impaired skin integrity related to peripheral edema
Goals
- The client will remain free from injury.
- The client will identify factors that promote fluid loss.
Interventions
- Monitor VS, weight, electrolytes, Intake and Output.
- Monitor lung sounds periodically for signs of pulmonary edema.
- Monitor for cardiac dysrhythmias.
- Maintain fluid restrictions as ordered.
- Administer drugs, including diuretics, as ordered.
- Monitor for signs/ symptoms of complications.
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