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

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