Angelite Nurses: 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

Angelite Nurses