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Fluid Volume Excess, Risk Factors: Excessive intake of fluids Abnormal Retention of Fluids (e.g. heart failure, renal failure) Interstitial to plasma fluid shift Excessive isotonic or hypotonic IV fluids Primary Polydipsia SIADH Cushing Syndrome Long Term use of Corticosteroids Excessive Salt intake Excessive sodium bicarbonate therapy Fluid Volume Excess HYPERVOLEMIA Pathophysiology - when excess water is retained in the ECF, Nursing Interventions: I&O (24 hr. record) q4h -q8h Monitor cardio changes Assess Respiratory status and changes Daily Weights Skin Assesment Neurologic Function: -LOL -PERRLA -Voluntary movement of extremeties -Muscle Strength -Reflexes Elevate the Head of Bed Encourage mobility Monitor electrolytes - esp. K and Na Assess for Hx. of conditions that may cause fluid retention; Heart failure, renal failure, pancreatitis, or high salt intake Teach the client to limit intake of oral fluids Teach the client early signs and symptoms asociated with water retention Fluid Volume Excess HYPERVOLEMIA Pathophysiology - when excess water is retained in the ECF, Possible Nursing Dx.: Excess fluid volume Impaired Gas Exchange Ineffective Airway Exchange Risk for impaired skin integrity Disturbed Body Image Potential Complications:pulmonary edema, ascites Ineffective Tissue Perfusion Fluid Volume Excess HYPERVOLEMIA Pathophysiology - when excess water is retained in the ECF, Complications: Fluid and Electrolyte Imbalance Polyuria Diarrhea Nonpitting edema Dysrhythmias Projectile Vomiting Fluid Volume Excess HYPERVOLEMIA Pathophysiology - when excess water is retained in the ECF, Clinical Manifestations: Headache Confusion Lethargy Peripheral Edema Distended Neck Veins Bounding Pulse Increased Blood Pressure Increased Central Venous Pressure Polyuria (w/ normal renal function) Dyspnea Crackles (rales) Pulmonary edema Muscle Spasms Weight Gain Seizures Coma Fluid Volume Excess HYPERVOLEMIA Pathophysiology - when excess water is retained in the ECF, Diagnositc Procedures And Medications: Blood Chemistry Specific Gravity H&H Fluid Volume Excess HYPERVOLEMIA Pathophysiology - when excess water is retained in the ECF