Can I pick Excess Fluid Volume for care plan?

  1. I am doing a care plan and am being asked for the highest priority two diagnoses of my post, (4 months) myocardial infarction patient with edema in both legs. Can I choose Excess Fluid volume, or can I not due to no doctor diagnosis of this? Will Risk for Fluid imbalance work? Thank You, Doug
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    About dbarnes2

    Joined: Nov '08; Posts: 30; Likes: 3
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  3. by   Daytonite
    The doctor's medical diagnoses has little bearing on the nursing diagnosis. Nursing diagnoses have to do with the nursing care that the patient needs. All you have told us about the patient is that there is edema in the legs. That is only one problem and you need to list two. I can't tell from that if it is due to fluid excess or a problem with cardiac output because you have told us nothing else about the history of what is going on with this patient and their problems.
  4. by   dbarnes2
    Thanks for answering. The patient is post MI, and has had a pleural effusion for fluid against the lungs. I was going to use " in relation to the disease or past history. I am trying to give a care plan that is the biggest priority, which I believe is keeping his fluid balanced due to probable low cardiac output. Thank You, Doug
  5. by   Daytonite
    doug, what are this patient's symptoms (aeb items) that support the use of excess fluid volume? dyspnea, edema, pulmonary artery pressure changes, pulmonary congestion, pleural effusion?

    pleural effusion is often the pathophysiological response to decreased cardiac output because of altered preload (the related factor). if you need an explanation of this, see the links to heart failure and edema on this website: symptoms are jugular vein distension, weight gain, increased cvp, increased pulmonary wedge pressures, dyspnea.

    is this patient in the icu? were cardiac outputs being measured? if so, it's a good bet that there was a cardiac output problem related to altered preload and the pleural effusion was a manifestation of that. pleural effusion, remember, is a medical diagnosis. we need to look at its pathophysiology and why it is occurring. the mechanism that regulates water distribution to the body tissues is hydrostatic/oncotic pressure. when these pressures that normally exist in a balance are disrupted, tissue edema results. when a patient has a pleural effusion cardiac output rises causing hydrostatic pressures to rise resulting in water being literally pushed into the interstitial tissues of the body and resulting in edema since the venous oncotic pressures cannot overcome the higher hydrostatic pressure. decreased cardiac output r/t altered preload may be your first diagnosis and excess fluid volume r/t arterial hydrostatic pressure exerting greater control than venous oncotic pressure over water movement into interstitial tissues aeb leg edema might be your second diagnosis.
  6. by   dbarnes2
    I gotta be honest- I am a first year, first semester student and this is my first basic care plan. We have had no training int his area, but have been told to do this. My patient is 84 yrs old, and in a long term care facility. The reason that I thought that Excessive fluid might be a priority is that he is post MI and takes meds for fluid retainment and has had a pleural effusion already due to fluid build up ( probably 2 mos ago). In the last week, he has shown a real increase in the edema in his ankles and feet, which made me wonder if fluid was becoming a problem again with this patient. It sounds like I blew it, but I am trying to figure this out. Is there a site where I can read a step-by-step guide on what goes through ones mind when considering/writing care plans or evaluating patients? Thanks, Doug
  7. by   Daytonite
    i recommend that students follow the steps of the nursing process. the book nursing care planning made incredibly easy is set up and organized exactly that way. the first section of nursing diagnosis handbook: a guide to planning care by betty j. ackley and gail b. ladwig explains that care plans are developed that way as well. it really makes a lot of sense.

    1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
      • a physical assessment of the patient
      • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
      • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
      • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
    2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
      • your instructors might have given it to you.
      • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95
      • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
      • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
      • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
    3. planning (write measurable goals/outcomes and nursing interventions)
      • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
        • improve the problem or remedy/cure it
        • stabilize it
        • support its deterioration
      • how to write goal statements:
      • interventions are of four types
        • assess/monitor/evaluate/observe (to evaluate the patient's condition)
          • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
        • care/perform/provide/assist (performing actual patient care)
        • teach/educate/instruct/supervise (educating patient or caregiver)
        • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)
    you can also see how this has been put into action on posts on this thread:
    what i can see from your posts is that you are struggling with the pathophysiology of what is going on with this patient. this patient had an mi. learning about what an mi is, what the pathophysiology of an mi is and how a pleural effusion fits into the picture along with other medical problems this patient might have will help explain many of the symptoms this patient is exhibiting. mi's, generally, are the result of atherosclerosis of the heart vessels. decreased cardiac output is a nursing diagnosis that covers all the components of cardiac output, both the electrical component and the physical ones which includes the arrhythmias and blood volume. when the terms preload and afterload come up people start tuning off because they sound like foreign terms. htn belongs in there too, but the understanding of it is often a real puzzle for most, so they end up just turning their backs to it.

    part of doing a care plan as a student involves looking up information about the medical disease the patient has, learning about it and how the doctors treat it. we need to know that information because we are often the ones who end up managing the administration of those treatments so we need to know and understand why they are being given and what the treatment is expected to do. and, in the same way, we are going to plan a few interventions of our own for many of those same things. for example--edema. it is a symptom of different types of heart failure. with an mi it is not uncommon for the heart to be weakened and some heart failure to occur. heart failure occurs in stages and over a period of time. docs watch the manifestations of it and their severity to evaluate the degree of failure. the edema is treated by the docs with things like diuretics. that is within their scope of practice. we give the diuretics. it a collaborative intervention. what we can do independently are things like keep their legs elevated to promote fluid to get back into the general circulation or encourage activity. the reason it works has to do with overriding the hydrostatic pressure (its a principle of physiology and biology).

    throughout nursing school you will be asked to draw upon this kind of information to support why you are ordering certain nursing interventions. medical students are asked to do the same. if there are things you do not know, recall or understand, then you hit the books looking for the answers. that is what care plans are designed to do for students and how you will learn much of nursing, especially when you get a patient you must write a care plan on who has a disease before you have had lectures about it.
  8. by   KarmaInMotion
    Daytonite, you are so awesome ... I am very interested in how HTN falls under decreased cardiac output. Could you perhapse start me on the path to understanding. Something related to pressure and yet inadequate movement? If you get the chance to take me to the water, thanks!
  9. by   Daytonite
    hypertension is due to
    • increased cardiac output
      • any condition that increases heart rate or stroke volume
    • increased total peripheral resistance
      • any factor that increases blood viscosity or reduces vessel diameter
    • both increased cardiac output and total peripheral resistance
    with total peripheral resistance. . .vasoconstriction or high pressures in vessels when prolonged over time will cause vessels to thicken and strengthen in order to tolerate the stress. the smooth muscle of the arteries will hypertrophy and sustain hyperplasia. the tunica intima and tunica media of the arteries will experience fibromuscular thickening that results in permanent narrowing of the vessel's lumen. these changes aggravate an inflammatory response resulting in biochemical mediators entering the areas where these changes are actively occurring (see for a description of the pathophysiology of the inflammatory response) which results in the permeability of the vascular endothelium. with this permeability, sodium, calcium, water, plasma proteins and other substances enter the vessel causing further vessel wall thickening and increasing the smooth muscle responsiveness to vasoconstriction.

    the kidney connection. . .renin, an enzyme produced and secreted from the kidney becomes angiotensin i which, according to my references does nothing until it is converted to angiotensin ii which stimulates the secretion of aldosterone which, in turn, causes the reabsorption of sodium in the kidneys. this renin-angiotensin system helps to regulate blood pressure. if it goes on the fritz, as it does in renal disease, and the kidneys fail to synthesize renin, the blood pressure becomes elevated.

    peripheral edema is a result of increased stroke volume and/or increased total peripheral resistance along with mismatched hydrostatic and oncotoc pressures. they are explained in detail on these two webpages: and the reading is very intense and may need several read throughs.