Goal for excess fluid volume?
- 0Feb 16, '12 by RN/MomI'm working on a careplan for a patient with the nursing diagnosis of excess fluid volume. This pt's fluid volume excess is due to both heart failure and acute on chronic renal failure. She's not on any fluid restrictions or diuretics and gets hemodialysis as needed (once or twice a week as ordered by MD). This pt has several manifestations of excess fluid volume, such as 1+ BLE edema, bilateral pleural effusions, and periodic episodes of hypertension.
I'm totally stuck on trying to write a goal for this patient because it needs to be something within an 8 hour time frame during which she is NOT getting hemodialysis, restricting fluids, or taking diuretics... Therefore, the goal CAN'T be anything along the lines of "pt will exhibit decreased edema."
I think it should be something along the lines of "pt will not experience worsening signs/symptoms of fluid overload this shift aeb increased edema, SBP >180, SOB, O2 desaturation, etc."
Does this make sense??? Can anyone offer guidance??? Thank you sooo much!
- 3Feb 16, '12 by GrnTea, BSN, MSN, RNyou could have as a goal that she doesn't get worse, sure you can. really. what would you do to prevent her from having worse fluid overload? as it stands, your aeb would be that her edema wouuld be stable or decreased (not likely, i know, but...), her subjective shortness of breath would be stable or improved, rr would be stable or decreased, etc., etc..
as an alternative, how about adding another nursing dx to the mix, say, activity intolerance? these would be due to her fluid overload causing respiratory difficulty (you can look in th nanda for the defining characteristics that fit this particular patient per your evaluation, but i'm thinking it's a good guess there are plenty of them). then your goals would be....
thank you for telling us what you've done already-- we don't do homework but we don't mind helping somebody who's stuck. (already went to nursing school ) hope that helps.
- 1Feb 16, '12 by RN/MomThanks for your reply! Actually, we have to choose 3 priority problems for our careplan patient, and activity intolerance is #2 and risk for injury is #3 (and those care plans are done already!)
I really think her number one problem is excess fluid volume, because if it gets too out of control, it can lead to other problems for her. So that's why I need to do a careplan where the interventions are monitoring fluid status each shift, and that's why I chose Excess Fluid Volume. Does my thinking sound right, or does it sound like there's another priority problem I'm missing?
Again, I really appreciate your input!
- 0Feb 16, '12 by Esme12, BSN, RN Senior Moderator