Edema is swelling caused by fluid build-up in the tissues. It can occur in any part of the body but is most noticeable in the arms, hands, legs, and feet. Show
Edema is a common finding and may go away on its own or may be a symptom of an underlying health condition, an allergic reaction, or an adverse effect of a medication. There are different types of edema but the most common ones include:
A detailed physical assessment and medical history are essential to determine the cause of edema. Diagnostic tests that help uncover potential causes include ultrasounds, x-rays, MRIs, blood tests, and urinalysis. The Nursing ProcessThe management of edema depends on its severity and the underlying condition. Mild edema will usually not require any interventions, as the swelling will subside on its own. Edema of the brain or lungs will require drug therapy like diuretics to help the body expel excess fluid. The underlying condition causing the edema must also be managed and treated. Nurses teach their patients interventions that can help improve swelling like repositioning and dietary modifications. Also, lifestyle modifications may be needed to reduce the recurrence of edema along with adherence to the management of the underlying condition causing the edema. Nursing Care Plans Related to EdemaExcess Fluid Volume Care PlanExcess fluid build-up in the body causes edema. Edema is characterized by excess fluid accumulating in the skin and surrounding tissues. Nursing Diagnosis: Excess Fluid Volume Related to:
As evidenced by:
Expected Outcomes:
Excess Fluid Volume Assessment1. Assess causative factors of edema. 2. Monitor the patient’s intake and output. 3. Assess lung sounds and respiratory patterns. 4. Assess laboratory studies
for any abnormalities. Excess Fluid Volume Interventions1. Administer medications. 2. Restrict fluids as
ordered. 3. Encourage a low-sodium diet. 4. Weigh daily. Risk for Impaired Skin Integrity Care PlanPatients with edema are at risk for impaired skin integrity. As fluid accumulates under the skin, it will appear tight and shiny. Skin can lose its integrity if edema persists, making it susceptible to injuries and possible infection. Nursing Diagnosis: Risk for Impaired Skin Integrity Related to:
As evidenced by:A risk diagnosis is not evidenced by any signs and symptoms, as the problem has not occurred yet and the nursing interventions will be directed at the prevention of symptoms. Expected Outcomes:
Risk for Impaired Skin Integrity Assessment1. Perform a complete skin assessment. 2. Assess pitting
edema. Risk for Impaired Skin Integrity Interventions1. Keep the skin clean and dry. 2.
Elevate edematous extremities. 3. Apply compression stockings. 4. Educate on
positioning. Ineffective Health Maintenance Care PlanIneffective health maintenance of acute and chronic conditions can result in edema. Edema can be effectively treated and managed in compliance with prescribed treatment regimens. Nursing Diagnosis: Ineffective Health Maintenance Related to:
As evidenced by:
Expected Outcomes:
Ineffective Health Maintenance Assessment1. Assess risk factors. 2. Determine the patient’s capabilities. Ineffective Health Maintenance Interventions1. Involve support systems. 2. Ensure the patient understands their disease process. 3. Refer to appropriate community and social services. References and Sources
Which clinical finding would be seen in a patient having fluid volume excess?An elevated blood pressure and bounding pulses are often seen with fluid volume excess. Decreased blood pressure with an elevated heart rate and a weak or thready pulse are hallmark signs of fluid volume deficit.
What is excess fluid volume related to nursing diagnosis?Excess fluid volume, fluid overload, and fluid or water retention are all phrases to describe the medical term, hypervolemia. Hypervolemia is when the body has too much fluid.
What indicates fluid volume excess?Fluid volume excess is characterized by the following signs and symptoms: Abnormal breath sounds: crackles. Altered electrolytes. Anxiety.
Which of the following symptoms would the nurse expect to assess in patients with fluid volume deficit?Signs and Symptoms
Weight loss (depending on the severity of fluid volume deficit) Concentrated urine, decreased urine output. Dry mucous membranes, sunken eyeballs. Weak pulse, tachycardia.
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