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FLUID VOLUME EXCESS (FVE) Cheat Sheet by

fluid     volume     nursing     medical     healthcare     excess     fve

FLUID VOLUME EXCESS

Fluid intake or retention is greater than the body's needs

CONT­RIB­UTING FACTORS

Kidney failure (late phase)
Heart failure
Cirrhosis
Inters­titial to plasma fluid shifts (hyper­tonic fluids, burns)
Excessive water intake
Long term cortic­ost­eroid therapy
 

MANI­FES­TAT­IONS

Cough, dyspnea, crackles
Increased BP
Tachypnea
Tachyc­ardia
Bounding pulse
Weight gain (1 L water = 1 kg weight)
Jugular vein distention
Increased central venous pressure
Pitting edema

DIAG­NOSTIC PROCED­URES

Serum: Electr­olytes, BUN, creati­nine, Hct
Urine: specific gravity and osmolarity
Chest x-ray if respir­atory compli­cations present
 

NURSING INTERV­ENT­IONS

Monitor respir­atory rate, symmetry, & effort
Monitor breath sounds for signs of pulmonary edema
Monitor for edema
Measure pitting edema on scale of 1+ (minimal) to 4+ (severe)
Monitor dependent edema by measuring circum­ference of extrem­ities
Monitor for ascites
Measure abdominal girth
Weight pt daily
Maintain strict I&O
Monitor vital signs
Administer diuretics (osmotic, loop) as prescribed
Limit fluid intake
Maintain skin integrity
Use semi-F­owler's position
Reposition every 2 hr
Restrict sodium intake

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