Care Plan for Alteration in Fluid Balance

Category / Primary Body System

• Cardiovascular System / Renal System

Problem

• Resident is at risk for alteration in fluid balance.

Goal

• Resident's fluid balance will be adequate for vascular support and overall health for 90 days.

Plan/Approach

1. Monitoring and Assessment

   • Elevate affected extremities as tolerated to reduce swelling and promote venous return.
   • Monitor lung sounds every shift to detect early signs of fluid overload.
   • Assess skin turgor, urine output, and mental status to evaluate hydration status.

2. Medication Management

   • Administer medications as ordered to manage fluid balance.

3. Communication and Reporting

   • Monitor physician of changes in the patient's condition promptly.
   • Monitor and report appropriate labs (e.g., electrolytes, BUN/creatinine) to assess fluid and electrolyte balance.

4. Patient and Family Education

   • Educate patient and family on the importance of monitoring fluid balance and recognizing signs of fluid imbalance.

Rationale

1. Monitoring and Assessment

   • Elevating extremities helps reduce edema and improve circulation.
   • Regular lung sound assessments can detect fluid accumulation early, preventing complications such as pulmonary edema.
   • Assessing skin turgor, urine output, and mental status provides indicators of the patient’s hydration status and overall fluid balance.

2. Medication Management

   • Administering medications as prescribed helps manage fluid balance by addressing underlying conditions and promoting excretion or retention of fluids as needed.

3. Communication and Reporting

   • Promptly notifying the physician of changes ensures timely interventions to prevent complications.
   • Regular lab monitoring provides critical data to guide treatment decisions and adjustments in the care plan.

4. Patient and Family Education

   • Educating the patient and family empowers them to participate in care and recognize early signs of fluid imbalance, improving outcomes.

Actions

1. Monitoring and Assessment

   • Elevate the affected extremities as tolerated, ensuring proper support and comfort.
   • Monitor lung sounds every shift, documenting findings and reporting any abnormal sounds (e.g., crackles, wheezes) to the physician.
   • Assess skin turgor by gently pinching the skin and observing how quickly it returns to normal.
   • Monitor urine output, noting the volume, color, and frequency.
   • Evaluate mental status regularly, observing for any changes in alertness, confusion, or agitation.

2. Medication Management

   • Administer prescribed medications on schedule, monitoring for effectiveness and side effects.
   • Adjust medications as needed in consultation with the healthcare provider based on patient response and lab results.

3. Communication and Reporting

   • Notify the physician promptly of any significant changes in the patient’s condition, such as increased edema, abnormal lung sounds, or changes in urine output.
   • Conduct and review lab tests as ordered, reporting any abnormalities to the healthcare provider.

4. Patient and Family Education

   • Provide education on the importance of fluid balance, including signs of dehydration and fluid overload.
   • Offer written and verbal instructions on managing fluid intake and recognizing symptoms that require medical attention.