D.0022 Hipervolemia

D.0022

Hipervolemia

Kategori               : Fisiologis

Subkategori        : Nutrisi dan Cairan

Definisi

Peningkatan volume cairan intravaskular, interstisial, dan/atau intraselular

Penyebab

1.       Gangguan mekanisme regulasi

2.       Kelebihan asupan cairan

3.       Kelebihan asupan natrium

4.       Gangguan aliran balik vena

5.   Efek agen farmakologis (mis kortikosteroid, chlorpropamide, tolbutamide, vincristine, tryptilinescarbamazepine)

Gejala dan Tanda Mayor

 Subjektif

1.     Ortopnea

2.     Dispnea

3.     Paroxysmal nocturnal dyspnea (PND)

 Objektif

1.     Edema anasarka dan/atau edema perifer

2.     Berat badan meningkat dalam waktu singkat

3.     Jugular Venous Pressure (JVP) dan/atau Cental Venous Pressure (CVP) meningkat

4.     Refleks hepatojugular positif

Gejala dan Tanda Minor

Subjektif

(tidak tersedia)

Objektif

1.     Distensi vena jugularis

2.     Terdengar suara napas tambahan

3.     Hepatomegali

4.     Kadar Hb/Ht turun

5.     Oliguria

6.     Intake lebih banyak dari output (balans cairan positif)

7.     Kongesti paru

Kondisi Kilnis Terkait

1.         Penyakit ginjal: gagal ginjal akut/kronis, sindrom nefrotik

2.         Hipoalbuminemia

3.         Gagal jantung kongestif

4.         Kelainan hormone

5.         Penyakit hati (mis. sirosis, asites, kanker hati)

6.         Penyakit vena perifer (mis. varises vena, trombus vena, plebitis)

7.         Imobilitas

Referensi

Ackley, B. J., Ladwig. G. B., & Makic, M. B. F. (2017), Nursing Diagnosis Handbook, An Evidence-Based Guide to Planning Care. 11^th Ed. St. Louis: Elsevier.

Carpernito-Moyet, L. J. (2013). Nursing Diagnosis Application to Clinical Practice. 14^th Ed. Philadelphia: Lippincott Williams & Wilkins.

de Souza, V., Zeitoun, S. S., Lopes, C. T., de Oliveira, A. D., Lopes, J. L., & de Barros A. L. (2015). Clinical usefulness of the definitions for defining characteristics of activity intolerance, excess fluid volume and decreased cardiac output in decompensated heart failure: a descriptive exploratory study. Journal Of Clinical Nursing, 24(17-18), 2478-2487.doi:10.1111/jocn. 12832

Doenges, M. E., Moorhouse, M., F., & Murr, A. C. (2013). Nursing Diagnosis Manual Planning, Individualizing and Documenting Client Care. 4^th Ed. Philadelphia: F. A. Davis Company

Guimarães H, de Barros A, de Gutierrez M. Identification of defining characteristics of the nursing diagnosis fluid volume excess. Revista Latino-Americana De Enfermagem (RLAE).

Herdman, T. H., & Kamitsuru, S. (2014). Nursing Diagnosis Definitions and Classification 2015-2017. 10^th Ed. Oxford: Wiley Blackwell.

International Council of Nurses (2015). Internasional Classification of Nursing Practice, Nursing Diagnosis and Outcomes Statement. Geneva, Switzerland: International Council of Nurses.

Martins, Q. S., Aliti, G. B., Linhares, J. C., & Rabelo, E. R. (2011). Excess Fluid volume: Clinical Validation in Patients with Decompensated Heart Failure. Revista Latino-Americana De Enfermagem (RLAE), 19(3), 540-547. doi:10.1590/S0104-11692011000300013.

Newfield, S. A., Hinz, M. D., Tiley, D. S., Sridaromont, K. L., Maramba, P. J. (2012). Cox’s Clinical Applications of Nursing Diagnosis Adult, Child, Women’s, Mental Health, Gerontic, and Home Health Considerations. 6^th Ed. Philadelphia: FA. Davis Company.

Sparks & Taylor (2011). Nursing Diagnosis Pocket Guide. Philadhelpia: Lippincott Willian & Wilkins.

1.