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Medical Diagnoses: Excess Fluid Volume and Compromised regulatory mechanism

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

No subjective data based on documents.

     

     

     

     

     

     

Objective

Atrial fibrillation w/ rapid ventricular response, left axis deviation, pulmonary disease pattern, inferior infarction

BP 145/86

HR 110; Rhythm Afib

Upon arrival to the ER, her VS were BP 178/110, HR 114

Hgb 10.2

Hct 29.6

She has a history of Type 2 diabetes mellitus, hypertension, coronary artery disease, chronic atrial fibrillation

Dorothy has no urinary output documented for the past 10 hours.

Intake includes 1100 ml of IV fluids and 3 cups of ice chips (~160 ml)

Strong hx of smoking and moderate life sytle.

Obese



Problem

    

Excess Fluid Volume

    

Long Term:

Client will remain free of edema, effusion, anasarca; weight appropriate for the client during hospital stay.

Monitor location and extent of edema; use a millimeter tape in the same area at the same time each day to measure edema in extremities. Generalized edema (e.g., in the upper extremities and eyelids) is associated with decreased oncotic pressure often as a result of nephrotic syndrome. Measuring the extremity with a millimeter tape is more accurate than using the 1 to 4 scale (Metheny, 2000). Heart failure and renal failure are usually associated with dependent edema because of increased hydrostatic pressure; dependent edema causes swelling in the legs and feet of ambulatory clients and the presacral region of clients on bed rest. EBN: Dependent edema was found to demonstrate the greatest sensitivity as a defining characteristic for excess fluid volume (Rios et al, 1991).

Monitor daily weight for sudden increases; use same scale and type of clothing at same time each day, preferably before breakfast. EB: Measurement of body weight change is a safe technique to assess hydration status (Armstrong, 2005). EB: Body weight could safely be used to monitor for fluid overload when administering hyperhydration with high-dose chemotherapy (Mank et al, 2003).

With head of bed elevated 30 to 45 degrees, monitor jugular veins for distention in the upright position; assess for positive hepatojugular reflex. Increased intravascular volume results in jugular vein distention, even in a client in the upright position, and a positive hepatojugular reflex (Kasper et al, 2005).

Turn clients with dependent edema frequently (i.e., at least every 2 hours). Edematous tissue is vulnerable to ischemia and pressure ulcers (Casey, 2004).

Teach client on diuretics to weigh self daily in the morning and notify the physician of a change in weight of 3 pounds or more (Karch, 2004).

    

    

     



     

R/T

Compromised regulatory mechanism

    

    

    

    

    

    

Short Term:

Client will maintain clear lung sounds, no evidence of dyspnea or orthopnea to be evaluated by the end of shift on 04.07.09.

    

Monitor vital signs; note decreasing blood pressure, tachycardia, and tachypnea. Monitor for gallop rhythms. If signs of heart failure are present, see the care plan for Decreased Cardiac output. Heart failure results in decreased cardiac output and decreased blood pressure. Tissue hypoxia stimulates increased heart and respiratory rates.

Monitor lung sounds for crackles, monitor respirations for effort, and determine the presence and severity of orthopnea. Pulmonary edema results from excessive shifting of fluid from the vascular space into the pulmonary interstitial space and alveoli. Pulmonary edema can interfere with the oxygen/carbon dioxide exchange at the alveolar-capillary membrane (Metheny, 2000), resulting in dyspnea and orthopnea.

    

    



    

AEB

decreased hematocrit; decreased hemoglobin

intake exceeds output change in mental status; changes in respiratory pattern;

    

    

    

    

    

    

 

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*I = Implementation.  Check those interventions/actions/orders that were implemented.

     

References:

     

Armstrong LE: Hydration assessment techniques, Nutr Rev 63(6 pt 2), S40S54, 2005.

Casey G: Edema: causes, physiology and nursing management, Nur Stand 18(51):45, 2004.

Karch AM: Practice errors. On the rebound: maintaining normal fluid intake is critical while on diuretics, Am J Nurs 104(10):73, 2004.

Kasper DL et al, editors: Harrison's principles of internal medicine, ed 16, New York, 2005, McGraw-Hill.

Mank A, Semin-Goossens A, Lelie J et al: Monitoring hyperhydration during high-dose chemotherapy: body weight or fluid balance Acta Haematol 109(4):163, 2003.

Metheny N: Fluid and electrolyte balance: nursing considerations, ed 4, Philadelphia, 2000, J.B. Lippincott.

Rios H, Delaney C, Kruckeberg T et al: Validation of defining characteristics of four nursing diagnoses using a computerized data base, J Prof Nurs 7:293, 1991.

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