No subjective data based
w/ rapid ventricular response, left axis deviation, pulmonary disease pattern, inferior
HR 110; Rhythm Afib
Upon arrival to the ER,
her VS were BP 178/110, HR 114
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.
Excess Fluid Volume
Client will remain free
of edema, effusion, anasarca; weight appropriate for the client during hospital
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).
Client will maintain clear
lung sounds, no evidence of dyspnea or orthopnea to be evaluated by the end of shift
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
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.