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Nursing Care Plan A Client with Fluid Volume Excess, Study Guides, Projects, Research of Nursing

Regain fluid balance, as evidenced by weight loss, decreasing edema, and normal vital signs. Experience decreased dyspnea. Maintain intact skin and mucous ...

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2021/2022

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CHAPTER 5 / Nursing Care of Clients with Altered Fluid,Electrolyte, or Acid-Base Balance 93
Home Care
Teaching for home care focuses on managing the underlying
cause of fluid volume excess and preventing future episodes of
excess fluid volume. Address the following topics when
preparing the client and family for home care.
Signs and symptoms of excess fluid and when to contact the
care provider
Prescribed medications: when and how to take, intended and
adverse effects, what to report to care provider
Recommended or prescribed diet; ways to reduce sodium in-
take; how to read food labels for salt and sodium content; use
of salt substitutes, if allowed. (see Box 5–8)
If restricted, the amount and type of fluids to take each day;
how to balance intake over 24 hours
Monitoring weight; changes reported to care provider
•Ways to decrease dependent edema:
a. Change position frequently.
b. Avoid restrictive clothing.
c. Avoid crossing the legs when sitting.
d. Wear support stockings or hose.
e. Elevate feet and legs when sitting.
How to protect edematous skin from injury:
a. Do not walk barefoot.
b. Buy well-fitting shoes; shop in the afternoon when feet
are more likely to be swollen.
Using additional pillows or a recliner to sleep, to relieve
orthopnea
BOX 5–8
Client Teaching
LOW-SODIUM DIET
•Reducing sodium intake will help the body excrete excess
sodium and water.
•The body needs less than one-tenth of a teaspoon of salt
per day.
•Approximately one-third of sodium intake comes from salt
added to foods during cooking and at the table; one-fourth
to one-third comes from processed foods; and the rest comes
from food and water naturally high in sodium.
•Sodium compounds are used in foods as preservatives, leav-
ening agents, and flavor enhancers.
•Many nonprescription drugs (such as aspirin, cough medi-
cine, laxatives, and antacids) as well as toothpastes and
mouthwashes contain high amounts of sodium.
•Low-sodium salt substitutes are not really sodium free and
may contain half as much sodium as regular salt.
•Use salt substitutes sparingly; larger amounts often taste bit-
ter instead of salty.
•The preference for salt will eventually diminish.
•Salt,monosodium glutamate, baking soda, and baking pow-
der contain substantial amounts of sodium.
•Read labels.
•In place of salt or salt substitutes, use herbs, spices, lemon
juice, vinegar, and wine as flavoring when cooking.
Nursing Care Plan
A Client with Fluid Volume Excess
Dorothy Rainwater is a 45-year-old Native American woman hos-
pitalized with acute renal failure that developed as a result of
acute glomerulonephritis. She is expected to recover, but she has
very little urine output. Ms. Rainwater is a single mother of two
teenage sons.Until her illness, she was active in caring for her fam-
ily,her career as a high school principal, and community activities.
ASSESSMENT
Mike Penning,Ms. Rainwater’s nurse, notes that she is in the olig-
uric phase of acute renal failure, and that her urine output for the
previous 24 hours is 250 mL; this low output has been constant for
the past 8 days. She gained 1 lb (0.45 kg) in the past 24 hours.
Laboratory test results from that morning are: sodium,155 mEq/L
(normal 135 to 145 mEq/L); potassium, 5.3 mEq/L (normal 3.5 to
5.0 mEq/L); calcium, 7.6 mg/dL (normal 8.0 to 10.5 mg/dL), and
urine specific gravity 1.008 (normal 1.010 to 1.030).Ms. Rainwater’s
serum creatinine and blood urea nitrogen (BUN) are high; how-
ever,her ABGs are within normal limits.
In his assessment of Ms. Rainwater ,Mike notes the following:
•BP 160/92; P 102, with obvious neck vein distention; R 28,
with crackles and wheezes; head of bed elevated 30 degrees;
T 98.6° F.
•Periorbital and sacral edema present; 3+ pitting bilateral pedal
edema; skin cool,pale, and shiny.
•Alert,oriented;responds appropriately to questions.
•Client states she is thirsty, slightly nause-
ated,and ex tremely tired.
Ms. Rainwater is receiving intravenous furosemide and is on a
24-hour fluid restriction of 500 mL plus the previous day’s urine
output to manage her fluid volume excess.
DIAGNOSES
Excess fluid volume related to acute renal failure
Risk for impaired skin integrity related to fluid retention and
edema
Risk for impaired gas exchange related to pulmonary con-
gestion
Activity intolerance related to fluid volume excess, fatigue,
and weakness
EXPECTED OUTCOMES
•Regain fluid balance, as evidenced by weight loss, decreasing
edema, and normal vital signs.
•Experience decreased dyspnea.
•Maintain intact skin and mucous
membranes.
•Increase activity levels as prescribed.
PLANNING AND IMPLEMENTATION
•Weigh at 0600 and 1800 daily.
(continued)
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Nursing Care Plan

A Client with Fluid Volume Excess

Dorothy Rainwater is a 45-year-old Native American woman hos- pitalized with acute renal failure that developed as a result of acute glomerulonephritis. She is expected to recover, but she has very little urine output. Ms. Rainwater is a single mother of two teenage sons.Until her illness, she was active in caring for her fam- ily, her career as a high school principal, and community activities.

ASSESSMENT

Mike Penning, Ms. Rainwater’s nurse, notes that she is in the olig- uric phase of acute renal failure, and that her urine output for the previous 24 hours is 250 mL; this low output has been constant for the past 8 days. She gained 1 lb (0.45 kg) in the past 24 hours. Laboratory test results from that morning are: sodium, 155 mEq/L (normal 135 to 145 mEq/L); potassium, 5.3 mEq/L (normal 3.5 to 5.0 mEq/L); calcium, 7.6 mg/dL (normal 8.0 to 10.5 mg/dL), and urine specific gravity 1.008 (normal 1.010 to 1.030).Ms.Rainwater’s serum creatinine and blood urea nitrogen (BUN) are high; how- ever, her ABGs are within normal limits. In his assessment of Ms. Rainwater , Mike notes the following:

  • BP 160/92; P 102, with obvious neck vein distention; R 28, with crackles and wheezes; head of bed elevated 30 degrees; T 98.6° F.
  • Periorbital and sacral edema present; 3+ pitting bilateral pedal edema; skin cool, pale, and shiny.
  • Alert, oriented; responds appropriately to questions.
    • Client states she is thirsty, slightly nause- ated, and extremely tired. Ms. Rainwater is receiving intravenous furosemide and is on a 24-hour fluid restriction of 500 mL plus the previous day’s urine output to manage her fluid volume excess.

DIAGNOSES

  • Excess fluid volume related to acute renal failure
  • Risk for impaired skin integrity related to fluid retention and edema
  • Risk for impaired gas exchange related to pulmonary con- gestion
  • Activity intolerance related to fluid volume excess, fatigue, and weakness

EXPECTED OUTCOMES

  • Regain fluid balance, as evidenced by weight loss, decreasing edema, and normal vital signs.
  • Experience decreased dyspnea.
  • Maintain intact skin and mucous membranes.
  • Increase activity levels as prescribed.

PLANNING AND IMPLEMENTATION

  • Weigh at 0600 and 1800 daily. (continued)

Nursing Care Plan

A Client with Fluid Volume Excess (continued)

  • Assess vital signs and breath sounds every 4 hours.
  • Measure intake and output every 4 hours.
  • Obtain urine specific gravity every 8 hours.
  • Restrict fluids as follows: 350 mL from 0700 to 1500; 300 mL from 1500 to 2300; 100 mL from 2300 to 0700. Prefers water or apple juice.
  • Turn every 2 hours, following schedule posted at the head of bed. Inspect and provide skin care as needed; avoid vigorous massage of pressure areas.
  • Provide oral care every 2 to 4 hours (can brush her own teeth, caution not to swallow water); use moistened applicators as desired.
  • Elevate head of bed to 30 to 40 degrees; prefers to use own pil- lows.
  • Assist to recliner chair at bedside for 20 minutes two or three times a day. Monitor ability to tolerate activity without increas- ing dyspnea or fatigue.

EVALUATION

At the end of the shift, Mike evaluates the effectiveness of the plan of care and continues all diagnoses and interventions. Ms. Rainwater gained no weight, and her urinary output during his shift is 170 mL. Her urine specific gravity remains 1.008. Her vital signs are unchanged, but her crackles and wheezes have de- creased slightly. Her skin and mucous membranes are intact. Ms. Rainwater tolerated the bedside chair without dyspnea or fatigue.

Critical Thinking in the Nursing Process

  1. What is the pathophysiologic basis for Ms. Rainwater’s in- creased respiratory rate, blood pressure, and pulse?
  2. Explain how elevating the head of the bed 30 degrees facili- tates respirations.
  3. Suppose Ms. Rainwater says,“I would really like to have all my fluids at once instead of spreading them out.”How would you reply, and why?
  4. Outline a plan for teaching Ms. Rainwater about diuretics. See Evaluating Your Response in Appendix C.