Assessment

Explanation of the Problem

Objective Short term: After 8 hours of nursing interventions, the patient will be able to stabilize fluid volume as evidenced by: a. Balanced intake and output b. Vitals signs within normal limits Long term: After 72 hours of nursing interventions, the patient will be able to free from edema

Nursing Interventions > Assess vital signs >Monitor daily weight for sudden increases; use same scale and type of clothing at same time each day, preferably before breakfast

Rationale > Baseline data >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).

Evaluation Goal met: After 8 hours of nursing interventions, the patient has a stable fluid volume as evidenced by: a. Balanced intake and output b. Vitals signs within normal limits Goal partially met: After 8 hours of nursing interventions, the patient has stable vital signs but with dramatic changes in input and output Goal not met: After 72 hours of nursing interventions, the patient has still edema and with unstable fluid input and output

> Fluid volume impairs glomerular Problem Number 1 filtration that resulted to fluid S> Medyo overload. With fluid volume excess, nababawasan naman hydrostatic pressure is higher than yung manas niya the usual, pushing excess fluid into kaysa nung the interstitial spaces. Since fluids kakahospital niya. as are not reabsorbed at the venous end, verbalized by the fluid volume overloads the lymph daughter system and stays in the interstitial spaces leading to edema and O> Peripheral edema hypertension. Fluid volume excess on both feet (bipedal) or hypervolemia occurs from an pitting, +4 via physical increase in total body sodium content assessment last July 9, and an increase in total body water. 2013 This fluid excess usually results from >Peripheral edema on compromised regulatory mechanisms both feet (bipedal), for sodium and water as seen in pitting, +2 last July 16, CHF,kidney failure, and liver failure. 2013, +1 on both upper extremities Bibliography: Gulanick, Meg, PhD, including the hands, RN,et.al (2003).NursingCare Plan: and upper and lower NursingDiagnosis forearms, +1 on right &Interpretation.Westline Dive upper limb where CVP St.Louise. Mosby Inc.5 is placed. th >Adventitious sound ed, p. 65 heard all over the lung fields characterized as explosive, and intermittent upon airway opening (Fine

>With head of bed elevated 30 to 45 degrees, monitor jugular veins for distention in the upright position

>Increased intravascular volume results in jugular vein distention, even in a client in the upright position

>Obtain patient history to ascertain the probable cause of the fluid disturbance.

>Which can help to guide interventions. May include increased fluids or sodium intake, or

crackles) > Central venous pressure reveals a negative 3 result (indicative of hemorrhage) > With a total of 3900 ml fluid output within the last 24 hours (1,400 ml in am, 900 ml in noon, 1600 ml in the evening) > Low potassium level in the urine at 3.43 mmol/L, normally at 3.5- 5.1 mmol/L > High BUN level at 25.10 mg/dL, normally at 8- 23 mg/dL > Low hemoglobin level at 84 g/l, normally at 110- 115 g/L > Low hematocrit level at 0.26 L/L, normally at 0.37- 0.47 L/L > With initial vital signs of BP: 140/80 mmHg, PR: 67 bpm, RR: 15 cpm, T: 36.8 C > With maximum

compromised regulatory mechanisms. >Assess or instruct patient to monitor weight daily and consistently, with same scale and preferably at the same time of day. >Evaluate weight in relation to nutritional status >To facilitate accurate measurement and to follow trends.

>In some heart failure patients, weight may be a poor indicator of fluid volume status. Poor nutrition and decreased appetite over time result in a decrease in weight, which may be accompanied by fluid retention even though the net weight remains unchanged.

>Assess for crackles in >For early recognition lungs, changes in of pulmonary respiratory pattern, congestion. shortness of breath, and orthopnea.

assistance needed in doing ADLs > With good skin turgor and capillary refill goes back after 2-3 seconds A> Excess fluid volume related to compromised regulatory mechanisms

>Assess for presence of edema by palpating over tibia, ankles, feet, and sacrum.

>Pitting edema is manifested by a depression that remains after one's finger is pressed over an edematous area and then removed. Grade edema trace, indicating barely perceptible, to 4, which indicates severe edema. Measurement of an extremity with a measuring tape is another method of following edema. >Although overall fluid intake may be adequate, shifting of fluid out of the intravascular to the extravascular spaces may result in dehydration. The risk of this occurring increases when diuretics are given. Patients may use diaries for home assessment.

>Monitor input and output closely.

>Elevate edematous extremities.

>To increase venous return and, in turn, decrease edema. >To prevent venous pooling.

>Reduce constriction of vessels (use appropriate garments, avoid crossing of legs or ankles). >Provide adequate activity or position changes as able.

>To prevent fluid accumulation in dependent areas