B Fluid Volume Excess - System Disorder PDF

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Summary

System Disorder...

Description

ACTIVE LEARNING TEMPLATE:

System Disorder

ST UDENT NAME _____________________________________

Fluid and Electrolyte Imbalances DISORDER/DISEASE PROCESS __________________________________________________________

Alterations in Health (Diagnosis) Fluid Volume Excess

Pathophysiology Related to Client Problem When excess water is retained in the ECF

57 REVIEW MODULE CHAPTER ___________

Health Promotion and Disease Prevention Consume a diet low in sodium, promote fluids

ASSESSMENT

Risk Factors -Causes of Hypervolemia -Causes of Overhydration

Laboratory Tests -HCT -Serum osmolarity -Serum sodium -Electrolytes, BUN, and creatinine -Arterial Blood Gases

SAFETY CONSIDERATIONS

Expected Findings Vital Signs: tachycardia, bounding pulse, hypertension, tacypnea, increased central venous pressure Neuromusculoskeletal: confusion, muscle weakness GI: weight gain, ascites Respiratory: dyspnea, orthopnea, crackles Other: Edema, distended neck veins

Diagnostic Procedures Chest X-rays

PATIENT-CENTERED CARE

Nursing Care -observe respiratory rate, symmetry, and effort. -Auscultate breath sounds - Measure client's weight daily -Monitor and document edema -Monitor I&O -Monitor and document circulation to extremities

Complications Medications -Administer Diuretics as prescribed

Client Education Encourage client to weigh himself daily. Instruct the client to consume a low-sodium diet, read food labels to check sodium content, and keep a record of daily sodium intake. Promote fluid restriction intake. Consult with provider regarding prescribed restrictions.

Therapeutic Procedures

Interprofessional Care

-Position client in semi-fowler's position -Provide fluids in small glass glass to promote the perception of a full glass -Administer supplemental oxygen as needed

Respiratory services may be consulted for oxygen managment.

ACTIVE LEARNING TEMPLATES

-Severe Fluid Volume Excess can lead to pulmonary edema and heart failure. -Reposition the client every 2 hours -Support arms and legs to decrease dependent edema.

-Shortness of breath -Dyspnea -Fluid and electrolyte imbalance

THERAPEUTIC PROCEDURE

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