Healthcare - Nursing Care Plan - Patients having an issue of Excess Fluid Volume PDF

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Summary

Sample format of the nursing care plan for patients with excess fluid volume and also sample content that may help in providing holistic care. It consists of interventions on dealing with this kind of issue and also properly dealing with it....

Description

NURSING CARE PLAN Patient’s Initial: ___T.H._____ Age: _34 yrs old __ Gender: __Male__ Date Handled: _May 3, 2021___ Medical Diagnosis: _Cushing Syndrome_____ Chief Complaint: __changes in his appearance over the past year ________ Clinical Area: __________________ Assessment

Nursing Diagnosis

Subjective: • The patient reports weight gain (particularly through his midsection), easy bruising, and edema of his feet, lower legs, and hands • The patient has been having increasing weakness and insomnia

Excess Fluid Volume related to compromised regulatory mechanism (fluid and sodium retention) as evidenced by increased blood pressure, edema in lower extremities and increased RBCs count.

Objective: • Physical examination: : BP 150/110 : 2+ edema of lower extremities : purplish striae on abdomen : thin extremities with thin friable skin : severe acne of the face and neck • Blood analysis: : Glucose -167 mg/dL (9.3 mmol/L) : White blood cell (WBC) Count 13,600/µL : Lymphocytes - 12% : Red blood cell

Planning Short Term Goal: After 8 hours of nursing intervention the client will be able to: • maintain normal blood pressure • maintain normal urine output • verbalize causative factors, symptoms and treatment of the condition.

Intervention Independent: • Educate patient and family members regarding fluid volume excess and its causes. • Monitor weight regularly using the same scale and preferably at the same time of day wearing the same amount of clothing.

• Monitor and note BP and HR. As evidenced by: • blood pressure within normal limits • urine output greater than or equal to 30 ml/hr Long Term Goal: After 1 day of nursing intervention the client will be able to: • demonstrate absence of edema • demonstrate balanced input and output and stable weight As evidenced by: • absence of swelling in lower extremities

Rationale

• Information is key to managing problems.

• Sudden weight gain may mean fluid retention. Different scales and clothing may show false weight inconsistencies. • increased BP and HR are the evident signs of fluid retention

• Monitor fluid intake.

• This enhances compliance with the regimen.

• Instruct the client to elevate feet when sitting down.

• This position decreases fluid accumulation in the lower extremities.

Evaluation Short Term Evaluation After 8 hours of nursing intervention the goal to: • maintain normal blood pressure • maintain normal urine output • verbalize causative factors, symptoms and treatment of the condition was: _√_ met ___ partially met ___ unmet As evidenced by: • blood pressure within normal limits • urine output greater than or equal to 30 ml/hr

Long Term Evaluation: After 1 day of nursing intervention the goal to: • demonstrate absence of edema • demonstrate balanced input and output and stable weight was:

• Educate patient and family members the importance of proper nutrition, and diet modification.

• Knowledge heightens compliance with the treatment plan.

• Monitor the client’s sodium and potassium levels.

• To monitor the occurrence of hypokalemia. _√_ met ___ partially met • Too much sodium in the diet ___ unmet promotes fluid retention and weight gain.

• Encourage the client to have low sodium and high potassium diet.

(RBC) count - 6.0 × 106/µL : K+ - 3.2 mEq/L (3.2 mmol/L)

• the amount of intake is equal to the amount of output.

As evidenced by: • absence of swelling in lower extremities • the amount of intake is equal to the amount of output.

• Monitor and manage complications such as skin ulcer and infection Dependent: • Limit sodium intake as prescribed.

• Restriction of sodium aids in decreasing fluid retention

• Instruct the client to reduce fluid intake • Limiting fluid intake is as indicated. important in preventing circulatory overload. • Administer antihypertensive medications as prescribed. • To treat high blood pressure. • Administer diuretics as prescribed.

Interdependent/ Collaborative: • Cooperate with the pharmacist to maximally concentrate IV fluids and medications.

• Diuretics promote sodium and water excretion. Potassium-sparing diuretics may also be prescribed to prevent additional loss of potassium. • Concentration decreases unnecessary fluids.

• Consult dietitian as needed.

• To develop dietary plan and identify foods to be limited.

• Assist with and result from laboratory tests and diagnostic studies.

• To assess etiology and precipitating factors.

• Collaborate in treatment of underlying condition that might be causing the excess fluid volume

• To treat the underlying cause of excess fluid volume.

Discussion Questions 1. Discuss the probable causes of the alterations in T.H.'s laboratory results.

 Hyperglycemia. Cushing's syndrome is a condition that occurs when there are high levels of cortisol in the blood. Cortisol elevates our blood pressure and glucose levels.  Increased WBCs and Decreased Lymphocytes. Cushing syndrome was caused by excessive endogenous exposure to pathologic Glucocorticoids levels, causes changes in white blood cell count and function, including granulocytosis, increased monocytes, and a decrease in lymphocytes. And elevated white blood cell (WBC) counts in Cushing's disease are associated with hypercortisolism; this is because glucocorticoid receptors expressed by WBCs play a part in cell adhesion and WBC recruitment from the bone marrow.  Increased RBCs. Corticosteroids have such an erythropoietic effect that can result in polycythemia or increased in red blood cells count.  Decreased Potassium level. By acting on mineralocorticoid receptors, cortisol reduces glomerular filtration rate and renal plasma flow from the kidneys, increasing phosphate excretion as well as sodium and water retention and potassium excretion. 2. Explain the pathophysiology of Cushing syndrome.  CD is caused by a benign monoclonal pituitary corticotroph adenoma that secretes too much ACTH, resulting in supraphysiological glucocorticoid release from the adrenal glands. Excess circulating cortisol disrupts the natural physiological diurnal variance in cortisol levels and inhibits CRH secretion from the hypothalamus through negative feedback inhibition. The adenoma, on the other hand, is relatively resistant to inhibition by endogenous circulating cortisol. As a result, CD is associated with suppressed CRH secretion and elevated ACTH levels in comparison to the degree of cortisol intake. 3. What diagnostic testing would identify the cause of T.H.'s Cushing syndrome?  Blood and urine tests. These tests assist the doctor in determining the volume of hormones in the body, such as cortisol and adrenocorticotropic hormone (ACTH).  Dexamethasone-Suppression test. Dexamethasone is a corticosteroid, which is a type of hormone released by the adrenal glands. The body's natural reaction to dexamethasone is to momentarily avoid producing cortisol when the brain senses the presence of dexamethasone and recognizes that it does not need to transmit the ACTH signal to produce the body's own cortisol. However, people with Cushing's syndrome, on the other hand, appear to produce cortisol even though dexamethasone is administered.  Saliva test. Cortisol levels fluctuate during the day; they are strongest in the morning and very low or undetectable after midnight. People with Cushing's syndrome, on the other hand, have less fluctuations in their cortisol levels and higher levels at night than usual. A tiny late-night salivary extract will be used by the doctor to assess your cortisol levels.  Imaging tests. Imaging examinations, such as computerized tomography (CT) scans or magnetic resonance imaging (MRI) scans, will assist the specialist in detecting any anomalies in your pituitary and/or adrenal glands. • Abdominal CT - to examine the abdomen for an adrenal gland tumor or another kind of tumor • Pituitary MRI - to check for a pituitary tumor • Dual x-ray absorptiometry (DXA) - to assess bone mineral density; people with Cushing's syndrome also have low bone mass.

4. What is the usual treatment of Cushing syndrome?  Pharmacologic treatment

•

Adrenal enzyme inhibitors - used to reduce hyperadrenalism.

• Potassium-sparing diuretics - promotes sodium excretion while conserving potassium.  Radiation therapy  Surgical treatment • Transsphenoidal hypophysectomy - if caused by the pituitary tumor • Adrenalectomy - if caused by adrenal tumor/disfunction 5. What is meant by a “medical adrenalectomy”?  It is often used to describe procedures that aim to inhibit adrenal activity instead of adrenalectomy. This term can only be applied to regimens that create a hormonal environment that is similar to that produced by surgical adrenalectomy. It is used to describe treatments that aim to inhibit adrenal steroidogenesis. 6. Patient-Centered Care: What are the priority nursing responsibilities in the care of T.H.?  Monitor vital signs, intake and output.  Restrict sodium and provide low carbohydrates, high protein and high potassium in the diet.  Weight the patient daily assessing abdominal girth  Reverse isolation due to immunosuppression  Provide or assst in skin care 7. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?  Excess Fluid Volume related to compromised regulatory mechanism (fluid and sodium retention) as evidenced by increased blood pressure, edema in lower extremities and increased RBCs count.  For collaborative, we can cooperate with the pharmacist to maximally concentrate IV fluids and medications and/or consult dietitian as needed....