Med-Surg+Case+Study+1

Brandi Burns=Red

​Case Study – Fluid Volume Excess Ms Water is an 82 y/o female admitted with cirrhosis and renal failure. The provider states she has fluid volume excess. Her history consists of Type II diabetes and hypertension. 1. What nursing assessment would you perform to detect Fluid Volume Excess and why?

I would assess the following:

· Peripheral edema: increased fluid retention in tissues · Mental Status Changes, confusion, lethargy. · Salt Intake: Increased salt intake - retention of water · Distended Neck Veins-increased fluid retention in surrounding tissues/increased workload on circulatory system · Bounding Pulse-increased workload · Hypertension-excessive workload on heart · Polyuria-urine may be dilute · Pulmonary Edema/ Crackles in lungs-failure of heart to remove fluid from lungs · Weight Gain: indicator of water retention · Seizures- · Coma- · Diarrhea-Increased fluid; systemically · SOB-increased workload on heart, fluid in/surrounding lungs/tissues/decreased O2 Dyspnea  Serum electrolytes, urine osmolality, and urine-specific gravity.

 urine concentration ( expect to find less concentrated urine)  decreased Hgb and Hct  changes in electrolytes, BUN, and creatinine.  tachycardia, bounding pulse, tachypnea, increased central venous pressure. confusion, muscle weaknes, weight gain, ascites, dyspnea, orthopnea, crackles, edema, distended neck veins.

 anasarca (massive edema), possible hepatojugular reflex ( return flow into the stomach),

 2. Upon assessment you note that Ms Water has SOB and orthopnea. Why would she have this and what nursing interventions can you do to help decrease this? What further assessments would you need to perform?

SOB/Orthopnea occurs when the excess fluid shifts into the air spaces in the lungs. This causes a decrease in the amount of O2 that can enter the blood and this is why Ms Water is experiencing this.

I would further need to assess: · Health Hx- co morbidities-related to any cardiac or pulmonary diseases (CHF, COPD), renal /adrenal insufficiency, surgical procedure · When does she experience SOB? Any specific time or activity? · What makes it worse, what makes it better? · What medications is she currently taking (if any)? · Current Sleeping/Sitting Position (if possible, head of bed should be elevated) · How many pillows does she sleep with? · Current Activity Level · Pulse 02/VS · ABG’s · Pt experiencing pain? · Anxiety? · Temperature/Humidity of room mental status, restlessness I &O- set an appropiate rate of fld intake/ infusion throughout 24hr period promote early ambulation assess breath sounds, monitor arterial blood gases for hypoxemia and resp. alkalosis, position pt in semi-fowlers, administer o2 if needed, monitor I+O

ecourage bed rest/may promote recumbency-induced diuresis (Doenges, 2006. p 459) monitor cardiac arrythmias/may be caused by HF (Doenges. 2006. p. 459) 3. Upon assessing the lungs you note bilateral crackles – why would she have this and what further nursing assessments and interventions would you do for this? Explain your rationale for the interventions. BNP order. she have crackles due to pulmonary congestion and pulmonary edema as increased hydrostatic pressure in the pulmonary vessels forces fld into alveoli. Assessment: VS, mental status for confusion/ personalities changes, restlessness, skin turgor, nutrition, note presence of edema, note patterns and amt of urination

pulmonary edema s/s is ascending crackles. It is likely from her fluid volume overload ( fluid excess). moniotr for persistant cough with pink, frothy sputum, tachypnea, dyspnea, orthpnea, restlessness, anxiety, hypoxemia, cyanosis, crackles, tachycardia, confusion, stupor.

assess: vital signs every 15 mins until stable pulse ox ( continuously) respiratory status for respiratory comprimise I+O hemodynamic status ( cardiac output) blood work

interventions: suction to maintain airway if needed position pt in high folers to decrease preload administer o2 if needed restrict fluid intake ( slow,d/c IV) admister meds such as lasix( gets rid of excess fluid), morphine ( promotes vasodilation), digogen ( improve cardiac output) monitor urine output hourly, report output less than 30/mL an hour monitor labs, ABG's, and serum pottasium

teach pt effective breathing techniques, instruct client about meds, instruct client on a low-sodium diet and fluid restriction, measure clients weight same time every day ( notify of weight gain of over 1-2 lbs per day)

4. Upon further assessment you note she has distended neck veins and 3+ pitting edema to her lower extremities – why would he have this in FVE and what nursing interventions would you do for this? Explain your rationale for the interventions. Distended neck vains are signs of fld volume excess due to renal failure and the pitting edema is due to renal fai;ure and cirrhosis- liver is unable to move proteins from the blood vessels into the lymph space. because of the pt age and h/o diabetes that req IV is important to prevent nephrotoxic injury secondary to dye. adm diuretic therapy to prevent fld overload. Fld intake must be monitored (fld restriction) to avoid sensible losses (K+) monitor Lab values, esp. K+ for hypokalemia / hyperkalemia. The provider orders the following: Explain the rationale for these orders and nursing assessments when performing these tasks. What is the rationale for the assessment? What findings would you feel necessary to report to the provider? - I&O - Daily weight- to monitor any fld retention in the body - Fluid restriction of 1000mL daily - 2gram Na+ diet - Patient in semi-fowler’s position- to facilitated breathing and prevention of aspiration this is low - normal values are 3.5-5.0 mEq/L potassium has a huge role on cardiac function, lung, muscle, and acid-base balance. This could be because of vomiting, suctioning, diarrhea, wound losses, prolonged use of IV solutions, or use of diuretics. encourage potassium rich foods such as bananas, or give oral potassium supplementation NEVER IV PUSH. monitor for phlebitis and adequate urine output.
 * 1) The provider orders a chem. Panel. The K+ comes back 2.8. What is the significance of this? What would you expect the provider to order and why?


 * 1) What are s/s of hypokalemia? cardiac arrythmias, muscle weakness, cramps, muscle aches, palpitations, constipation, polyuria, cardiac arrest, anorexia, thirst, tetany

2. Two hours later you go into the room and notice that the IV has infused incorrectly because of IV pump malfunction. You immediately notify the provider. What other nursing assessments would you perform and why? Depending upon if the infusion was not enough or too much. If the infusion was too much I would stop the flow adjust the drip rate and use gravity method as KVO then contact the provider. Prior to my contact with provider, I would obtain V/S, I would document the amount of fluid pt. recieved and the type. I would place patient in semi-fowler position. assess for signs and symptoms of hyperkalemia such as irritability, abdominal cramping, diarrhea, weakness in lower extremeies and irregular pulse. assess for fluid overload such as fatigue, edema, difficulty breathing, ascites. 3. The provider orders a Chem 7. The K+ comes back 6.2. What is the significance of this? this is a high level for potassium. This could result in a slow irregular pulse, hypotension, weakness, hyperactive bowel sounds, paresthesias, ventricular fibrillation. irritability, anxiety, nausea.

increase potassium excretion with diuretics such as Lasic, administer Kayexalate ( cation exchange resins ) increase fluid intake to encourage renal potassium elimination. 4. What would you expect to see on her EKG? What cardiac implications does hyperkalemia have? I would expect to see Ventricular fibrillation, peaked T waves, and widened QRS prolonged PR interval, loss of P wave, ventricular standstill. 5. The provider order 1unit regular insulin per 1mLof D5W fluid to infuse at 100ml/hr. Why would this be ordered? When a patient is a diabetic the lack of insulin can cause a rise in glucuse. Without insulin fat cells breakdown whick release ketones into the blood turning the blood acidic. (Diabetic Ketoacidosis.), the high glucose amd acidosis causes fluid and potassium to shift out of the cell into the blood circulation. Add this to poor kidney function (difficulty excreting potassium) can cause hyperkalemia it encourages cellular uptake of potassium and preven hypoglycemia. Kayexalate fast working, think skin integrity. 6. 12 hours later the patient’s K+ is 5.3. The provider orders a diet restriction of potassium rich foods. How would the nurse counsel this patient regarding the diet restriction? Who could help you with this education? avoid foods such as avacados, broccoli, dairy products, dried fruit, cantaloupe, and bananas. I would contact the nutrionist Remember what type of medication on.


 * [|what is diabetes]**