excess fluid volume ppt (case press)

8/13/2019 Excess Fluid Volume Ppt (Case Press)

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CLUES

* August 11, 2012

HGB = 75g/dL (120-170; low)

HCT=.21 (.37-.54; low)

Creatinine = 6.31mg/dL (0.5-1.2; low)

Ionized calcium = 1.0mmol/dL (1.12-1.32 ;

low)

Na = 135mmol/L (137-147; low)

Pulmonary congestion

Minimal pleural effusion is noted on left

side

* August 12 , 2012

-intake exceeds output (I=1000ml, O=830ml)

* August 13, 2012

-intake exceeds output (I=1130ml, O=830ml)

* August 14, 2012

(+)edema on both legs

(+) crackles(+) restlessness

(+) oliguria

CUE

* August 14

“nahihirapan ako huminga, lalo

kapag nakahiga”



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*Excess Fluid Volume related tocompromised regulatory mechanism due to

chronic kidney problem as evidenced by

altered sodium and calcium levels,

decreased hemoglobin and hematocrit,increased creatinine, oliguria, edema,

crackles, restlessness, orthopnea,

pulmonary congestion, and pleural effusion.



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*Glomerulonephritis damages the glomeruli, lettingprotein and sometimes red blood cells leak into theurine. Sometimes a glomerulonephritis interfereswith the clearance of waste products by the kidney,so they begin to build up in the blood. In normalblood, albumin acts like a sponge, drawing extrafluid from the body into the bloodstream, where itremains until the kidneys remove it. But when

albumin leaks into the urine, the blood loses itscapacity to absorb extra fluid from the body. Fluidcan accumulate outside the circulatory system inthe face, hands, feet, or ankles and cause swelling.

(www.kidney.niddk.nih.gov, March, 2012)

(Eric Cohen MD, et. Al, May 2012 retrieved from www. mcw.edu)



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After 5 hours of nursing interventions, the patient will

be able to:

*Verbalize willingness about sodium and fluid restriction.*Enumerate ways to reduce discomfort of fluid restrictions

like frequent oral care, chewing candy or gum, and use of

lip balm.

*Verbalize willingness to record intake and output.

*Be safe from injuries like falls which may be caused by

changes in mentation due to altered electrolyte levels.

*Enumerate ways in reducing edema: ice, activity,

elevation, compression stockings.



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After 2 weeks of nursing interventions, the patient willbe able to:

*Adhere to sodium and fluid restriction, and intake andoutput monitoring.

*Be able to use interventions to reduce discomfort offluid restrictions like frequent oral care, chewing candyor gum, and use of lip balm.

*Demonstrate ways in reducing edema: ice, compressionstockings, elevation, activity.

*Have stabilized fluid volume as evidenced by balancedintake and output, vital signs within normal range,

stable weight, and decreased or absent edema.



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1. Increased sodium would

retain fluid, further increase

in fluid intake would worsenthe problem.

2.To still add flavor to

client’s food and prevent

loss of appetite.

3.To maintain fluid

restriction and correct the

imbalance.

1. Advise to restrict

fluid and sodium

intake as indicated.

2. Suggest substitutes

for salt like lemon and

oregano.

3. Discuss “hidden

sources” of fluid like

ice cream, soups, and

gelatin.



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4. Suggest ways to reduce

discomfort caused by fluid

restriction:

• Use lip balm• Chew gum or candy

• Frequent oral care

5. Record intake and output

accurately, and teach the client

and her family how to do so.

6. Place client in semi-fowler’s

position.

4. Moistens the lips and oral

mucosa.

5. Evaluates effectiveness of

interventions, and allows for

client and family participation

towards care.

6. To facilitate movement of

diaphragm thus improving

respiratory effort.



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7. Remind about the need to

ambulate and/ or have frequent

position changes.

8. Maintain safety precautions like

keeping the side-rails up, and

ensuring that client would not be

left alone.

9. Elevate edematous extremities

and change position frequently.

7. To prevent fluid stasis and

reduce risk of tissue injury.

8. Altered electrolyte levels

may cause altered motor

responses, mentation and

level of consciousness.

9. To reduce tissue pressure

and risk of skin

breakdown.



10. Teach client ways to reduce leg

edema:

•Avoid standing or sitting in one place

too long. Pumping the feet up anddown at the ankle to move the calf

muscle as exercise helps too.

•Elevate the legs higher than the level

of the heart for 20-minute periods 3-4

times throughout the day.

•Use of compression stockings.

•Use of ice packs wrapped in towels

applied to the swollen area for about

15-20 minutes

10. To promote client participation in

care

•Activity and exercise increases

circulation and pumps excess fluidsfrom the legs.

•Elevation techniques put gravity to

use by using its force to draw fluids

from the legs and up to the heart.

•Applies pressure to the legs to

stimulate circulation and move fluid

from the tissues.

•Ice helps to constrict the blood

vessels and reduce the amount offluid that is deposited.

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excess fluid volume ppt (case press)

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