30years old female is transfered to Medsurg floor today.Diagnosis : Fluid volume excess. Alert and oriented x 4.Weight 190lbs Height 5ft 7inches.Hx of renal failure, liver disease, hormones imbalance, decreased cardiac output. Objective findings dyspnea with exertion,fatigue and weak,pitting edema in ankles,legs and feet,increased pulse,shallow Respiration, crackles,gained 6lbs in two weeks. Cracked lips,dried oral mucosa.Pulmonary edema. Jugular vein distention.Increase in sodium intake.Taunt,Shiny skin. Possible excessive IV fluid infusion,low protein intake and increase in salt intake.
Subjective findings:Sometimes I can’t catch my breath, I feel bloated and I feel like my heart is pounding fast.I feel like I am overweight my clothes can’t fit me anymore. NURSING GOALS FOR THIS PATIENT. 1.Maintain urine specific gravity within normal range from 1.010 to 1.025.
2.Maintain balance between intake and output.
3.Practice self care behaviors to promote fluid, electrolytes and acid based balance. 4.Monitor intake and output. Follow doctor orders,discontinue IV fluid, decrease sodium intake. Lasix 40mg IV Q8hours.The doctor is responsible in prescription of IV that will be used for the patient.
QUESTIONS AND ANSWERS.
1.What is the most accurate indicator of fluid balance status?.
A.Skin turgor.
B.Sodium intake.
C.Intake and output.
D.Daily weight.
Correct answer is D.
Daily weight is the best indicator of how patient is doing. A,B,and C are not always accurate indicator.
2.The movement of the solvent water from an area of lesser solute concentration to an area of greater solute concentration until equilibrium is called what?.
A.Diffusion.
B.Fluid imbalance.
C.Osmosis.
D.filtration.
Correct answer is C.(Osmosis)A,B and D are wrong. Filtration fluid move through permeable membrane of greater pressure to lower pressure. Whereas with Osmosis is the movement of solvent water from area of lesser concentration to area of greater solute concentration.
Nurses You Move Me 