Med-Surg+Case+Study+1

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? Skin Assessment - Pitting edema in dependent areas, skin pale and cool to the touch Respiration's- increase respiratory rate, shallow respiration, moist crackles, increased dyspnea with exertion. Cardiovascular - increased pulse rate, elevated blood pressure, distended neck and hand veins weight gain, bounding pulse. Neuromuscular- Altered level of consciousness, headache, visual disturbance, paresthesias

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? Orthopnea is shortness of breath or difficulty breathing when lying flat, so the pt is most comfortable sitting up in bed or in a chair. Orthopnea is caused by increased hydrostatic pressure in the pulmonary vessels which forces the fluid into the alveoli. Some nursing interventions to help decrease this are. 1) Monitor IV rates (avoid rapid infusion) and I&O to make sure the pt is not getting too much. 2) Place pt in position of comfort. 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. Crackling lung sounds and fluid volume excess would be caused by excessive fluid in the lungs. A CXR (chest xray) would confirm this. Reducing fluid intake, an asking for an order for a diurectic would be interventions to help eliminate fluid in the lungs. (jr) 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. Bulging neck viens can be caused by excess fluid in or around the heart (pericardial sac) backing up blood and fluid into the veins and arties close to the heart. interventions for this would be fluid restriction, salt restriction, high fowlers position, and diurectics. +3 pitting edema is caused bt excessive fluid that backs up into the distal extremities, which causes pooling, edema, and discomfort. Interventions are elevate the extremities, stockings worn to the knees or thigh, and again, resticted salt,(attracts water), cut back on fluids, and diurectics if aloud. (jr) 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- t his will measure the amount the patient takes in ( 24 hour period) and puts out. Fluid retention may not be visible.The source of excessive fluid intake or fluid loss can be identified. This gives valuable information regarding fluid and electrolyte problems. - Daily weight –daily weight is a very reliable indicator of FVE. - Fluid restriction of 1000mL daily- T he daily water intake depends on the daily urine output. Generally 600mL plus the amount equal to the previous days output. The restriction is related to her "fluid volume excess and renal failure. The amount daily allowance is the amount the body requires and can tolerate. - 2gram Na+ diet- To prevent Hyponatrememia r/t excessive water gain - Patient in semi-fowler’s position – this is the most comfortable position for a pt with Orthopnea
 * 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? This is significant because it means that the pt's K+ is less than normal meaning that her electrolyte balance is off. This can be caused by non-potassium sparing diuretics. We would expect the MD to order a potassium supplement.
 * 2) What are s/s of hypokalemia? Some of the S/S of hypokalemia are fatigue, muscle weakness, cramps, nausea & vomiting, decreased reflexes, weak irregular pulse.
 * 3) 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? The MD needs to know that the IV has incorrectly infused because this pt has fluid overload, if the IV contained potassium and infused too quickly it could lead to hyperkalemia. We would immediately assess for s/s of hyperkalemia in the pt because it can lead to death if not treated.
 * 4) The provider orders a Chem 7. The K+ comes back 6.2. What is the significance of this?
 * 5) What would you expect to see on her EKG? What cardiac implications does hyperkalemia have? The pt's EKG may have a tall peaked T-wave, a prolonged PR interval, a ST segment depression, loss of P wave, widening QRS, V-fib or ventricular standstill. If a person has severe hyperkalemic, they will go into cardiac arrest.
 * 6) The provider order 1unit regular insulin per 1mLof D5W fluid to infuse at 100ml/hr. Why would this be ordered? Type II diabetes is usually controlled with diet, exercise. however some Patient may require Insulin injection/ IV related to severe stress such as and illness or surgery.This Patient is certainly experiencing severe stress.
 * 7) 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? The nurse could explain the dangers of hyperkalemia and provide the pt with a list of foods high in potassium that the pt should avoid. The nurse could get the dietitian to help with pt education.


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