Nursing Group Sample Assignment

§ Vomiting and diarrhea

b) What are some common causes of fluid overload (fluid volume excess)?

· Excessive sodium or fluid intake

o Causes:

§ IV therapy using NS or LR

§ Blood/plasma replacement

§ High intake of dietary sodium

· Fluid or sodium retention

o Causes:

§ Heart failure

§ Cirrhosis

§ Nephrotic syndrome

§ Corticosteroid therapy

§ Hyperaldosteronism

· Shift in fluid from the interstitial space into the intravascular space.

o Causes:

§ Remobilization of fluids after burn tx

§ Administration of hypertonic fluid (eg. Mannitol/hypertonic saline solution)

§ Use of plasma proteins

· Acute/chronic renal failure with low urine output

c) What are the symptoms of dehydration and fluid overload?

• DEHYDRATION SYMPTOMS:

o Change of MENTAL STATUS (seizures, coma)

o Dizziness

o Weakness

o Extreme thirst

o Fever (less fluid available for perspiration)

o Dry skin

o Dry mucus membrane

o Poor skin turgor

o HR ­, BP ¯

o Low urine output because less fluid is circulating

o Urine is more concentrated

• HYPOVOLEMIA SYMPTOMS:

o Change of MENTAL STATUS

o Dizziness, nausea, tachycardia, delayed capillary refill, orthostatic hypotension, urine output < 10mL, cool/pale over the arms and legs weight loss, flat jugular veins, decreased CVP (central venous pressure), weak or absent peripheral pulses

• HYPERVOLEMIA SYMPTOMS:

o CO ­ as the body tries to compensate for the excess volume

o Rapid and bounding pulse

o ­ BP, CVP (blood pressure in the venae cavae, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood back into the arterial system)

o When heart fails, BP and CO ¯

§ A 3^rd heard sound (S3) develops with HF

o Distended veins (esp in hands and neck)

o When pt raises hands above heart level, hand veins remain distended for more than 5 seconds

o Edema

o Pulmonary Edema

d) If a client has dehydration or fluid volume overload, what independent nursing interventions should the nurse implement in each of these situations?

• Independent nursing intervention for dehydration:

a) Provide a source of fluids that the patient can retain (oral or parenteral).

b) Monitor symptoms and vital signs closely so you can intervene quickly.

c) Accurately record the patient’s intake and output, including urine and stool.

d) Maintain I.V. access as ordered. Monitor I.V. infusions. Watch for signs and symptoms of cerebral edema when your patient is receiving hypotonic fluids. These include headache, confusion, irritability, lethargy, nausea, vomiting, widening pulse pressure, decreased pulse rate, and seizures.

e) • Monitor serum sodium levels, urine osmolality, and urine specific gravity to assess fluid balance.

f) Insert a urinary catheter as ordered to accurately monitor output.

g) Provide a safe environment for any patient who is confused, dizzy, or at risk for a seizure, and teach his family to do the same.

h) Obtain daily weights (same scale, same time of day) to evaluate treatment progress.

i) Provide skin and mouth care to maintain the integrity of the skin surface and oral mucous membranes.

j) Assess the patient for diaphoresis—it can be the source of major water loss.

• Independent nursing intervention for hypovolemia:

o Make sure the patient has a patent airway.

o Apply and adjust oxygen therapy as ordered.

o Lower the head of the bed to slow a declining blood pressure.

o If the patient is bleeding, apply direct, continuous pressure to the area and elevate it if possible.

o If the patient’s blood pressure doesn’t respond to interventions as expected, look again for a site of bleeding that might have been missed. Remember, a patient can lose a large amount of blood internally from a fractured hip or pelvis. Furthermore, fluids alone may not be enough to correct hypotension associated with a hypovolemic condition. A vasopressor may be needed to raise blood pressure.

o Maintain patent I.V. access. Use short, large-bore catheters to allow for faster infusion rates. Typically, this patient should have two large-bore I.V. catheters.

o Administer I.V. fluid, a vasopressor, and blood as prescribed. An autotransfuser, which allows for reinfusion of the patient’s own blood, may be required.

o Draw blood for typing and crossmatching as ordered to prepare for transfusion.

Independent nursing intervention for hypervolemia:

· Assess the patient’s vital signs and hemodynamic status, noting his response to therapy.

· Watch for signs of hypovolemia due to overcorrection. Remember that elderly, pediatric, and otherwise compromised patients are at higher risk for complications.

· Monitor respiratory patterns for worsening distress, such as increased tachypnea or dyspnea.

· Watch for distended veins in the hands or neck.

• Record intake and output hourly.

· Listen to breath sounds regularly to assess for pulmonary edema. Note crackles or rhonchi.

· Follow ABG results and watch for a drop in oxygen level or changes in acid-base balance.

· Monitor other laboratory test results for changes, including potassium levels (decreased with use of most diuretics) and HCT.

· Raise the head of the bed (if blood pressure allows) to help the patient’s breathing, and administer oxygen as ordered.

· Make sure the patient restricts fluids if necessary. Alert the family and staff to ensure compliance

· Reposition patient every 2 hours to decrease risk to skin.

· Insert a urinary catheter as ordered to more accurately monitor output before starting diuretic therapy.

· Maintain I.V. access as ordered for the administration of medications such as diuretics. If the patient is prone to hypervolemia, use an infusion pump with any infusions to prevent administering too much fluid.

· Give prescribed diuretics and other medications and monitor the patient for effectiveness and adverse reactions.

· Watch for edema, especially in dependent areas.

· Check for an S3, audible when the ventricles are volume overloaded. S3 is best heard over the heart’s apex over the mitral area.

· Provide frequent mouth care.

· Obtain daily weight and evaluate trends.

· Provide skin care because edematous skin is prone to break down.

· Offer emotional support to the patient and his family.

· Document your assessment findings and interventions.

Reduce oral fluid and sodium intake as directed by health care provider or designee (about 1 L/day with most taken in the waking hours and ,2,000 mg of sodium/day). A fluid-intake schedule is arranged and the patient instructed in fluid restriction.

Administer diuretics as prescribed, monitoring serum potassium levels. Overhydration requires restoration of normal circulating volume to decrease blood pressure and reduce the workload on the heart. When the fluids are excessive, fluids will cross the alveolar capillary barrier and pool fluids in the lungs (pulmonary edema), interfering with oxygen–carbon dioxide diffusion. This reduces blood oxygen levels. When dependent edema is present, it interferes with normal circulation in the tissues, resulting in lower tissue oxygen. The patient’s cooperation is required to succeed at fluid restriction. Rapid diuresis will often result in low serum potassium. Serum potassium within the normal range is essential for normal cardiac function. If the patient is not able to urinate due to renal failure, hemofiltration or dialysis may need to be arranged to assist in restoration of normal fluid balance. Potassium levels must be monitored to ensure the patient is not retaining too much potassium. Reposition patient every 2 hours to decrease risk to skin.

e) What medications or treatments can the nurse anticipate the health care provider would order for clients with dehydration or fluid volume deficit?

a) Medications/treatment of dehydration:

a. Vasopressin may be ordered for patients with diabetes insipidus.

b. A severely dehydrated patient should receive I.V. fluids to replace lost fluids. Most patients receive hypotonic, low-sodium fluids, such as dextrose 5% in water (D5W). Remember, if you give a hypotonic solution too quickly, the fluid moves from the veins into the cells, causing them to become edematous. Swelling of cells in the brain can create cerebral edema. To avoid such potentially devastating problems, give fluids gradually, over a period of about 48 hours

b) Medications/treatment of hypovolemia:

a. Oxygen therapy (to ensure sufficient tissue perfusion)

b. I.V. fluid

c. Vasopressor (dopamine)

d. Blood transfusion

e. Surgery to control bleeding

f. Oral fluids generally aren’t enough to adequately treat hypovolemia. Isotonic fluids, such as normal saline solution or lactated Ringer’s solution, are given I.V. to expand circulating volume.

c) Medications/treatment of fluid volume overload:

a. Diuretics

b. Hypertonic solutions are used only in severe situations to draw fluid out of the cells and require close patient monitoring.