LEARNING ACTIVITY #1 FOR RELATED LEARNING EXPERIENCE

Nursing Care Plan for A Person with Fluid Volume Excess

Name: Serquina, Johniza Hope G. Date: September 20, 2020 Score: ___________________

Case Scenario:

Mercy Roque is a 45-year-old woman hospitalized with acute renal failure that developed as a result of
acute glomerulonephritis. She is expected to recover, but she has very little urine output. Ms Roque is a
single mother of two teenage sons. Until her illness, she was active in caring for her family, her career
as a primary school teacher’s aide and community activities.

Assessment
Mike Bautista, Ms Roque’s nurse, notes that she is in the oliguric phase of acute renal failure and that
her urine output for the previous 24 hours is 250 mL; this low output has been constant for the past 8
days. She gained 0.45 kg in the past 24 hours. Laboratory test results from that morning are sodium,
155 mEq/L (normal 135 to 145 mEq/L); potassium, 5.3 mEq/L (normal 3.5 to 5.0 mEq/L); calcium,
7.6 mg/dL (normal 8.0 to 10.5 mg/dL) and urine-specific gravity 1.008 (normal 1.010 to 1.030). Ms
Roque’s serum creatinine and urea are high; however, her ABG s are within normal limits.
In his assessment of Ms Smith, Mike notes the following:
 BP 160/92; P 102, with obvious neck vein distension; R 28, with crackles and wheezes; head of
bed elevated 30 degrees; T 37.0°C.
 Periorbital and sacral oedema present; 3+ pitting bilateral pedal oedema; skin cool, pale and
shiny.
 Alert, oriented; responds appropriately to questions.
 States she is thirsty, slightly nauseated and extremely tired.

Ms Roque is receiving intravenous furosemide and is on a 24-hour fluid restriction of 500 mL plus the
previous day’s urine output to manage her fluid volume excess.

Diagnoses
 Excess fluid volume related to acute renal failure
 Risk of impaired skin integrity related to fluid retention and oedema
 Risk of impaired gas exchange related to pulmonary congestion
 Activity intolerance related to fluid volume excess, fatigue and weakness

Planning
 Advise Ms Roque that they need to be weighed twice daily, at 0600 and 1800 hours to monitor
fluid balance daily.
 Explain to Ms Roque that the nurses will be monitoring vital signs and SaO2 every 4 hours and
the reasons for monitoring vital signs.
 Explain the purpose for Ms Roque being placed on restricted fluids and suggested ways to
maintain the fluid restriction.
 Explain to Ms Roque that all fluids consumed and all urine output will need to be measured and
documented on a fluid balance chart.
 Instruct and educate Ms Roque on the importance of oral hygiene and the effectiveness of
moistened oral applicators to prevent mouth dryness.
  Advise Ms Roque of the importance to sit out of bed on a chair three times a day and of the
necessity to call for assistance when ambulating or if dyspnoea is increasing.
 Reiterate the importance of keeping the head of the bed elevated 30 to 40 degrees and the
importance of not staying in one position for a prolonged period of time.
 Attend to pressure area care as required to maintain skin integrity.

Expected outcomes
Regain fluid balance, as evidenced by weight loss, decreasing oedema and normal vital signs.
Experience decreased dyspnoea.
Maintain intact skin and mucous membranes.
Increase activity levels as prescribed.

Implementation
 Weighed the Ms Roque at 0600 and 1800 daily and record the findings.
 Documented and reviewed the vital signs, fluid balance chart hourly.
 Obtained, measured and documented urine-specific gravity every 8 hours.
 Discussed and consulted with Ms Roque about her compliance with the prescribed fluid
restriction.
 Consult with Ms Roque about her ability to move and inspect her skin for any signs of pressure
areas.
 Consult with Ms Roque and identify her ability to maintain oral hygiene. Provide extra
assistance if required to maintain oral care every 2 to 4 hours.
 Consult with Ms Roque and identified if the elevation of the head of bed is reducing the
dyspnea.
 Observeed and monitored Ms Roque’s ability to sit out of bed and ambulate safely without
increasing shortness of breath and fatigue.

Evaluation
At the end of the shift, Mike evaluated the effectiveness of the plan of care and continued all diagnoses
and interventions. Ms Roque has gained no weight and her urinary output during this shift is 170 mL.
Her urine-specific gravity remains at 1.008. Her vital signs are unchanged, but her crackles and
wheezes have decreased slightly. Her skin and mucous membranes are intact. Ms Roque tolerated the
bedside chair without dyspnea or fatigue.

Critical Thinking in the Nursing Process

1. What is the pathophysiological basis for Ms Roque’s increased respiratory rate, blood
pressure and pulse?
A possible pathogenesis of increased blood pressure and pulse for Ms. Roque is her excess dietary salt
intake. We saw that her Sodium level is above normal that’s why it may interact to produce
hypertension/increased BP. Also, increased in respiratory rate can be caused by an excess of acid in
the body or a decrease in a base in the body (a disruption in the acid-base balance of the body.) When
the body senses that the blood is too acidic (metabolic acidosis), it blows off carbon dioxide out of the
lung in an attempt to rid the body of acid. When the acid level is too high in the blood, breathing rate
increases to blow off carbon dioxide. Some causes of this include diabetic ketoacidosis, lactic acidosis,
and hepatic encephalopathy.
 2. Explain how elevating the head of the bed 30 to 40 degrees facilitates respirations.
When the client is halfway lying and halfway sitting in this position, gravity will push the secretion
from the lungs down to the bottom of the lung tissue allowing the client to breathe more easily
because he/she is only using the top half of the lungs.

3. Suppose Ms Roque says, ‘I would really like to have all my fluids at once instead of
spreading them out.’ How would you reply and why?
As a nurse, I would acknowledge the concern of Ms. Roque. But first of all, I will assess her condition if
she can tolerate it. Assessment is required in order to distinguish possible problems that may have
lead to fluid volume excess well as identify any incident that may occur during nursing care. I would
tell her that I will first ask her physician if she/he will permit to do so. If we have patient with fluid
volume excess it’s better to do a procedure one by one and prioritize to treat the one who can give
danger to the patient.

4. Outline a plan for teaching Ms Roque about diuretics.

General Use Diuretics help reduce the amount of water in the
body. They make you pee more often, flushing
water and salts from your body. Diuretics are a
treatment for high blood pressure (hypertension)
and conditions such as heart failure, liver failure,
and swelling (edema).
Home care  Follow the fact sheet that came with your
medicine. It tells you when and how to
take your medicine. Ask for a sheet if you
didn't get one.
 Tell your doctor if you are taking any other
medicines, including herbal remedies or
over-the-counter medicines.
 Plan your activities in advance until you
know how this medicine affects you.
 Take your diuretic in the morning. This
medicine makes you pee more. If you take
it in the morning, you may not need to use
the bathroom during the night. That way,
the medicine won't interfere with a good
night's sleep.
 Take your medicine exactly as directed,
even if you feel fine.
 Learn to take your own pulse. Keep a
record of your results. Ask your doctor
which readings mean that you need
medical attention.

Possible side effects Tell your doctor if you have any of these side
effects. Don't stop taking the medicine until your
doctor tells you to. Mild side effects include the
following:
 Dizziness or lightheadedness
 Headache
  Loss of appetite
 Diarrhea
 Increased sensitivity to light
 Nervousness
 Stomach cramps with mild pain

When to call your healthcare provider Call your healthcare provider right away if any of
these occur:
 Blood in your urine or stool or black, tarry
stool
 Cough or hoarseness
 Fever or chills
 Lower back or side pain, or muscle cramps
or pain
 Trouble peeing or pain when you pee
 Pinpoint red spots on skin
 Ringing or buzzing in your ears or any
hearing loss
 Skin rash or hives
 Severe stomach pain with nausea and
vomiting
 Unusual bleeding or bruising
 Yellow vision or yellowing of your eyes or
skin (jaundice)
 Increased thirst
 Irregular heartbeat or weak pulse
 Palpitations

REFLECTION ON THE NURSING PROCESS

1. As the Registered Nurse, how do you know if the education pertaining to fluid restriction
has been effective?
We all know that nursing process if part of our daily task in the health care setting. As a RN, in order
for us to know if the education given was effective, we evaluate if the goals and outcome were met. In
Ms. Roque’s case we can say it’s effective if the

 Patient is normovolemic as evidenced by urine output greater than or equal to 30 mL/hr.

 Patient has balanced intake and output and stable weight.
 Patient maintains HR 60 to 100 beats/min.
 Patient has clear lung sounds as manifested by absence of pulmonary crackles.
 Patient verbalizes awareness of causative factors and behaviors essential to correct
fluid excess.
 Patient explains measures that can be taken to treat or prevent fluid volume excess.
 Patient describes symptoms that indicate the need to consult with health care provider.
 2. Outline what you have learned from this case study that you will apply to your future
practice.
Fluid is very important to have in our bodies. It makes up the blood that transports oxygen and
nutrients to organs, hydrates our tissues and carries waste products outside our body when we
urinate, breathe and sweat. In order to stay healthy, you must have the right amount of fluid in your
body. When a person has too much fluid, the condition is called fluid volume excess. As a student
nurse, the things I learned from this case study is that it is important to identify fluid volume excess so
that specific interventions can be performed. Like any liquid, the fluid in the body has weight. The
nurse should weigh the patient every day at the same time, usually in the morning. A weight
measurement is a good indicator of how much fluid is in the body when comparing the readings from
day to day. Also, like what I’ve said on the previous question, nursing process is very important in the
field of nursing. If we are able to assess the condition of the patient properly, we will surely meet our
plan of care/goal. Lastly, another thing I will surely apply in my future practice is that monitoring
patient’s vital signs in a patient with FVE is a must and being able to identify the clinical manifestation
by just observing the patient’s physical appearance. In that way, I can easily address the problem to
the attending physician.