Week 7: Course Task_Regulatory Mechanisms

HYPERVOLEMIA
A patient was admitted in the medical ward with chief complaints of shortness of breath. Furtherassessment reveals
the following findings:
 BP –140/90 mm Hg
 HR –111 bpm
 RR –24 cpm
 +2 bipedal edema
 Bibasilar crackles upon auscultation
The doctor initially ordered furosemide 20 mg ampule TIV every 8 hours and the following laboratory tests: Complete
Blood Count (CBC), Serum Sodium, Serum Potassium, Blood Ure Nitrogen, Serum Creatinine, Total Protein, and Chest
X-ray.

Write down three (3) priority nursing diagnoses for the patient and create a hypothetical FDAR.
a. Impaired Gas Exchange related to altered blood flow as evidenced by shortness of breath and tachycardia.
FDAR
Date/Time: 10/20/2021 – 3:00 pm
Focus: Breathing
Data: Increased respiratory rate of 24cpm
Action: Position the patient in a High Fowler’s position with the head of the bed elevated up to 90°. Administer oxygen
therapy as ordered.
Response: Patient demonstrated improvement in gas exchange as evidenced by normal breath sounds and normal
respiratory rate.

b. Fluid Volume Excess related to compromise regulatory mechanism as evidenced by shortness of breath and edema.
FDAR
Date/Time: 10/20/2021 – 3:00 pm
Focus: Edema
Data: +2 bipedal edema
Action: Change position frequently. Elevate feet when sitting. Inspect skin surface,keep dry, and provide padding as
indicated.,
Response: Patient demonstrated stabilized fluid volume with vital signs withinacceptable range, stable weight, and
lesser/absence of edema.

c. Decrease Cardiac Output related to altered heart rhythm as evidenced by tachycardia and hypertension
FDAR
Date/Time: 10/20/2021 – 3:00 pm
Focus: Heart Rate
Data: BP –140/90 mmHg and HR –111 bpm
Action: Provide a restful environment and encourage periods of rest and sleep; assistwith activities. Minimizing
controllable stressors and unnecessary disturbancesreduces cardiac workload and oxygen demand.
Response: Patient will demonstrate adequate cardiac output as evidenced by vitalsigns within acceptable limits,
dysrhythmias absent/controlled, and no symptoms offailure.

What laboratory test may give the hint to the doctor about the oncotic pressure of the patient?
* The serum creatinine provides a sufficient screen for advanced renal insufficiency, and theserum albumin permits a
useful approximation of the plasma oncotic pressure.

Create a drug study for FUROSEMIDE specifying the following:

Drug classification: Diuretic
Mechanism of action: Furosemide promotes diuresis by blocking tubular reabsorption of sodium and chloride in the
proximal and distal tubules, as well as in the thick ascending loop of Henle. This diuretic effect is achieved through the
competitive inhibition of sodium-potassium-chloride cotransporters (NKCC2) expressed along these tubules in the
nephron, preventing the transport of sodium ions from the lumenal side into the basolateral side for reabsorption.
This inhibition results in increased excretion of water along with sodium, chloride, magnesium, calcium, hydrogen,
and potassium ions. As with other loop diuretics, furosemide decreases the excretion of uric acid.
Indication (*for the case of the patient mentioned above): Loop diuretics such as furosemide improve some
haemodynamic parameters and dyspnoea due to congestion, such as water and salt retention. The dose is adjusted on
the basis of clinical response, renal status and previous use of a loop diuretic, especially in chronic heart failure.
Contraindication: Furosemide is contraindicated in patients with anuria. It should be used cautiously in any patient
with renal disease such as severe renal impairment or renal failure. Drug-induced hypovolemia can precipitate
azotemia in these patients.
Side effects: Peeing more than normal, most people need to pee a couple of times within a few hours of taking
furosemide - and may also lose a bit of weight as your body loses water. Feeling thirsty with a dry mouth and
headaches.
Nursing Considerations: Assess weight, I&O daily to determine fluid loss; effect of productmay be decreased if used
daily.

2. HYPOVOLEMIA
A teenage patient was rushed to the emergency department due to wrist laceration from a suicide attempt. The
patient is lethargic and have the following findings upon assessment:
BP –80/50 mm Hg
HR –110 bpm
RR –25 bpm
The doctor initially ordered fluid resuscitation with PNSS 1L, to fast-drip 200 cc then the remaining fluid to run for 6
hours. Stat blood typing was ordered, and 3 units of whole blood was ordered to be transfused immediately after
proper cross-matching. The patient was hooked to oxygen 8 liters per minute via face mask.

What parameters will the nurse check while the patient is undergoing rapid fluid resuscitation?
If a reaction occurs, the fluids must be stopped immediately and the reaction noted. Patients receiving fluid infusions
need to have regular checks of their blood pressure, temperature, pulse, respiration and mental state.

For a patient who will undergo blood transfusion, enumerate the steps that the nurse should prudently undertake
while performing the procedure.
1. Verify Blood Product
 Two RNs at the patient’s bedside must verify the below:
 Physician’s order with patient identification compared to the blood bank’s documentation
 Patient’s name, date of birth, and medical record number
 Patient’s blood type versus the donor’s blood type and Rh-factor compatibility
 Blood expiration date
2. Educate the patient
 Relay the signs and symptoms of a transfusion reaction. If these occur, the patient should notify their
RN during the transfusion
 Rash, itching, elevated temperature, chest/back/headache, chills, sweats, increased heart
rate, increased respiratory rate, decreased urine output, blood in urine, nausea, or vomiting
3. Assess and document the patient’s status
 Baseline vital signs (HR, RR, Temp, SPO2, BP), lung sounds, urine output, and color
4. Start the blood transfusion
 Prepare the Y tubing with normal saline and have the blood ready in an infusion pump
 Run the blood slowly for the first 15 minutes (2mL/min or 120cc/hr)
 Remain with the patient for the first 15 minutes; this is when most transfusion reactions can occur
  Increase the rate of transfusion after this period if your patient is stable and doesn’t display signs of a
transfusion reaction
 Document vital signs after 15 minutes, then hourly, and finally, at the completion of the transfusion
During the Transfusion
1. Look for any of these transfusion reactions
 Allergic
 Febrile
 GVHD (Graft vs. Host Disease)
 TRALI (Transfusion Related Acute Lung Injury)
2. If you suspect a reaction, do the following
 Stop the transfusion IMMEDIATELY
 Disconnect the blood tubing from the patient
 Stay with the patient and assess their status
 Continue to check for status changes every five minutes
 Notify the doctor and blood bank
 Prepare for further doctor’s orders
 Document everything

List down three (3) priority nursing diagnoses for the patient and create a hypothetical FDAR.
a. Decreased Cardiac Output related to active fluid volume loss secondary to suicide attempt as evidenced by
decreased blood pressure and Tachycardia.
FDAR
Date/Time: 10/21/21 – 3:00 pm
Focus: Heart Rhythm
Data: BP –80/50 mmHg and HR –110 bpm
Action: Administer fluid and blood replacement therapy as prescribed.
Response: Patient demonstrated adequate cardiac output, as evidenced by strong peripheral pulses, normal blood
pressure, HR 60 to 100 beats per minute with regular rhythm.

b. Deficient Fluid Volume related to active fluid volume loss secondary to suicide attempt as evidenced by hypotension
and tachycardia.
FDAR
Date/Time: 10/21/21 – 3:00 pm
Focus: Hypovolemia
Data: BP –80/50 mmHg and HR –110 bpm
Action: Prepare to administer a bolus of 1 to 2 L of IV fluids as ordered. Use crystalloid solutions for adequate fluid
and electrolyte balance.
Response: Patient demonstrated normovolemia as evidenced by HR 60 to 100 beats per minute, systolic BP greater
than or equal to 90 mm Hg, absence of orthostasis, urinary output greater than 30ml/hr, and normal skin turgor.

c. Ineffective Individual Coping related to Inadequate coping skills as evidenced by

laceration by suicide.
FDAR
Date/Time: 10/21/21 – 3:00 pm
Focus: Counselling
Data: wrist laceration from a suicide attempt
Action: Identify situations that trigger suicidal thoughts. Identify targets for learning more adaptive coping skills.
Elucidate those things that are not under the person’s control. One cannot control another’s actions, likes, choices, or
health status.
Response: Patient demonstrated at least two behaviors in dealing with emotional pain
 3. THIRD SPACE EDEMA
A patient with portal hypertension secondary to chronic liver cirrhosis was admitted in the surgical ward. The patient
presented with emaciated body build, distended abdomen with prominent veins, and jaundice. The doctor
ordered paracentesis and the following laboratory tests prior the procedure: Prothrombin time (PT), Activated Partial
Thromboplastin Time (APTT), Total Protein, Albumin-Globulin ratio, AST, ALT.

1. List down two (2) nursing diagnoses and create a hypothetical FDAR for the patient.

DATE/ HOUR FOCUS PROGRESS NOTE

10/3/21 Excess Fluid Volume Data:
9:00PM  Excess sodium/fluid intake
 Edema, anasarca, weight gain
 Intake greater than output,
oliguria,changes in urine specific
gravity
 Dyspnea, adventitious breath
sounds, pleural effusion
 BP changes, altered CVP
 Altered electrolyte levels

Action:
 Measure I&O, weigh daily, and note
gain of more than 0.5 kg/day.
 Monitor BP (and CVP if available).
Note JVD and abdominal vein
distension.
 Measure abdominal girth.
 Encourage bedrest when ascites is
present.
 Administer salt-free
albumin/plasma expanders as
indicated.

Response:
 Stabilized fluid volume, with
balanced I&O, stable weight, vital
signs within patient’s normal range,
and absence of edema.
10/3/21 Risk for Injury Data:
9:00PM  Portal hypertension
 Abnormal blood profile; altered
clotting factors (decreased
production of prothrombin,
fibrinogen, and factors VIII, IX, and
X; impaired vitamin K absorption;
and release of thromboplastin)

Action:
 Monitor pulse, BP (and CVP if
 available).
 Closely assess for signs and
symptoms of GI bleeding: check all
secretions for frank or occult
blood. Observe color and
consistency of stools, NG drainage,
or vomitus.
 Observe for presence of
petechiae, ecchymosis, bleeding
from one or more sites.
 Use small needles for injections.
Apply pressure to small bleeding
and venipuncture sites for longer
than usual.

Response:
 Maintain homeostasis with
absence of bleeding
 Demonstrate behaviors to
reduce risk of bleeding

2. Why is there a need to check the PT and APTT levels of the patient prior paracentesis?

-Prothrombin Time (PT) which measures the integrity of the extrinsic system as well as factors common to both
systems and Partial Thromboplastin Time (PTT), which measures the integrity of the intrinsic system and the
common components. The partial thromboplastin time (PTT; also known as activated partial thromboplastin time
(aPTT)) is a screening test that helps evaluate a person's ability to appropriately form blood clots. It measures the
number of seconds it takes for a clot to form in a sample of blood after substances (reagents) are added. In patients
without clinical evidence of active bleeding, routine labs such as prothrombin time (PT), activated partial
thromboplastin time (aPTT), and platelet counts may not be needed prior to the procedure .

3. What is the rationale behind the order of checking the Total Protein, Albumin-Globulin ratio?

Proteins are important building blocks of all cells and tissues. They are important for body growth, development, and
health. They form the structural part of most organs and make up enzymes and hormones that regulate body
functions. This test measures the amount of protein in your blood. Two classes of proteins are found in the blood,
albumin and globulin:

 Albumin is made by the liver and makes up about 60% of the total protein. Albumin keeps fluid from leaking out of
blood vessels, nourishes tissues, and transports hormones, vitamins, drugs, and substances like calcium throughout
the body.
 Globulins make up the remaining 40% of proteins in the blood. The globulins are a varied group of proteins, some
produced by the liver and some by the immune system. They help fight infection and transport nutrients. The test also
compares the amount of albumin with globulin and calculates what is called the A/G ratio. A change in this ratio can
provide your healthcare practitioner with a clue as to the cause of the change in protein levels. Total protein levels in
the blood may increase or decrease, to a greater or lesser degree, with various conditions. Total protein levels may
decrease in conditions that:
 Interfere with production of albumin or globulin proteins, such as malnutrition or severe liver disease
  Increase the breakdown or loss of protein, such as kidney disease (nephrotic syndrome)
 Increase or expand the volume of plasma, the liquid part of blood (diluting the blood), such as congestive heart
failure Total protein levels may increase with conditions that cause:
 Abnormally high production of protein (e.g., inflammatory disorders, multiple myeloma)
 Dehydration

4. Enumerate the following regarding the nursing role in assisting with paracentesis:

 Position of choice
 Site of insertion
 At least three (3) nursing considerations.

POSITION OF CHOICE SITE FOR INSERTION NURSING CONSIDERATION

The patient is placed in the
supine position and slightly
rotated to the side of the
procedure to further minimize
the risk of perforation during
paracentesis. Because the
cecum is relatively fixed on
the right side, the left-lateral
approach is most commonly
used
The insertion sites may be midline or
through the oblique transverses
muscle, which is lateral to the thicker
rectus abdominus muscles.
1. Reassure the patient during the
procedure. Checks of blood pressure,
heart rate and respiratory rate, and
temperature monitoring, and observe
for any signs of complications, such
as leakage of ascetic fluid, infection,
bladder and bowel perforation and
bleeding.
2. Observe the characteristic and
amount of fluid aspirated.

3. Measure his/her abdominal girth

for comparison with the baseline
measurement