Prelimination exams just ended, and we entered our midterm period.

Our first topic is all about

fluid, and electrolyte imbalances. The body composition of a person consists of fluid. In a fetus,
the fluid present in the body is 100%. At birth, the child has 80% fluid. As a human grows older
and reaches adulthood the fluid in their body will be at 70%. As humans reached old age, the
fluid decreases by 50%. The fluid in one’s body usually retains in the skeletal muscle usually in
males. In females, their body fats have a higher amount. An average fluid intake of an adult is
2,5000 ml/day. Urination should be 30-50 m/hr. In regular hydration, the intracellular fluid is
40% while the extracellular fluid is 20%. In isotonic dehydration, the intracellular fluid is
normal, but the extracellular fluid contracts. In hypotonic dehydration, the intracellular fluid
expands, and the extracellular fluid contracts. In hypertonic dehydration, the intracellular fluid
contracts while the extracellular fluid expands. We also discussed hypovolemia, hypervolemia,
and third spacing. In hypovolemia, the fluid is low resulting in to increase in heart rate, and low
blood pressure. Hypervolemia means that there is a fluid excess resulting in edema, and weight
gain. Lastly is all about third spacing, also known as “anasarca” or brown edema. As future
nurses, we should be mindful of administering fluids to the patient to make sure that the care we
are giving proper care and will result in better well-being.
 HYPERVOLEMIA

1. Nursing Diagnosis and FDAR

I. Fluid imbalance (rt) increased fluid in blood (AEB) patient having +2 bipedal edema, blood
pressure of 140/90 mmHg, heart rate of 111bpm and having respiration of 24 bpm.

II. Ineffective airway clearance (rt) accumulation of fluid in the lungs (AEB) patient having
bibasilar crackles upon auscultation.

III. Risk for increased cardiac output (rt) fluid overload in blood (AEB) +2 bipedal edema and
blood pressure of 140/90 mmHg.

FOCUS DATA ACTION RESPONSE

Alleviate patient S: shortness of Provide patient care After performing the
condition. breath and action, patient
O: medication as condition alleviated,
BP-140/90 mmHg ordered: diagnosis for patient
HR - 111 bpm Furosemide 20 mg have been identified
RR - 24 cpm ampule TIV every 8 and patient verbalized
+2bipedal edema hours. understanding and
Bibasilar crackles Assist patient for provided feedback to
upon auscultation laboratory testing: the nurse.
Complete Blood
Count
(CBC), Serum
Sodium,
Serum Potassium,
Blood
Urea Nitrogen,
Serum
Creatinine, Total
Protein, and Chest X-
ray. Provide health
 teaching to the
patient depending on
client’s condition.

2. What laboratory test may give the hint to the doctor about the oncotic pressure of the
patient?

Total protein, because oncotic pressure is is a form of osmotic pressure induced by

proteins, notably albumin, in a blood vessel's plasma (blood/liquid) that displaces water
molecules, thus creating a relative water molecule deficit with water molecules moving back into
the circulatory system.

3. FUROSEMIDE

A. Drug classification: Diuretics (water pills); It works by causing the kidneys to get rid of
unneeded water and salt from the body into the urine.

B. Mechanism of Action: Furosemide, like other loop diuretics, acts by inhibiting the luminal
Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle, by binding to the
chloride transport channel, thus causing sodium, chloride, and potassium loss in urine.

C. Indication: furosemide is indicated for adults or patients treatment for edema related to fluid
imbalance specifically the hypervolemia, and also indicated for patient who have hypertension.

D. Contraindication: Hypersensitivity, Cross-sensitivity with thiazides and sulfonamides may

occur, Hepatic coma or anuria, some liquid products may contain alcohol, avoid in patients with
alcohol intolerance.

E. Side Effects: CNS: blurred vision, dizziness, headache, vertigo; CV: hypotension; DERM:
erythema multiforme, stevens-johnson syndrome, toxic epidermal necrolysis, photosensitivity,
pruritis, rash, urticaria; EENT: hearing loss, tinnitus; ENDO: hypercholesterolemia,
hyperglycemia, hypertriglyceridemia, hyperuricemia; F and E:dehydration, hypocalcemia,
hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic
alkalosis; GI: anorexia, constipation, diarrhea, dry mouth, dyspepsia, ↑ liver enzymes, nausea,
pancreatitis, vomiting; GU: ↑ BUN, excessive urination, nephrocalcinosis; HEMAT: APLASTIC
ANEMIA, AGRANULOCYTOSIS, hemolytic anemia, leukopenia, thrombocytopeniaMS:
muscle cramps neuro: paresthesia; MISC: fever

F. Nursing considerations:

I. ASSESSMENT: History: Allergy to furosemide, sulfonamides, tartrazine; electrolyte

depletion anuria, severe renal failure; hepatic coma; SLE; gout; diabetes mellitus; lactation,
pregnancy.; Physical: Skin color, lesions, edema; orientation, reflexes, hearing; pulses, baseline
ECG, BP, orthostatic BP, perfusion; R, pattern, adventitious sounds; liver evaluation, bowel
sounds; urinary output patterns; CBC, serum electrolytes (including calcium), blood sugar, LFTs,
renal function tests, uric acid, urinalysis, weight.

II. IMPLEMENTATION: Do not confuse Lasix (furosemide) with Luvox

(fluvoxamine); If administering twice daily, give last dose no later than 5 pm to minimize
disruption of sleep cycle; IV route is preferred over IM route for parenteral administration.
 HYPOVOLEMIA

1. Parameters

A. Patients receiving fluid resuscitation need to have regular checks of their blood
pressure, temperature, pulse, respiration and mental status.

2. Steps of blood transfusions:

A. Verify doctor's order.

B. Check for cross matching and typing.

C. Obtain and record baseline vital signs.

D. Practice strict asepsis.

E. Check the label of the blood transfusion.

i. Serial number.

ii. Blood component

iii. Blood type.

iv. Rh factor

v. Expiration date

vi. Screening test (VDRL, HBsAg, malarial smear) – this is to ensure that the
blood is free from blood-carried diseases and therefore, safe from transfusion.

F. Warm blood at room temperature before transfusion to prevent chills.

G. Identify client properly. Two Nurses check the client’s identification.

H. Use needle gauge 18 to 19 to allow easy flow of blood

I. Use BT set with special micron mesh filter to prevent administration of blood clots and
particles.
 J. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes.

Adverse reaction usually occurs during the first 15 to 20 minutes.

K. Monitor vital signs. Altered vital signs indicate adverse reaction (increase in temp,
increase in respiratory rate)

L. Do not mix medications with blood transfusion to prevent adverse effects. Do not
incorporate medication into the blood transfusion. Do not use blood transfusion lines for IV push
of medication.

M. Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with
dextrose. Dextrose based IV fluids cause hemolysis.

N. Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets,
cryoprecipitate, transfuse quickly (20 minutes) clotting factor can easily be destroyed.

O. Observe for potential complications. Notify physician.

3. Nursing diagnosis and FDAR

A. Fluid imbalance (rt) decreased blood volume (AEB) patient have laceration in the
wrist due to suicide attempt, Blood pressure of 80/50 mmHg, Heart rate of 110 bpm and
Respiratory rate of 25 bpm.

B. Decreased cardiac output (rt) blood loss (AEB) the patient have blood pressure of
80/50 mmHg.

C. Risk for hopelessness (rt) suicidal attempt (AEB) patient have laceration on the wrist.

FOCUS DATA ACTION RESPONSE

Alleviate patient S: N/A Adminisrter PNSS After performing the
condition. O: 1L, to fast-drip 200c action, patient
Improve mental BP-80/50 mmHg then the remaining condition alleviated,
condition of the HR - 110 bpm fluid run for 6 and patient is
patient. RR - 25 bpm hours as ordered by undergone in
the doctor for fluid psychological
resuscitation. intervention and
Administer 3 units of improved patients
whole blood and to mental condition.
be transfused
immediately after
proper cross
matching.
Monitor patients
oxygen Provide
psychological
assessment and
intervention to the
patient.
 THIRD SPACE EDEMA

1. NURSING DIAGNOSIS AND FDAR

A. Increased cardiac output (rt) increased pressure within the portal vein

B. Imbalanced nutrition (rt) inadequate diet (AEB) patient presented with emaciated

body build, distended abdomen with prominent veins, and jaundice.

FOCUS DATA ACTION RESPONSE

Improve patient S: N/A Prepare for After performing the
condition.
O: paracentesis action, patient
Emaciated body Assist the patient for condition improved
build. the following and patient respond
Distended laboratory tests prior to the nurse of his
abdomen w/ the procedure: understanding about
prominent veins. Prothrombin time health lifestyle and
Jaundice. (PT), Activated diet.
Partial
Thromboplastin Time
(APTT), Total
Protein, Albumin-
Globulin ratio, AST,
ALT. Monitor
patients vital
signs and condition
Provide health
teaching about proper
diet and healthy
lifestyle
2. PTT and APTT levels is checked to know or help the doctors assess body’s ability to form
blood clots. Bleeding triggers a series of reactions known as the coagulation cascade.
Coagulation is the process your body uses to stop bleeding.

3. Total protein and albumin-globulin is checked in order to know the ability of the body to fight
infection and transport nutrients. The total serum protein test measures all the proteins in your
blood. It can also check the amount of albumin you have compared to globulin, or what's called
your “A/G ratio.

4. Nursing Role

I. POSITION OF CHOICE: 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 leftlateral approach is
most commonly used. Most ascetic fluid reaccumulates rapidly.

II. SITE OF INSERTION: The insertion sites may be midline or through the oblique

transversus muscle, which is lateral to the thicker rectus abdominus muscles.

III. NURSING CONSIDERATION:

a. Ensure informed consent is provided to the patient

b. Ensure patient is prepared for the procedure

c. Provide health teaching prior to patients condition