Frances Katherine I.

Garcia

Activity 1: CASE SCENARIO (Fluid Volume Excess)

A Client with Fluid Volume Excess

Dorothy is a 45-year-old Native American 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. Rainwater is a single mother of two teenage sons.

Until her illness, she was active in caring for her family, her career as a high school

principal, and community activities.

Assessment

Mike Penning, Ms. Rainwater’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 input

has been constant for the past 8 days. She gained 1 lb (0.45kg) in the past 24 hours.

Laboratory test results from that morning are sodium, 155 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. Rainwater’s serum creatinine and blood urea nitrogen

(BUN) are high; however, her ABGs are within normal limits.

In his assessment of Ms. Rainwater’, Mike notes are the following:

• BP 160/92; P 102, with obvious neck vein distention; r 28, with crackles and

wheezes; head of bead elevated 30 degrees; T 98.6 F.

• Periorbital and sacral edema present 3+ pitting bilateral pedal edema; skin cool;

pale; and shiny.

• Alert, oriented; responds appropriately to questions

• Client states she is thirsty, slightly nauseated, and extremely tired.

Ms. Rainwater 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.

21
FLUIDS AND ELECTROLYTES IMBALANCE

Fill in the following information needed based on the above case scenario

1. Nursing Diagnosis: Fluid Volume Excess

- Related Cause

Mrs. Rainwater’s nursing diagnosis is related to oliguria as evidence by decreased urine output.

- Expected Outcomes

In this case it is she shows signs of oliguria due to renal failure, high sodium in her labs results that can
manifest edema which she does have (Periorbital and sacral edema present 3+ pitting bilateral pedal
edema) High blood pressure, vital signs are elevated, and other abnormal lab results can be observed.

Expected outcomes is that Mrs. Rainwater must increase her urine output.

- Planning and Implementation

After 8 hours of nursing intervention, the client must be normovolemic as evidenced by urine output
greater than or equal to 30 mL/hr. The client will be given diuretics to stabilize blood pressure and
increase urine output.

- Evaluation

Mrs. Rainwater’s blood pressure is at normal at 110/80 and she urinated and obtained an output of 30
mL in/hr.

2. Risk for impaired gas exchange

- Related Cause

abnormal respiratory rate secondary to abnormal breath sounds.

- Expected Outcomes

Based on the case, she presents signs of respiratory distress by having 28 cpm respiratory rate
accompanied by wheezing and crackles breath sound.

The expected outcome is that the client maintains optimal gas exchange as evidenced by usual mental
status, unlabored respirations at 12-20 per minute.

- Planning and Implementation

After 8 hours of nursing intervention, client maintains clear lung fields and remains free of signs of
respiratory distress. Elevating the bed is implemented to promote better breathing and administering
medication as prescribed.

- Evaluation

The client shows signs of better breathing free from discomfort.

Activity 2: Critical Thinking in the Nursing Process

1. What is the pathophysiological basis for Ms. Rainwater’s increase respiratory

rate, blood pressure, and pulse?

Mrs. Rainwater is diagnosed with acute kidney failure, our kidneys other than filtering wastes products
also is responsible for regulating circulatory volume by controlling sodium and water balance, thus
maintaining extracellular fluid volume (ECFV) homeostasis. The renin-angiotensin-aldosterone system
(RAAS) is a central element in the control of the salt and water balance of the body and arterial blood
pressure. Her having a problem in her kidneys means she has a tendency to have higher sodium in her
body which can affect the RAAS. High sodium means high fluid retention that can cause high blood
pressure which can also be the cause of the ineffective tissue perfusion thus having increase respiratory
rate, blood pressure, and pulse is more likely. Her periorbital and sacral edema manifest this
phenomenon, periorbital edema presents itself when there is an obstruction of part of the heart called
the superior vena cava can cause blood to build up in body parts above the heart while sacral edema
presents itself because of increased blood pressure in the veins, fluid seeps out into the surrounding
tissue.

2. Explain how elevating the head 30 degrees facilitates respirations.

Irregularity of rate and amplitude of respiration are noted in the supine position, while respirations of
regular rate and amplitude are frequently found in the prone position. The amplitude of respiration was
greater in the supine position than in the prone position. To sum it up, gravity affects breathing.
Elevating the head of the bed allows for better chest expansion, improving breathing by facilitating
oxygenation. Other advantages include an increase in blood and cerebral spinal fluid drainage and
improved hemostasis

3. Suppose Ms. Rainwater 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, it is my duty to educate my patients. I would tell Mrs. Rainwater that having excess fluids in
our body doesn’t necessarily mean “hydration” especially her case that she has high sodium in her body.
Sodium attracts water and excess water is what causes her edema, all the displaced fluid collects at her
periorbital and sacral cavity with can pose huge risks if not tend properly. I will state this in a calm and
friendly voice ensuring she understood everything.

4. Outline a plan for teaching Ms. Rainwater about diuretics. (Use this format)

- Nursing Diagnosis

Knowledge deficit related to medication

- Planning

After 8 hours of nursing intervention, the client will verbalize the accurate information about the
medication and its side effects.
- Intervention

1. Assess current knowledge base about the medication.

2. Create a learning-friendly environment
3. Encourage the patient to ask questions.

- Rationale

1. A baseline of the patient’s knowledge provides an excellent way to develop a starting point of a
teaching plan without overwhelming the patient.
2. Unfamiliar environments and uncertainty about a new health diagnosis can be intimidating and
discourage a patient from engaging in learning.
3. Questions allow the patient to participate in the learning process.

- Evaluation

After 8 hours of nursing intervention, the client verbalized the accurate information about the
medication and its side effects.

5. Discuss the possible home care management for Ms. Rainwater.

The patient can continue taking medication as advised, she must have a healthy diet and eat fruits and
advice to drink cranberry juice. Avoid salty foods and stay fit.

6. Explain the fluid restriction guidelines in patient with fluid excess.

The patient should not drink alcoholic drinks such as beer and coffee because of her kidney disease,
processing these drinks is hard and can cause unwanted effects on her health. The patient can only have
a certain amount of liquid each day it is important to be cautious.

7. Discuss the importance of diagnostic test and medical management in this

particular type of client.

Diagnostic tests and diagnostics management have been proven to help us assess properly the patients
to improve their overall health. In cases like this where it will not be obvious to tell whether the patient
has a disease or not if lab tests are not done. There are diseases that does not reflect to the appearance
of the patient but when labs are done the numbers and slight elevation or decreased values can affect
the patient without them knowing. There are assessments that we cannot just hear from the
stethoscope of be felt by palpation it can be found in the fluids and blood that runs in our body and to
determine their values needs special procedures thus stressing the importance of performing different
diagnostic tests.