Auscultate heart sounds, being alert for the presence of an S3
Fluid volume deficit,
Sympathetic nervous system compensation increases the heart rate and results in peripheral vasoconstriction in an effort to maintain BP within normal limits.
Pulses may be weak and thready.
Assess for orthostatic changes.
Respiratory care
Monitor pulse oximetry and auscultate lung sounds as needed
In excess
Pulmonary congestion and pulmonary edema, as increased hydrostatic pressure in the pulmonary vessels forces fluid into the alveoli.
The patient will experience shortness of breath and moist crackles on auscultation
deficit will demonstrate
An increased respiratory rate because of decreased tissue perfusion and resultant hypoxia.
Administer oxygen as ordered.
Patient Safety
Deficit is at risk for falls because of orthostatic hypotension, muscle weakness, and changes in level of consciousness.