Nursing implementation

Nursing implementation

  • Daily weights
    • Most accurate measure of volume status
  • Input & Output
    • Record to find out any information that will show fluid and electrolyte imbalance
  • Laboratory findings
    • Monitor laboratory results when available and calculate the serum osmolality
    • Patient with a fluid volume deficit often has increased BUN, sodium, and hematocrit levels with increased plasma and urine osmolality.
    • Patient with fluid volume excess will have decreased BUN, sodium, and hematocrit levels with decreased plasma and urine osmolality
  • Cardiovascular care
    • Changes in BP, central venous pressure, pulse force, and jugular venous distention reflect ECF volume imbalances
    • Know what can happen when there is excess and deficit
      • In excess,
        • The pulse is full, bounding, and not easily obliterated.
        • Increased volume causes distended neck veins (jugular venous distention)
        • Increased central venous pressure and high BP
        • 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.
  • Skin care
    • Examine the skin for turgor and mobility