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.
- In excess,
- 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.
- In excess
- Monitor pulse oximetry and auscultate lung sounds as needed
- 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