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8/13/2019 Excess Fluid Volume Ppt (Case Press)
http://slidepdf.com/reader/full/excess-fluid-volume-ppt-case-press 1/10
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8/13/2019 Excess Fluid Volume Ppt (Case Press)
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CLUES
* August 11, 2012
HGB = 75g/dL (120-170; low)
HCT=.21 (.37-.54; low)
Creatinine = 6.31mg/dL (0.5-1.2; low)
Ionized calcium = 1.0mmol/dL (1.12-1.32 ;
low)
Na = 135mmol/L (137-147; low)
Pulmonary congestion
Minimal pleural effusion is noted on left
side
* August 12 , 2012
-intake exceeds output (I=1000ml, O=830ml)
* August 13, 2012
-intake exceeds output (I=1130ml, O=830ml)
* August 14, 2012
(+)edema on both legs
(+) crackles(+) restlessness
(+) oliguria
CUE
* August 14
“nahihirapan ako huminga, lalo
kapag nakahiga”
8/13/2019 Excess Fluid Volume Ppt (Case Press)
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*Excess Fluid Volume related tocompromised regulatory mechanism due to
chronic kidney problem as evidenced by
altered sodium and calcium levels,
decreased hemoglobin and hematocrit,increased creatinine, oliguria, edema,
crackles, restlessness, orthopnea,
pulmonary congestion, and pleural effusion.
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*Glomerulonephritis damages the glomeruli, lettingprotein and sometimes red blood cells leak into theurine. Sometimes a glomerulonephritis interfereswith the clearance of waste products by the kidney,so they begin to build up in the blood. In normalblood, albumin acts like a sponge, drawing extrafluid from the body into the bloodstream, where itremains until the kidneys remove it. But when
albumin leaks into the urine, the blood loses itscapacity to absorb extra fluid from the body. Fluidcan accumulate outside the circulatory system inthe face, hands, feet, or ankles and cause swelling.
(www.kidney.niddk.nih.gov, March, 2012)
(Eric Cohen MD, et. Al, May 2012 retrieved from www. mcw.edu)
8/13/2019 Excess Fluid Volume Ppt (Case Press)
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After 5 hours of nursing interventions, the patient will
be able to:
*Verbalize willingness about sodium and fluid restriction.*Enumerate ways to reduce discomfort of fluid restrictions
like frequent oral care, chewing candy or gum, and use of
lip balm.
*Verbalize willingness to record intake and output.
*Be safe from injuries like falls which may be caused by
changes in mentation due to altered electrolyte levels.
*Enumerate ways in reducing edema: ice, activity,
elevation, compression stockings.
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After 2 weeks of nursing interventions, the patient willbe able to:
*Adhere to sodium and fluid restriction, and intake andoutput monitoring.
*Be able to use interventions to reduce discomfort offluid restrictions like frequent oral care, chewing candyor gum, and use of lip balm.
*Demonstrate ways in reducing edema: ice, compressionstockings, elevation, activity.
*Have stabilized fluid volume as evidenced by balancedintake and output, vital signs within normal range,
stable weight, and decreased or absent edema.
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1. Increased sodium would
retain fluid, further increase
in fluid intake would worsenthe problem.
2.To still add flavor to
client’s food and prevent
loss of appetite.
3.To maintain fluid
restriction and correct the
imbalance.
1. Advise to restrict
fluid and sodium
intake as indicated.
2. Suggest substitutes
for salt like lemon and
oregano.
3. Discuss “hidden
sources” of fluid like
ice cream, soups, and
gelatin.
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4. Suggest ways to reduce
discomfort caused by fluid
restriction:
• Use lip balm• Chew gum or candy
• Frequent oral care
5. Record intake and output
accurately, and teach the client
and her family how to do so.
6. Place client in semi-fowler’s
position.
4. Moistens the lips and oral
mucosa.
5. Evaluates effectiveness of
interventions, and allows for
client and family participation
towards care.
6. To facilitate movement of
diaphragm thus improving
respiratory effort.
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7. Remind about the need to
ambulate and/ or have frequent
position changes.
8. Maintain safety precautions like
keeping the side-rails up, and
ensuring that client would not be
left alone.
9. Elevate edematous extremities
and change position frequently.
7. To prevent fluid stasis and
reduce risk of tissue injury.
8. Altered electrolyte levels
may cause altered motor
responses, mentation and
level of consciousness.
9. To reduce tissue pressure
and risk of skin
breakdown.
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10. Teach client ways to reduce leg
edema:
•Avoid standing or sitting in one place
too long. Pumping the feet up anddown at the ankle to move the calf
muscle as exercise helps too.
•Elevate the legs higher than the level
of the heart for 20-minute periods 3-4
times throughout the day.
•Use of compression stockings.
•Use of ice packs wrapped in towels
applied to the swollen area for about
15-20 minutes
10. To promote client participation in
care
•Activity and exercise increases
circulation and pumps excess fluidsfrom the legs.
•Elevation techniques put gravity to
use by using its force to draw fluids
from the legs and up to the heart.
•Applies pressure to the legs to
stimulate circulation and move fluid
from the tissues.
•Ice helps to constrict the blood
vessels and reduce the amount offluid that is deposited.
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