Med-Surg+Case+Study+1

Case Study – Fluid Volume Excess Ms Water is an 82 y/o female admitted with cirrhosis and renal failure. The provider states she has fluid volume excess. Her history consists of Type II diabetes and hypertension. 1. What nursing assessment would you perform to detect Fluid Volume Excess and why? ​ Some nursing assessments would be to check for edema, edema would show that excess fluid is in the outside tissue of the patient. The nurse would also check for urine output, whats going in should be coming out. Assess for increased weight. Hypervolemia could also cause fluid in the lungs, so the nurse would assess for shortness of breath and ausiltating lung sounds for crackles. 2. Upon assessment you note that Ms Water has SOB and orthopnea. Why would she have this and what nursing interventions can you do to help decrease this? What further assessments would you need to perform? The pt would experience this due to the excess fluid build up creating pressure on the internal organs while laying flat, and excess fluid may build in the lungs causing SOB. The pt should be brought up to semi Fowles position or higher to relieve discomfort and aid in breathing. Oxygen administered if ordered. I would encourage the pt to try deep breathing and instruct her to cough. Assessments would include; vitals, B/P, lung sounds, Pulse Ox, turgor, skin temp and apperance, check for edema, check lab vaules, I&O, HCT & Hb. ​ 3. Upon assessing the lungs you note bilateral crackles – why would she have this and what further nursing assessments and interventions would you do for this? Explain your rationale for the interventions. The patient having bilateral crackles could possibly mean that the fluid has entered her lungs. The nurse should make the doctor aware of this and he may order a chest xray for the patient. The chest xray would show the amount of fluid in the lungs and direct the doctor in giving orders to help with this. Possible deep suctioning. And possible medications to help bring this up such as mucomyst. 4. Upon further assessment you note she has distended neck veins and 3+ pitting edema to her lower extremities – why would he have this in FVE and what nursing interventions would you do for this? Explain your rationale for the interventions. This would indicate ascites, a fluid buildup of serous fluid in either the abdominal or peritoneal cav​ity. Elevate edematous extremities to promote venous return, notify the pt's HCP, providing him with all the assessment findings . Have pt reposition often or Q2 to avoid fluid build up and skin breakdown. 5. The provider orders the following: Explain the rationale for these orders and nursing assessments when performing these tasks. What is the rationale for the assessment? What findings would you feel necessary to report to the provider? - I&O- to determine that the amount of fluids going in is coming out in urine. - Daily weight - This is the most accurate way to measure I & O. A gain of 2lbs or more would be a significant finding to report to the provider. While taking weight I would asses pt's skin, activity tolerance, any other areas of fluid build up, lung sounds, pulse. - Fluid restriction of 1000mL daily- restricting the fluid so that the hypervolemia does not increase in severity - 2gram Na+ diet- decreasing the amount of salt intake also decreased h2o absorbtion - Patient in semi-fowler’s position - Semi-fowler's position facilitates breathing. Abdominal organs drop in this position, providing more space in the thoracic cavity. The insulin was ordered because she is a diabetic and the doctor would like her insulin running at a continous rate due to her hyperkalemia.
 * 1) The provider orders a chem. Panel. The K+ comes back 2.8. What is the significance of this? What would you expect the provider to order and why? Patient is hypokalemic. The provider will likely order an oral or IV KCL supplement to correct the imbalance.
 * 2) What are s/s of hypokalemia? tachycardia, decreased urine output, decreased blood pressure, confusion, dry mucous membranes, Risk for potentially fatal ventricular dysrhythmias, skeletal muscle weakness, paralysis, weakness or paralysis of respiratory muscles (possibly leading to shallow respiration and respiratory arrest)
 * 3) Two hours later you go into the room and notice that the IV has infused incorrectly because of IV pump malfunction. You immediately notify the provider. What other nursing assessments would you perform and why? Check for s/s of hyperkalemia: cramping leg pain, weakness or paralysis of skeletal muscles. Check ECG for cardiac abnormalities especially V-fib. Abdominal cramping, diarrhea. Also check for irritability, anxiety, paresthesias (tingling or prickling sensation).
 * 4) The provider orders a Chem 7. The K+ comes back 6.2. What is the significance of this? Patient is hyperkalemic, the most serious complications include V-fib or sudden cardiac arrest.
 * 5) What would you expect to see on her EKG? What cardiac implications does hyperkalemia have? Flattening of P wave, widening of QRS complex, shortened QT interval r/t more rapid repolarization. T wave becomes more narrow and peaked.
 * 6) The provider order 1unit regular insulin per 1mLof D5W fluid to infuse at 100ml/hr. Why would this be ordered?
 * 1) 12 hours later the patient’s K+ is 5.3. The provider orders a diet restriction of potassium rich foods. How would the nurse counsel this patient regarding the diet restriction? Who could help you with this education? The nurse would tell the patient to not eat potassium rich foods like bananas, strawberries, cucumber, oranges, avacados, potatos, tomatos, cabbage, belll pepper, apricots, cauliflower, and egg plant. I would also give the patient a list of foods that are potassium rich. I could call in the dietition to help me with the patient teaching.