Cheatography
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FLUID VOLUME EXCESSFluid intake or retention is greater than the body's needs |
CONTRIBUTING FACTORSKidney failure (late phase) | Heart failure | Cirrhosis | Interstitial to plasma fluid shifts (hypertonic fluids, burns) | Excessive water intake | Long term corticosteroid therapy |
| | MANIFESTATIONSCough, dyspnea, crackles | Increased BP | Tachypnea | Tachycardia | Bounding pulse | Weight gain (1 L water = 1 kg weight) | Jugular vein distention | Increased central venous pressure | Pitting edema |
DIAGNOSTIC PROCEDURESSerum: Electrolytes, BUN, creatinine, Hct | Urine: specific gravity and osmolarity | Chest x-ray if respiratory complications present |
| | NURSING INTERVENTIONSMonitor respiratory rate, symmetry, & effort | Monitor breath sounds for signs of pulmonary edema | Monitor for edema | Measure pitting edema on scale of 1+ (minimal) to 4+ (severe) | Monitor dependent edema by measuring circumference of extremities | Monitor for ascites | Measure abdominal girth | Weight pt daily | Maintain strict I&O | Monitor vital signs | Administer diuretics (osmotic, loop) as prescribed | Limit fluid intake | Maintain skin integrity | Use semi-Fowler's position | Reposition every 2 hr | Restrict sodium intake |
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