Cheatography
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FLUID VOLUME EXCESS
Fluid intake or retention is greater than the body's needs |
CONTRIBUTING FACTORS
Kidney failure (late phase) |
Heart failure |
Cirrhosis |
Interstitial to plasma fluid shifts (hypertonic fluids, burns) |
Excessive water intake |
Long term corticosteroid therapy |
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MANIFESTATIONS
Cough, 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 PROCEDURES
Serum: Electrolytes, BUN, creatinine, Hct |
Urine: specific gravity and osmolarity |
Chest x-ray if respiratory complications present |
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NURSING INTERVENTIONS
Monitor 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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