What did you learn?- Fluid Volume Excess
A client is brought to the emergency department with reports of shortness of breath. Assessment reveals a full, bounding pulse, severe edema, and audible crackles in lower lung fields bilaterally. The nurse notifies the physician to obtain orders for which of these problems? Hyperkalemia Fluid volume excess Hyponatremia Hypocalcemia
Peripheral and pulmonary edema as well as a bounding pulse and dyspnea are indicators of fluid volume overload.
The nurse is developing a plan of care for a client with Meniere's disease and identifies a nursing diagnosis of excess fluid volume related to fluid retention in the inner ear. Which intervention would be most appropriate to include in the plan of care? Limit foods that are high in sodium. Encourage intake of caffeinated fluids. Administer prescribed antihistamine. Restrict high-potassium foods.
Sodium and fluid retention disrupts the delicate balance between the endolymph and perilymph in the inner ear. Therefore, many clients can control their symptoms by adhering to a low-sodium diet. Caffeinated fluids are to be avoided because of their diuretic effect. Diuretics, not antihistamines, would be prescribed to lower the pressure in the endolymphatic system. Foods high in potassium would be encouraged if the client is prescribed a diuretic that causes potassium loss.
During a period of extreme excess fluid volume, a renal dialysis client may be administered which type of IV solution to shrink the swollen cells by pulling water out of the cell? 0.9% sodium chloride. 5% dextrose and water. 3% sodium chloride. Lactated Ringer's solution.
When cells are placed in a hypotonic solution, which has a lower effective osmolality than the ICF, they swell as water moves into the cell. When they are placed in a hypertonic solution, which has a greater effective osmolality than the ICF, they shrink as water is pulled out of the cell.
Edema happens when there is which fluid volume imbalance? extracellular fluid volume deficit water excess extracellular fluid volume excess water deficit
When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.
The nurse is working with a child with altered genitourinary status. Which intervention would be included in the plan of care for the client with excess fluid volume? Weigh the child daily on the same scale. Measure the amount of nitrates present in the urine. Avoid administering IV therapies. Hold all medication until the fluid retention is improving.
A child with edema and fluid overload should be weighed daily, on the same scale, at the same time, with the same amount of clothing. This gives the most accurate picture of fluid gain or loss. The nurse also should assess the blood pressure and pulse rate regularly to determine if hypovolemia is occurring. This can occur from fluid shifts occurring if fluid is lost too quickly. Medications need to be administered, especially diuretics to help reduce the edema. The child should be on fluid restriction. This includes PO and IV. If IV fluids are necessary the volume should be calculated into the daily amount of fluid restriction. Nitrates in the urine do not affect edema. They indicate an infection.
A client is returning from the operating room after inguinal hernia repair. The nurse notes that the client has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? jugular vein distention bibasilar crackles right upper quadrant pain dependent edema
Bibasilar crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload and indicate left-sided heart failure. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.
Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. Decreased blood pressure Distended neck veins Shortness of breath Bradycardia Crackles in the lung fields
Clinical manifestations of FVE include distended neck veins, crackles in the lung fields, shortness of breath, increased blood pressure, and tachycardia.
Which clinical manifestation would lead the nurse to suspect a client has developed fluid volume excess? Decreased urine output Weight gain Increased blood urea nitrgen (BUN) Decreased blood pressure
Isotonic fluid volume excess is manifested by an increase in interstitial and vascular fluids and is characterized by weight gain over a short period of time. As vascular volume increases, central venous pressure increases, leading to distended neck veins, slow-emptying peripheral veins, a full and bounding pulse, and an increase in central venous pressure. Decreased blood pressure as well as a weak, rapid pulse reflect volume deficit. BUN and hematocrit may decrease as a result of dilution due to expansion of the plasma volume.
A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate? Discontinue the nasogastric tube suctioning. Assess for signs and symptoms of fluid volume deficit. Document the findings and reassess in 24 hours. Assess for edema
The client's 24-hour intake is 1800 mL (75 x 24). The client's 24-hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Because the output is significantly higher than the intake, the client is at risk for fluid volume deficit. The nurse should not discontinue the nasogastric suctioning without a physician's order. The findings should be documented and reassessed, but the nurse needs to take more action to prevent complication. Edema is usually associated with fluid volume excess.
Edema happens when there is which fluid volume imbalance? extracellular fluid volume deficit water deficit water excess extracellular fluid volume excess
When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.
The nurse is completing an initial assessment of a client admitted with chronic kidney disease. Which finding indicates the client has fluid volume excess? weight gain dry cough cool, dry skin poor tissue turgor
When the kidneys are not functioning, fluid volume excess presents. Signs of fluid excess are indicated by weight gain, hypertension, jugular vein distention, adventitious breath sounds (including crackles), and a wet cough. Cool, dry skin and poor tissue turgor are signs of fluid volume deficit.
Which of the following statements is an appropriate nursing diagnosis for a client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion? Fluid Volume Excess related to loss of sodium and potassium Fluid Volume Deficit related to congestive heart failure, as evidenced by shortness of breath Congestive Heart Failure related to edema Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea
Extracellular volume excess is the state in which a person experiences an excess of vascular and interstitial fluid.
The nurse is caring for a client with a disease causing excess antidiuretic hormone (ADH). When performing the assessment, the nurse should focus on which manifestation of excess ADH? Dehydration Excess salivation Increased urinary output Fluid volume excess
The nurse is caring for a client with a disease causing excess antidiuretic hormone (ADH). When performing the assessment, the nurse should focus on which manifestation of excess ADH?
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? nausea and vomiting fingerprinting over sternum distended neck veins muscle twitching
Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.
A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? Checking the client's lungs for crackles during every shift Weighing the client daily at the same time each day Assessing the client's vital signs every 4 hours Measuring and recording fluid intake and output
Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.
A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? weighing the client daily at the same time each day assessing the client's vital signs every 4 hours checking the client's lungs for crackles during every shift measuring and recording fluid intake and output
Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.
A child is admitted to the pediatric medical unit with the diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Based on the typical signs and symptoms of this disorder, which nursing diagnosis will the nurse identify as relating to this client? Imbalanced nutrition: More than body requirements Noncompliance Excess fluid volume Delayed growth and development
Syndrome of inappropriate antidiuretic hormone (SIADH) occurs when ADH (vasopressin) is secreted in the presence of low serum osmolality because the feedback mechanism that regulates ADH does not function properly. ADH continues to be released, and this leads to water retention, decreased serum sodium due to hemodilution, and extracellular fluid volume expansion; thus, Excess fluid volume from edema is the highest priority.
A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, jugular vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? toileting self-care deficit urinary retention excess fluid volume electrolyte disturbance
A client with renal failure can't eliminate sufficient fluid. This issue increases the risk of fluid overload and consequent respiratory and electrolyte problems. This client shows signs of excess fluid volume and is acutely ill. Urine retention may cause renal failure but is a less urgent concern than fluid imbalance. Electrolyte disturbance and Toileting self-care deficit may also be appropriate nursing diagnoses but they take lower priority because they aren't life-threatening.
Select the nursing diagnosis that would warrant immediate health care provider notification. Acute pain related to upper airway irritation secondary to an infection Deficient knowledge regarding prevention of upper airway infections, treatment regimens, the surgical procedure, or postoperative care Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation Deficient fluid volume related to decreased fluid intake and increased fluid loss secondary to diaphoresis associated with a fever
Ineffective airway clearance can lead to respiratory depression, which necessitates immediate intervention.
The nurse is performing an assessment for a client who is experiencing shortness of breath. The nurse notes a full and bounding pulse, crackles in the lung fields, and jugular vein distention. The nurse recognizes symptoms of which problem? Hyponatremia Diabetes insipidus Isotonic fluid volume excess Hypernatremia
Isotonic fluid volume excess is manifested by an increase in interstitial and vascular fluids. It is characterized by weight gain over a short period of time. An increase in vascular volume may be evidenced by distended neck veins, slow-emptying peripheral veins, a full and bounding pulse, and an increase in central venous pressure. When excess fluid accumulates in the lungs, there are complaints of shortness of breath and difficult breathing, respiratory crackles, and a productive cough.
