HESI Case Study: Fluid Balance

Upon entering Donna's room with the medication, the nurse checks Donna's ID band. Donna states, "You take care of me every day. Why do you keep looking at my ID?

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When Donna was first admitted, the HCP did not include intake and output measurement in the initial prescriptions, but the primary nurse initiated this assessment activity.

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Since Donna is receiving a diuretic that contributes to the loss of potassium, the nurse must provide dietary teaching. Which foods selected by the client indicate an understanding of potassium rich foods? - Baked potato. - Green beans. - Chicken breast. - Apple. - Grapefruit juice.

- Baked potato (844 mg K). - Chicken breast (458 mg K). - Grapefruit juice (378 mg K). Rationale: - 1 long potato contains 844 mg potassium. This shows that the client has an understanding of potassium-rich foods. - 4 oz. of chicken breast contains 458 mg potassium. This shows that the client has an understanding of potassium-rich foods. - 8 oz. of grapefruit juice contains 378 mg of potassium. This shows that the client has an understanding of potassium-rich foods.

The nurse resolves the obstruction, and the IV solution begins to infuse. The next day the nurse observes that the IV insertion site is inflamed and tender. The label on the IV site indicates the current IV has been in place for 36 hours.

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The nurse who made the errors is very upset about writing a variance (incident) report and states, "I've never made an error before. What if I get fired?"

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What is the best response by the nurse? - "It is hospital policy to always check client ID. - "Your HCP has asked that we always perform this check." - "Wearing an ID band is important for all clients." - "This is a double check to ensure that no errors occur."

"This is a double check to ensure that no errors occur." Rationale: This response provides the best client teaching. The client can participate in the plan of care more actively if explanations for interventions are provided.

How should the primary nurse respond? - "The variance report will show that this is your first medication error. " - "As long as you understand the error, we can disregard this report." - "Since no harm was done to the client, the variance report will not matter." - "Variance reports are used to find ways to prevent further errors."

"Variance reports are used to find ways to prevent further errors." Rationale: Variance reports are used by the risk management department of healthcare agencies to look for patterns that contribute to errors so that preventative measures can be instituted.

Before Donna's discharge, the nurse provides client teaching related to the prescribed hydrochlorothiazide (HydroDIURIL).

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Donna has abnormal breath sounds, bilateral pitting edema, and jugular vein distention.

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Further findings include oxygen saturation level of 90%, seem sodium of 140 mEq/L, serum chloride 105 mmil/L, albumin 4 g/dL, AST 30 IU/L, and serum potassium of 3 mEq/L.

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The nurse also observes that Donna's feet and ankles are swollen. When the nurse presses a finger over the client's ankle (boney prominence), an 8 mm indentation appears.

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The nurse continues to assess the client and observes that Donna's skin tents when a fold of skin over her sternum is pinched.

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The nurse is aware that the elderly often experience an increase in the amount of free, unbound drug molecules, which has the potential to increase the pharmacological effects of the drug.

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The nurse is preparing discharge instructions for Donna. Which signs and symptoms of fluid volume deficit should the nurse include when educating the client and her daughter prior to discharge? (Select all that apply) - Changes in mental status. - Changes in urine output. - Presence of tachycardia. - Tenting on arm when checking skin turgor. - Longitudinal furrows on the tongue.

- Changes in mental status. - Changes in urine output. - Presence of tachycardia. - Longitudinal furrows on the tongue. Rationale: - Cognitive impairment is associated with dehydration in the older adult. - Decreased renal perfusion and altered renal function can compromise the client's fluid volume status. - Presence of tachycardia is associated with dehydration in the older adult. - Longitudinal furrows on the tongue are indicative of dehydration.

Which identifiers are acceptable for the nurse to use when verifying the right client prior to medication or treatment administration? (Select all that apply) - Client full name. - Date of birth. - Current photograph. - Room number. - Physical location.

- Client full name. - Date of birth. - Current photograph. Rationale: - Two identifiers should be used to verify that a medication will be administered to the right client by using either a bar code scanning system or at least 2 identifiers such as a full name, date of birth, and current photograph

Which items should be measured as fluid intake? - Scrambled egge - Bowl of oatmeal - Fresh orange. - Milk. - Apple juice.

- Milk. - Apple juice. Rationale: Oral fluid intake includes only foods that are liquid at room temperature.

What additional action should the primary nurse take? - Discuss the consequences of the error with the hospital legal counsel. - Notify the healthcare provider of the error in treatment that occurred - Report to the hospital pharmacist that a variance report was written. - Notify the hospital educator of the need for staff training about IV fluids.

- Notify the healthcare provider of the error in treatment that occurred Rationale: Since the prescription was not initially followed, the healthcare provider should be notified in case a change in the treatment plan is warranted.

Which lab values are most important for the nurse to monitor? (Select all that apply) - Hemoglobin. - White blood cell count. - Serem potassium. - Prothrombin Time (PT/INR) - Magnesium.

- Serem potassium. - Magnesium. Rationale: - Hydrochlorothiazide (HydroDIURIL), a potassium wasting diuretic, may cause significant hypokalemia. - Use of hydrochlorothiazide (HydroDIURIL) may also result in a decrease in serum magnesium and sodium and an increase in serum calcium and glucose.

How will the nurse document this finding? - Gross edema in the lower extremities. - 4+ pitting edema present around ankles and feet. - Stage 1 pressure ulcer forming due to ankle edema. - Blanching and induration present bilaterally.

4+ pitting edema present around ankles and feet. Rationale: This documentation concisely describes the degree of indentation present and its location.

*Math* Donna's daughter reports that her mother usually weights 137 lbs (62.14 kg) and is 5' 3" (160 cm) in height. The nurse weighs Donna and obtains a measurement of 60 kg. The nurse explains to Donna's daughter that Donna has lost approximately how many pounds? - 3. - 5. - 4. - 7.

5. Rationale: 60 kg x 2.2=132 lbs. 137 lbs.-132 lbs. = 5 lbs. This represents an approximate weight loss of 5 pounds.

A short while later, a prescription for 0.9% Normal Saline at 100 ml/hour is received. Donna's primary nurse is at lunch, so another nurse hangs the solution. When checking Donna upon returning from lunch, the primary nurse observes that a solution of 5% Dextrose and 0.9% Normal Saline is infusing at 125 ml/hour.

Medication Errors (Title)

The nurse will emphasize the importance of taking this medication only once a day, on what schedule? - Before eating breakfast. - With breakfast. - After lunch. - At bedtime.

With breakfast. Rationale: To reduce the likelihood of nocturia, the client should be instructed to take diuretics in the morning. Additionally, taking the medication with food may reduce adverse effects, such as nausea.

What action should the nurse implement? - Confirm this finding by pinching the skin on her hand. - Notify the healthcare provider that the client is now retaining fluid. - Advise Donna that the fluid deficit seems to be worsening. - Document the presence of inelastic skin turgor.

Document the presence of inelastic skin turgor. Rationale: Skin turgor is best assessed in the elderly by gently pinching a fold of skin over the sternum. Inelastic turgor is an expected finding in a client with fluid volume deficit. Additional findings may include weakness, confusion, and tachycardia.

The nurse discusses factors that contributed to the fluid volume deficit with Donna and her daughter.

Age-related Risk Factors (Title)

When assessing the IV site, what step of the nursing process did the nurse use? - Analyze the data. - Plan interventions. - Determine the problem. - Establish a goal.

Analyze the data. Rationale: The nurse analyzes the assessment data to determine if characteristics occur that define a problem. A problem is then stated, a goal established, and the interventions are planned and implemented.

In addition to obtaining Donna's vital signs, the nurse performs additional assessments.

Assessment (Title)

Which assessment is important for the nurse to perform? - Auscultate the client's breath sounds. - Measure the client's tympanic temperature. - Compare the client's muscle strength bilaterally. - Ask the client if she is experiencing any syncope.

Auscultate the client's breath sounds. Rationale: Fluid volume excess often causes abnormal breath sounds. Fluid collection in the lungs can impair oxygen exchange and result in hypoxemia.

*Vital signs: Orthostatic Changes* Since Donna has fluid volume deficit, the nurse anticipates a decrease in which vital sign when Donna changes position? - Respiratory rate - Blood pressure - Temperature - Pulse rate

Blood pressure Rationale: Fluid volume deficit often causes orthostatic hypotension and tachycardia. Because the client may experience dizziness with orthostatic hypotension, the nurse should take additional safety precautions during this assessment.

For ongoing evaluation of Donna's fluid volume status, it is more important to obtain which assessment data? - Urine color. - Capillary refill. - Body weight. - Skin turgor.

Body weight. Rationale: Daily weights provide the most important data about fluid volume status, so an initial weight upon admission must be obtained.

What action should the primary nurse implement? - Obtain a container of 0.9% Normal Saline to hang when the present solution has finished infusing. - Decrease the infusion rate of the present solution to 75 ml/hour to compensate for the error made. - Stop the IV solution currently infusing and monitor the client for signs of an anaphylactic reaction. - Change the currently infusing solution to 0.9% Normal Saline and change the rate to 100 ml/hour.

Change the currently infusing solution to 0.9% Normal Saline and change the rate to 100 ml/hour. Rationale: Two errors have occurred: the wrong solution and wrong rate of administration. These error should both be corrected.

Now that Donna is taking oral fluids well, what action should the nurse implement? - Notify the healthcare provider that a prescription to continue intake and output measurement is needed. - Continue the measurement of the client's fluid intake and output. - Stop measuring the client's fluid intake and output as long as she takes oral fluids. - Measure the client's fluid output, but discontinue measuring fluid intake.

Continue the measurement of the client's fluid intake and output. Rationale: Since Donna is still receiving a significant volume of IV fluids, she remains at risk for fluid volume alterations. The nurse may initiate and maintain intake and output measurement without a prescription from the HCP.

The nurse takes the first blood pressure measurement. After recording the first blood pressure measurement, what action will the nurse take? - Count the client's radial pulse rate. - Remove the blood pressure cuff. - Help the client changes position. - Assess for auscultatory gap.

Count the client's radial pulse rate. Rationale: Both the blood pressure and pulse rate are typically measured in each position: lying, sitting, and standing.

Which problem often occurs in the elderly and may have contributed to the fluid volume deficit Donna is experiencing? - Decreased hepatic blood flow. - Decreased drug absorption. - Decreased drug half life - Decreased GI acidity.

Decreased hepatic blood flow. Rationale: Decreased hepatic blood flow commonly occurs in the elderly. This decreases drug metabolism, which allows drugs to remain in the body longer and produce a greater drug effect.

Case Outcome

Donna's fluid balance is restored. She is taking oral fluids well, her IV solution has been discontinued, and she has received client teaching about fluid balance and the correct administration of her diuretic. The nurse observes that Donna is able to break the scored medication tablet without difficulty. Donna is discharged home, accompanied by her daughter.

Donna's intake and output measurements indicate her intake is greater than her output. The nurse is concerned that Donna may develop fluid volume excess.

Fluid Volume Excess (Title)

Which change in Donna's pulse will the nurse anticipate? - Increase in rate and volume. - Decrease in rate and volume. - Increase in rate, but no change in the volume. - Decrease in rate, but no change in the volume.

Increase in rate and volume. Rationale: As fluid volume increases to the point of fluid volume excess, the client will develop tachycardia (increase in rate) and a bounding pulse (increase in volume).

Donna continues to receive 0.9% Normal Saline at a rate of 100 ml/hour. She is stronger and has started taking oral food and fluids well. She receives a regular no added salt diet. Her breakfast includes one cup of scrambled eggs, one bowl of oatmeal, a fresh orange, apple juice, and a carton of milk.

Intake and Output Measurement (Title)

The nurse starts an intravenous line to administer fluids. The prescription states, "3% Normal Saline to infuse at 100 ml/hour." The client's most recent seem sodium level is 135 mEq/L.

Intravenous Fluids (Title)

After hanging the correct IV solution at the correct rate of infusion, the nurse discusses the error with the nurse who hung the first IV solution. Together, the nurses complete a variance (incident) report.

Legal Considerations: Treatment Error (Title)

Later that day, Donna's IV pump alarm sounds. The nurse notes that the IV is not infusing in the right antecubital area, and the alarm indicates an obstruction is present. The nurse determines that all the clamps are open and there are no kinks in the tubing.

Local IV Site Complications (Information)

In preparing to administer the hydrochlorothiazide, the nurse notes that the prescribed dose is 12.5 mg, and the tablet available is 25 mg.

Medication Administration: Oral Tablets (Title)

Donna King is an 80 year old female with coronary artery disease and hypertension. Her daughter brought her to the Emergency Department because she has become increasingly weak and confused and was found by a neighbor wandering her neighborhood unable to locate her home. Donna's daughter tells the nurse that her mother takes a "water pill" for her blood pressure 2 or 3 times a day. The label on the medication bottle that she brought to the hospital states, "hydrochlorothiazide (HydroDIURIL). Take 1 tablet daily." Donna is admitted with fluid volume deficit.

Meet the Client (Title)

The nurse used the nursing process in deciding to remove Donna's IV and restart it in a new location.

Nursing Process (Title)

Which actin should the nurse take? - Observe the tablet to see if it is scored. - Notify the pharmacist of the error. - Hold the medication until the right does is available. - Document the change in dose on the medication record.

Observe the tablet to see if it is scored. Rationale: A scored tablet can safely be divided so that the client may receive the prescribed dose. Hydrochlorothiazide is a scored tablet, and 25 mg is the lowest tablet strength available. The nurse should therefore assess Donna's ability to break the tablet.

What action should the nurse take? - Hang 0.9% Normal Saline at 100 ml/hour. - Begin infusing the solution at a keep open rate. - Start the intravenous solution as prescribed. - Obtain appropriate IV fluid prescription.

Obtain appropriate IV fluid prescription. Rationale: Three percent saline is a hypertonic solution, which will pull fluid from the intestinal and intracellular spaces into the bloodstream. It is usually prescribed for severe hyponatremia.

Donna's fluid volume excess improves and the prescription for hydrochlorothiazide (HydroDIURIL) 12.5 mg PO daily is restarted.

Pharmacology: Diuretics (Title)

The nurse plans to assess Donna for orthostatic vital sign changes. Which action will the nurse take first? - Assist Donna to a standing position. - Position Donna in a supine position. - Elevate the head of Donna's bed. - Dangle Donna's feet at the bedside.

Position Donna in a supine position. Rationale: Orthostatic vital signs are measured in each position: lying, sitting, standing. The client's vital signs are first assessed in the supine position so that changes that occur when the client sits and stands can be determined.

The nurse reviews the client's laboratory results. Which laboratory result is critical and should be reported to the HCP. - Sodium 140. - Chloride 105. - Albumin 4. - Potassium 3.

Potassium 3. Rationale: The client's potassium level is low and will need to be addressed by the HCP.

The nurse reports the findings to the healthcare provider and receives several prescriptions. Which prescriptions should the nurse question? - Furosemide (Lasix) 40 mg IV push now. - Potassium chloride 40 mEq PO. - Decrease the Normal Saline to KVO. - Administer oxygen per nasal cannula at 2 L/minute.

Potassium chloride 40 mEq PO. Rationale: Donna's serum potassium is low. She needs potassium replacement via IV solution instead of the PO route. A prescription for potassium chloride diluted in an IV solution to be administered over several hours should be obtained from the HCP.

Which action should the nurse take? - Continue the IV with the arm elevated on a pillow. - Remove the IV and restart it in a different location. - Notify the healthcare provider that the IV site appears inflamed. - Complete a variance report regarding the IV site.

Remove the IV and restart it in a different location. Rationale: The client is experiencing phlebitis, which can lead to further complications if left untreated. Since the nurse has the responsibility to take action when IV site complications occur, the IV should be discontinued, action should be taken for the inflammation according to agency policy, and a new IV should be started at a different site.

Which problem did the nurse identify as most pertinent in that situation? - Risk for impaired skin integrity. - Risk for injury (thrombus formation) - Fluid volume deficit. - Infection.

Risk for injury (thrombus formation) Rationale: The phlebitis at the IV site places Donna at high risk for thrombus formation. So, the nurse identified this problem, established the goal that the risk for injury will be reduced, and implemented the interventions of removing the IV and providing care at the site of inflammation.

Which lab test will the nurse monitor to determine if this may be a factor contributing to Donna's problem? - Serem creatinine - Serem protein - AST. - BUN.

Serem protein Rationale: Drug molecules may be distributed through the body bound to plasma protein molecules. A decrease in serum protein levels is an indication that there may be in an increase in free, unbound drug molecules in the bloodstream.

Which intervention should the nurse take next? - Apply light pressure about the site. - Lower the IV solution below the site. - Straighten the joint above the site. - Change the IV site dressing.

Straighten the joint above the site. Rationale: Obstruction is often caused by client movement, resulting in a bend in the client's proximal joint. Therefore, this noninvasive measure should be the next action taken by the nurse.