| Interventions | Rationales |
|---|---|
| Place the patient in a semi-Fowler's or high-Fowler's position. | Raising the head of bed provides comfort in breathing. |
| Aid with repositioning every 2 hours if the patient is not mobile. | Repositioning prevents fluid accumulation in dependent areas. |
What are nursing interventions for hypokalemia?
What are nursing interventions for hypokalemia? Measures to identify and stop ongoing losses of potassium include the following: Discontinue diuretics/laxatives. Use potassium-sparing diuretics if diuretic therapy is required (eg, severe heart failure) Treat diarrhea or vomiting. Administer H2 blockers to patients receiving nasogastric suction.
What are the nursing interventions for pulmonary edema?
- Monitor ABCs – Airway, Breathing, Circulation.
- Placement of the patient in a high flower position can help improve oxygenation.
- The blood vessels and air passages should be flushed out to remove excess fluids and promote normal lung expansion.
- Monitor respiratory status every 15 minutes for signs of pulmonary edema.
What are nursing interventions for dehydration?
- Maintain fluid balance.
- Vital signs (pulse = 80-100 beats / min, temperature = 36-37oC)
- Capillary refill less than 3 seconds.
- Akral warm.
- Urine output: 1-2 cc / kg body weight / hour.
What are the signs and symptoms of fluid volume overload?
What Are the Symptoms of Fluid Overload?
- Swelling. You may have swelling in your feet, legs, hands, or face. ...
- High blood pressure. The extra fluid in your body makes your heart work harder. ...
- Shortness of breath. It can be difficult for you to breathe if the extra fluid gets in your lungs. ...
- Discomfort. ...
- Weight gain. ...
- Chest pain. ...
What is the treatment for a Patient with excess fluid volume?
Treatment options may include: Diuretics — medicines that help you get rid of extra fluid. Dialysis — a treatment that filters your blood through a machine. Paracentesis — a procedure that uses a small tube to drain fluid from your abdomen.
What nursing intervention will you provide for a Patient with fluid imbalance?
Fluid and Electrolyte Imbalance Nursing Care Plan 5Nursing Interventions for Fluid and Electrolyte ImbalanceRationaleEducate the patient to eat foods high in magnesium, such as whole grains, bran, nuts, and seeds.To increase in magnesium levels in the body.7 more rows
What is a nursing intervention for a Patient experiencing fluid overload?
Excess Fluid Volume Nursing Care Plan[1,2] Perform: Weight in daily- document changes in weight in response to therapy for edema. Frequent position changes in bed, elevate feet when sitting.
How do you treat excess fluid?
Lifestyle and home remediesMovement. Moving and using the muscles in the part of your body affected by edema, especially your legs, may help pump the excess fluid back toward your heart. ... Elevation. ... Massage. ... Compression. ... Protection. ... Reduce salt intake.
Which independent nursing actions are appropriate for a client with deficient fluid volume?
Nursing Interventions for Fluid Volume DeficitUrge the patient to drink the prescribed amount of fluid. ... Aid the patient if they cannot eat without assistance, and encourage the family or SO to assist with feedings as necessary. ... Provide a comfortable environment by covering the patient with light sheets.More items...•
What are nursing interventions for dehydration?
Nursing Care Plan for Dehydration 1Nursing Interventions for DehydrationRationalesStart intravenous therapy as prescribed. Encourage oral fluid intake.To replenish the fluids lost from profuse sweating, and to promote better blood circulation around the body.7 more rows
What are four 4 acute signs and symptoms of fluid overload?
Signs of fluid overload may include:Rapid weight gain.Noticeable swelling (edema) in your arms, legs and face.Swelling in your abdomen.Cramping, headache, and stomach bloating.Shortness of breath.High blood pressure.Heart problems, including congestive heart failure.
What is fluid volume excess?
Fluid Volume Excess (FVE), or hypervolemia, refers to an isotonic expansion of the ECF due to an increase in total body sodium content and an increase in total body water.
Pathophysiology
Fluid Volume deficit (dehydration) is a state or condition where the fluid output exceeds the fluid intake. The body loses both water and electrolytes from the ECF in similar proportions. Common sources are the gastrointestinal tract, polyuria, and increased perspiration.
Etiology
Common causes are decreased fluid intake, bleeding, diarrhea, diuresis, abnormal drainage, increased metabolic rate, movement of fluid into third space, and abnormal losses through the skin, GI tract, or kidneys.
Desired Outcome
Patient has normal vital signs. Demonstrates adequate lifestyle changes to avoid dehydration. Patient has normal urine output
What is the goal of glomerulonephritis in nursing?
Nursing care planning goals for the child with acute glomerulonephritis is directed toward the excretion of excess fluid through urination, participate in an activity within tolerance, preventing infection, and absence of complication.
What to do during acute phase of AGN?
Encourage foods low in sodium, potassium, and protein during the acute phase of AGN; Instruct to increase intake of food high in carbohydrates and fats (only during the acute phase of AGN), as ordered.
How to prevent transfer of disease?
Prevents transfer of disease. Instruct parents to avoid exposure of the child to others with an existing upper respiratory infection. Avoids respiratory infections in the susceptible child. Instruct parents to notify health care provider if fever , cough, sore throat is present.
How to reduce the work of the kidneys?
Conserves energy and limits the production of waste materials which increase s the work of the kidneys. Schedule care and provide rest periods. after any activity in a quiet environment. Provides adequate rest and reduces stimuli and fatigue. Provide for quiet play, reading, TV, games as symptoms subside.
What is the purpose of activity restriction?
Explain to the child and parents the purpose of activity restriction. Promotes understanding of the need to conserve energy and rest to help in recovery. Inform parents and child about the importance of rest after ambulation or any activity.
How often should you monitor vital signs?
Monitor vital signs every 4 hours; notify any significant changes. An assessment provides baseline information for monitoring changes and evaluating the effectiveness of therapy. Auscultate breath sounds for the presence of crackles. Observe for increased work of breathing, cough, and nasal flaring.
Clinical symptoms of Heart failure
Heart failure’s early signs and symptoms are breathlessness or dyspnea, orthopnea, paroxysmal nocturnal dyspnea, lethargy/fatigue/weakness, oedema, abdominal distension, and right hypochondrial pain.
Epidemiology of Heart failure
Heart failure is mostly found in elderly patients (>60 years of age). About 2% to 3% of the United States Of America population are affected by Heart failure, of which 10% are male and 8% are female. According to a CDC report, around 6.3 million heart failure patients were there in 2018.
Nursing diagnosis-4: Deficient knowledge
Patients or relatives can understand the information and follow the instructions.
What is the diffusion of a pure solvent, such as water, across a semipermeable membrane in response
D: Osmosis is the diffusion of a pure solvent, such as water, across a semipermeable membrane in response to a concentration gradient in situations where the molecules of a higher concentration are non diffusible.
What is intracellular fluid?
Intracellular fluid functions as a stabilizing agent for the parts of the cell, helps maintain cell shape, and assists with transport of nutrients across the cell membrane, in and out of the cell. Extracellular fluid. Extracellular fluid mostly appears as interstitial tissue fluid and intravascular fluid.
What is the fluid and electrolyte balance?
Fluid and Electrolytes, Acid-Base Balance. Fluid and electrolyte balance is a dynamic process that is crucial for life and homeostasis. Fluid occupies almost 60% of the weight of an adult. Body fluid is located in two fluid compartments: the intracellular space and the extracellular space.
What is the body fluid?
Fluid occupies almost 60% of the weight of an adult. Body fluid is located in two fluid compartments: the intracellular space and the extracellular space. Electrolytes in body fluids are active chemicals or cations that carry positive charges and anions that carry negative charges. The major cations in the body fluid are sodium, potassium, calcium, ...
What is the difference between overhydration and edema?
Overhydration and Edema. Overhydration. Overhydration is an excess of water in the body. Edema. Edema is the excess accumulation of fluid in interstitial tissue spaces, also called third-space fluid. Cause of edema. Edema is caused by a disruption of the filtration and osmotic forces of the body’s circulating fluids.
What is the role of a patient in fluid deficit?
Patient verbalizes awareness of causative factors and behaviors essential to correct fluid deficit. Patient explains measures that can be taken to treat or prevent fluid volume loss. Patient describes symptoms that indicate the need to consult with health care provider.
What is the goal of fluid management?
The goals of management are to treat the underlying disorder and return the extracellular fluid compartment to normal, to restore fluid volume, and to correct any electrolyte imbalances. ADVERTISEMENTS.
What is fluid volume deficit?
Fluid volume deficit (FVD) or hypovolemia is a state or condition where the fluid output exceeds the fluid intake. It occurs when the body loses both water and electrolytes from the ECF in similar proportions. Common sources of fluid loss are the gastrointestinal tract, polyuria, and increased perspiration. Risk factors for FVD are as follows: ...
How does fluid come into the body?
Most fluid comes into the body through drinking, water in food, and water formed by oxidation of foods. Verifying if the patient is on a fluid restraint is necessary. Note presence of nausea, vomiting and fever. These factors influence intake, fluid needs, and route of replacement.
Is hypotension evident in hypovolemia?
Hypotension is evident in hypovolemia. Assess skin turgor and oral mucous membranes for signs of dehydration. Signs of dehydration are also detected through the skin. Skin of elderly patients losses elasticity, hence skin turgor should be assessed over the sternum or on the inner thighs.
What is the nursing care plan for fluid and electrolyte imbalances?
Nursing care plan and goals for fluid and electrolyte imbalances include: maintaining fluid volume at a functional level, patient exhibits normal laboratory values, demonstrates appropriate changes in lifestyle and behaviors including eating patterns and food quantity/quality, re-establishing and maintaining normal pattern and GI functioning.
What diuretics are used to excrete excess fluid?
To achieve excretion of excess fluid, either a single thiazide diuretic or a combination of agents may be selected, such as thiazide and spironolactone.
What are the functions of body fluids?
Body fluids have a variety of important functions in the human body: the facilitate transport of nutrients, hormones, proteins, and other molecules into cells; aid in the removal of metabolic waste products; regulate body temperature; lubricates musculoskeletal joints; provide a medium for which cellular metabolism could take place, and act as a component in body cavities.
What causes excessive fluids in the body?
This can happen as a result of an alteration in body systems, chronic disease, certain medications, or an underlying illness.
What is the term for the expansion of the extracellular fluid?
Hypervolemia refers to an isotonic volume expansion of the extracellular fluid (ECF) caused by the abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ECF. Hypovolemia occurs when loss of extracellular fluid exceeds the intake of fluid.