Nursing Diagnosis - Fluid Imbalances
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Questions and Answers

What is the selection of the nursing diagnosis of Excess Fluid Volume based on? (Select all that apply)

  • Assessment findings of dependent edema and dyspnea (correct)
  • Increased urine output
  • History of sudden weight gain (correct)
  • Mrs. Ellis's diagnosis of heart failure (correct)
  • Primary care provider's diagnosis

    • What other nursing diagnoses related to fluid volume excess could be selected for Mrs. Ellis based on her clinical data?

    Decreased Cardiac Output

    What are the defining characteristics of the nursing diagnosis label Readiness for Enhanced Fluid Balance? (Select all that apply)

  • Absence of or mild dependent edema (correct)
  • No manifestations of fluid volume deficit (correct)
  • Intake equals output (correct)
  • Moist mucous membranes (correct)
  • Stable daily weights (correct)

    • Match the nursing diagnosis with the supporting evidence.

    <p>Excess Fluid Volume = Edema, dyspnea, sudden weight gain Deficient Fluid Volume = Dry skin and mucous membranes, sudden weight loss, decreased urine output Risk for Fluid Imbalance = About to undergo a major surgical procedure Decreased Cardiac Output = Low blood pressure, tachycardia, dyspnea, fatigue</p> Signup and view all the answers

    For the outcome 'Achieve and maintain fluid balance', which goal statement measures this outcome?

    <p>The patient's intake will approximately equal output during a 12-hour shift.</p> Signup and view all the answers

    Which goal meets all of the criteria for correctly written goals?

    <p>The patient will consume at least 1800 mL of oral fluids during a 24-hour shift.</p> Signup and view all the answers

    Match the role of each member of the health care team with how they help patients meet goals related to fluid balance.

    <p>Registered Dietician = Advise the patient about reduced sodium diet, monitor sodium intake Nursing Assistant = Assist with monitoring daily weights, vital signs, and intake and output Pharmacy = Monitor continued need for medications and ensure correct dosage Physical Therapist = Assist in meeting ambulation, mobility goals; improve physical conditioning</p> Signup and view all the answers

    Match each element with its patient-centered goal.

    <p>Deficient Fluid Volume = Patient will drink 100 mL of water every hour for the 12-hour day shift. Excess Fluid Volume = Patient will exhibit no edema of the ankles or feet for the 12-hour shift. Fluid Imbalance Goal = Patient will have required fluid levels on completion of treatment.</p> Signup and view all the answers

    What nursing diagnostic label do these assessment data suggest? Patient is dyspneic with audible crackles and gained 1.8 kg over the past 24 hours.

    <p>Excess Fluid Volume</p> Signup and view all the answers

    What is an appropriate nursing diagnosis related to fluid imbalance for a patient preparing to undergo a major surgical procedure?

    <p>Risk for Fluid Imbalance</p> Signup and view all the answers

    What is the appropriate nursing diagnosis for a patient with a history of nausea and vomiting, signs of lethargy, and dry mucous membranes?

    <p>Deficient Fluid Volume related to loss of fluids through nausea and vomiting</p> Signup and view all the answers

    What is an appropriate nursing diagnosis related to fluid volume excess for Mrs. Ellis?

    <p>Decreased Cardiac Output</p> Signup and view all the answers

    What are the defining characteristics of the nursing diagnosis label Readiness for Enhanced Fluid Balance? (Select all that apply)

    <p>No manifestations of fluid volume deficit</p> Signup and view all the answers

    What represents a measurable, patient-centered goal for a patient with a nursing diagnosis of Deficient Fluid Volume?

    <p>The patient will consume at least 100 mL of fluids every hour for a 12-hour shift.</p> Signup and view all the answers

    Which goals would be appropriate for the nursing diagnosis of Excess Fluid Volume?

    <p>The patient will maintain a urinary output of greater than 30mL per hour for 24 hours.</p> Signup and view all the answers

    What goal statement would most directly measure the outcome: Achieve and maintain fluid balance?

    <p>The patient's intake and output will be approximately equal during a 24-hour day.</p> Signup and view all the answers

    Study Notes

    • Nursing Diagnosis: Excess Fluid Volume

      • Related to retention of excess body fluid.
      • Evidenced by: edema, dyspnea, sudden weight gain, activity intolerance.
      • Key considerations: heart failure diagnosis, assessment findings of dependent edema and dyspnea, history of sudden weight gain.

    • Clinical Manifestations of Fluid Volume Excess (FVE)

      • Possible nursing diagnoses: Decreased Cardiac Output due to impact on cardiac workload.

    Readiness for Enhanced Fluid Balance

    • Defining characteristics include:
      • Stable daily weights indicating no rapid fluid gain.
      • Moist mucous membranes showing absence of fluid deficit.
      • Intake equaling output, demonstrating fluid balance.
      • No manifestations of fluid volume deficit.

    Nursing Diagnosis Matching

    • Excess Fluid Volume: Edema, dyspnea, sudden weight gain.
    • Deficient Fluid Volume: Dry skin/mucous membranes, sudden weight loss, decreased urine output.
    • Risk for Fluid Imbalance: Patient undergoing major surgery.
    • Decreased Cardiac Output: Low blood pressure, tachycardia, dyspnea, fatigue.

    Patient-Centered Goals

    • Goal for fluid balance:

      • Patient’s intake approximately equals output during a 12-hour shift.
      • Adequate oral fluid consumption (e.g., 100 mL/hour for 12 hours).
      • Maintain systolic blood pressure above 90 for stability.

    • Collaborative Care Team Roles:

      • Registered Dietician: Advise on a reduced sodium diet.
      • Nursing Assistant: Monitor daily weights, vital signs, and intake/output.
      • Pharmacist: Monitor medication needs and dosages.
      • Physical Therapist: Assist in mobility and conditioning goals.

    Assessment Findings for Nursing Diagnoses

    • Excess Fluid Volume indicators:
      • Weight gain of 1.5 kg in 24 hours, jugular venous distension, crackles in lungs.
    • Deficient Fluid Volume diagnosis based on:
      • Lethargy, low urine output, dry mucous membranes, low blood pressure, tachycardia.

    Surgery and Fluid Risks

    • Patients preparing for major surgery present a Risk for Fluid Imbalance due to potential fluid loss.

    Measurable Outcomes for Nursing Goals

    • Goals should be specific, measurable, and time-bound:
      • E.g., fluid intake of at least 1800 mL in 24 hours, maintain an adequate hourly urine output.

    Additional Goals for Excess Fluid Volume

    • Sodium intake restricted to no more than 1500 mg daily to reduce edema.
    • Maintain urinary output of greater than 30 mL/hour for 24 hours.
    • Capability to ambulate 50 feet without dyspnea by the end of the shift.

    Overall Fluid Balance Goals

    • Measurable outcomes include:
      • Daily intake/output balance over specified timeframes, directly addressing intended nursing outcomes.

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    Description

    Test your knowledge on nursing diagnoses related to fluid imbalances, specifically focusing on Excess Fluid Volume. This quiz utilizes case scenarios to challenge your understanding of evidence-based assessments and planning in medical-surgical nursing.

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