Podcast
Questions and Answers
What is the selection of the nursing diagnosis of Excess Fluid Volume based on? (Select all that apply)
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?
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)
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.
Match the nursing diagnosis with the supporting evidence.
For the outcome 'Achieve and maintain fluid balance', which goal statement measures this outcome?
For the outcome 'Achieve and maintain fluid balance', which goal statement measures this outcome?
Which goal meets all of the criteria for correctly written goals?
Which goal meets all of the criteria for correctly written goals?
Match the role of each member of the health care team with how they help patients meet goals related to fluid balance.
Match the role of each member of the health care team with how they help patients meet goals related to fluid balance.
Match each element with its patient-centered goal.
Match each element with its patient-centered goal.
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.
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.
What is an appropriate nursing diagnosis related to fluid imbalance for a patient preparing to undergo a major surgical procedure?
What is an appropriate nursing diagnosis related to fluid imbalance for a patient preparing to undergo a major surgical procedure?
What is the appropriate nursing diagnosis for a patient with a history of nausea and vomiting, signs of lethargy, and dry mucous membranes?
What is the appropriate nursing diagnosis for a patient with a history of nausea and vomiting, signs of lethargy, and dry mucous membranes?
What is an appropriate nursing diagnosis related to fluid volume excess for Mrs. Ellis?
What is an appropriate nursing diagnosis related to fluid volume excess for Mrs. Ellis?
What are the defining characteristics of the nursing diagnosis label Readiness for Enhanced Fluid Balance? (Select all that apply)
What are the defining characteristics of the nursing diagnosis label Readiness for Enhanced Fluid Balance? (Select all that apply)
What represents a measurable, patient-centered goal for a patient with a nursing diagnosis of Deficient Fluid Volume?
What represents a measurable, patient-centered goal for a patient with a nursing diagnosis of Deficient Fluid Volume?
Which goals would be appropriate for the nursing diagnosis of Excess Fluid Volume?
Which goals would be appropriate for the nursing diagnosis of Excess Fluid Volume?
What goal statement would most directly measure the outcome: Achieve and maintain fluid balance?
What goal statement would most directly measure the outcome: Achieve and maintain fluid balance?
Flashcards are hidden until you start studying
Study Notes
Nursing Diagnosis and Planning Related to Fluid Imbalances
-
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.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
