Nursing Management PDF

11/27/23, 4:33 AM Realizeit for Student Nursing Management To assess for FVE, the nurse measures I&O at regular intervals to identify excessive fluid retention. The patient is weighed daily, and rapid weight gain is noted. Breath sounds are assessed at regular intervals in at-risk patients, partic...

11/27/23, 4:33 AM Realizeit for Student Nursing Management To assess for FVE, the nurse measures I&O at regular intervals to identify excessive fluid retention. The patient is weighed daily, and rapid weight gain is noted. Breath sounds are assessed at regular intervals in at-risk patients, particularly if parenteral fluids are being given. The nurse monitors the degree of edema in the most dependent parts of the body, such as the feet and ankles in ambulatory patients and the sacral region in patients confined to bed. Pitting edema is assessed by pressing a finger into the affected part, creating a pit or indentation that is evaluated on a scale of 1+ (minimal) to 4+ (severe). Peripheral edema is monitored by measuring the circumference of the extremity with a tape measure marked in millimeters (Weber & Kelley, 2018). Preventing Hypervolemia Specific interventions vary with the underlying condition and the degree of FVE. However, most patients require sodium-restricted diets in some form, and adherence to the prescribed diet is encouraged. Patients are instructed to avoid over-the-counter (OTC) medications without first checking with a health care provider, because they may contain sodium (e.g., Alka-Seltzer). If fluid retention persists despite adherence to a prescribed diet, hidden sources of sodium, such as the water supply or use of water softeners, should be considered. Detecting and Controlling Hypervolemia It is important to detect FVE before the condition becomes severe. Interventions include promoting rest, restricting sodium intake, monitoring parenteral fluid therapy, and administering appropriate medications. Regular rest periods may be beneficial, because bed rest favors diuresis of fluid. The mechanism is related to diminished venous pooling and the subsequent increase in effective circulating blood volume and renal perfusion. Sodium and fluid restriction should be instituted as indicated. Because most patients with FVE require diuretics, the patient’s response to these agents is monitored. The rate of parenteral fluids and the patient’s response to these fluids are also closely monitored (Frandsen & Pennington, 2018). If dyspnea or orthopnea is present, the patient is placed in a semi-Fowler position to promote lung expansion. The patient is turned and repositioned at regular intervals because edematous tissue is more prone to skin breakdown than normal tissue. Because conditions predisposing to FVE are likely to be chronic, patients are taught to monitor their response to therapy by documenting fluid I&O and body weight changes. The importance of adhering to the treatment regimen is emphasized. Educating Patients About Edema https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZsc2gfB3djkaGXwQ9ctgb2A3gz%2bCKrCW4cKwIi8CIqb… 1/2 11/27/23, 4:33 AM Realizeit for Student Because edema is a common manifestation of FVE, patients need to recognize its symptoms and understand its importance. The nurse gives special attention to edema when instructing the patient with FVE. Edema can occur as a result of increased capillary fluid pressure, decreased capillary oncotic pressure, or increased interstitial oncotic pressure, causing expansion of the interstitial fluid compartment (Hall, 2016). Edema can be localized (e.g., in the ankle, as in rheumatoid arthritis) or generalized (as in cardiac failure and kidney injury) (Sterns, 2018b). Severe generalized edema is called anasarca. Edema occurs when there is a change in the capillary membrane, increasing the formation of interstitial fluid or decreasing the removal of interstitial fluid. Sodium retention is a frequent cause of the increased ECF volume. Burns and infection are examples of conditions associated with increased interstitial fluid volume. Obstruction to lymphatic outflow, a plasma albumin level less than 1.5 to 2 g/dL, or a decrease in plasma oncotic pressure contributes to increased interstitial fluid volume. If there is decreased cardiac output as in heart failure, the kidneys sense low perfusion and secrete renin which triggers the renin–angiotensin–aldosterone system that increases sodium and water retention (Sterns, 2018b). A thorough medication history is necessary to identify any medications that could cause edema, such as nonsteroidal anti-inflammatory drugs (NSAIDs), estrogens, corticosteroids, and antihypertensive agents (Vallerand & Sanoski, 2019). Ascites is a type of edema in which fluid accumulates in the peritoneal cavity; it results from heart failure, nephrotic syndrome, cirrhosis, and some malignant tumors. The patient commonly reports shortness of breath and a sense of pressure because of pressure on the diaphragm. The goal of treatment is to preserve or restore the circulating intravascular fluid volume. Thus, in addition to treating the cause of the edema, other treatments may include diuretic therapy, restriction of fluids and sodium, elevation of the extremities, application of anti-embolic stockings, paracentesis (pulling fluid out of the peritoneal cavity using a needle and syringe), dialysis, and continuous renal replacement therapy in cases of kidney injury or life-threatening fluid volume overload (Sterns, 2018b). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZsc2gfB3djkaGXwQ9ctgb2A3gz%2bCKrCW4cKwIi8CIqb… 2/2