Criterion 1
NANDA
Excess Fluid Volume R/T right sided CHF AEB Edema on legs, crackles on lung sound, shortness of breath
Criterion 2
Fluid volume excess, or hypervolemia, is a disorder characterized by excessive fluid volume and an increase in total body sodium content. The condition of fluid volume excess results from compromised controlling mechanisms for sodium and water as seen in congestive heart failure (CHF), kidney failure, and liver failure. It may also be affected by extreme consumption of sodium from foods, IV solutions, medications, or diagnostic contrast dyes. As the heart function fails, blood backs up and returns to the veins. (Gulanick 79)
Criterion 3 subjective and objective
-Presence of edema on legs
- Presence of crackles
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CHF makes heart beats faster to pump enough blood to the body (hypertension)
Criterion 5
Patient will demonstrate adequate fluid balanced AEB output equal to exceeding intake, clearing breath sounds, and decreasing edema by the end of the shift
Criterion 6 and 7
Teaching intervention Teach patient to avoid medications that may cause fluid retention, such as over-the-counter NSAIDs, certain vasodilators, and steroids.
Rationale
Thorough understanding of specific causes, such as medication side effects, is necessary for appropriate follow-up of treatment. (Gulanick 82)
Therapeutic Intervention
Administer or instruct the patient to take diuretics as prescribed.
Diuretics aid in the excretion of excess body fluids. (Gulanick 81)
Diagnosis Intervention
Assess for crackles in the lungs, changes in respiratory pattern, and shortness of breath every two hours
Rationale
These signs are caused by accumulation of fluid in the lungs.
▪Assess for the presence of edema by palpating over the tibia, ankles, feet, and sacrum.
Rationale
Edema occurs when fluid accumulates in the extravascular spaces. Dependent areas more readily exhibit signs of edema formation. (Gulanick 80)
Referral intervention
Refer pt to dietician for sodium restriction intake and fluid
The risk factors that Jessica presented with are a history that is positive for smoking, bronchitis and living in a large urban area with decreased air quality. The symptoms that suggest a pulmonary disorder include a productive cough with discolored sputum, elevated respiratory rate, use of the accessory respiratory muscles during quite breathing, exertional dyspnea, tachycardia and pedal edema. The discolored sputum is indicative of a respiratory infection. The changes in respiratory rate, use of respiratory muscles and exertional dyspnea indicate a pulmonary disorder since there is an increased amount of work required for normal breathing. Tachycardia may arise due to the lack of oxygenated blood available to the tissue stimulating an increase in heart rate. The pedal edema most probably results from decreased systemic blood flow.
Ascertaining the adequacy of gaseous exchange is the major purpose of the respiratory assessment. The components of respiratory assessment comprises of rate, rhythm, quality of breathing, degree of effort, cough, skin colour, deformities and mental status (Moore, 2007). RR is a primary indicator among other components that assists health professionals to record the baseline findings of current ventilatory functions and to identify physiological respiratory deterioration. For instance, increased RR (tachypnoea) and tidal volume indicate the body’s attempt to correct hypoxaemia and hypercapnia (Cretikos, Bellomo, Hillman, Chen, Finfer, & Flabouris, 2008). The inclusive use of a respiratory assessment on a patient could lead to numerous potential benefits. Firstly, initial findings of respiratory assessment reveals baseline data of patient’s respiratory functions. Secondly, if the patient is on respiratory medication such as salbutamol and ipratropium bromide, the respiratory assessment enables nurses to measure the effectiveness of medications and patient’s compliance towards those medications (Cretikos, Bellomo, Hillman, Chen, Finfer, & Flabouris, 2008). Thirdly, it facilitates early identification of respiratory complications and it has the potential to reduce the risk of significant clinical
A cardiac assessment: Listen to heart sounds listening for extra heart sounds, fast heartbeat, and monitor EKG looking for dysthymias. Assess vitals especially BP, BP should be kept low in heart failure patients to put less stress on the heart. Assess the patient for edema as a result of fluid retention. Listen for crackles in the lungs due to fluid built up. Watch I&O’s and weight the patient to assess for edema, ask about activity intolerance. Assess for changes in mental status, cool extremities, pale or cyanotic, fatigue, and JVD (Indications of poor perfusion) (Ignatavicius &Workman, p.756).
This systematic review conducted by Takeda A, Taylor SJC, Taylor RS, Khan F, Krum H, Underwood M, (2012) sourced twenty-five trials, and the overall number of people of the collective trials included was 5,942. Interventions were classified and assessed using the following headings.-
The ability to carry out and document a full respiratory and cardiovascular assessment is an essential skill. The severity of illness can be initially evaluated by inspection, palpation, percussion, and auscultation. During analysis, specific locations of symptoms can be identified using landmarks such as the midaxiallary, midclavicular, and, the midsternal line. Indicate anterior or posterior thorax, and use the midaxillary line location when applicable (Bickley & Szilagyi, 2013).
J.P. was positive for dyspnea and a productive cough. She also was positive for dysuria and hematuria, but negative for flank pain. After close examination of her integumentary and musculoskeletal system, the examiner discovered a shiny firm shin on the right lower extremity with +2 edema complemented by severe pain. A set of baseline vitals were also performed, revealing a blood pressure of 124/80, pulse of 87 beats per minute, oxygen saturation of 99%, temperature of 97.3 degrees Fahrenheit, and respiration of 12 breaths per minute. The blood and metabolic panel exposed to several abnormal labs.
This only keeps the blood moving for a short while. The heart muscle walls weaken and are unable to pump as strongly. This makes the kidneys respond by causing the body to retain fluid and sodium. When the body builds up fluids, it becomes congested. Many conditions can cause heart failure, and they include coronary artery disease, heart attack, cardiomyopathy, and conditions that overwork the heart.
Name the observation that you would perform on a patient that has had a fractured arm pined and plated and is now in a full cast. Identify what is accessed in this type of observation.
Discussion between the physician and the patient regarding treatment options and the risks and benefits of treatment.
-The patient was having pitting edema and inspiratory rales because the increase of sodium caused an increase of fluid in the vascular system and lungs.
This disease is usually detected early in infants before symptoms occur, but children grow up not being able to breathe properly or exercise to their full potential because of how this disease restricts their airways. The thick mucus blocks and clogs the lungs, not allowing for all of the surface area to be used for the oxygen and carbon dioxide exchange. This disease can cause other life threatening side effects like pneumothorax, enlargement of the right side of the heart which can lead to heart failure, increased pressure of the lungs, and damaged airways (WebMD). This significantly decreases the ability to breathe; both the dynamic and tidal volumes are smaller than that of a normal
Occurs approximately during the first week, usually start within 24 to 48 hours after the direct lung injury. In this phase, the injury of alveolar capillary endothelial cells and type I pneumocytes lead interstitial alveolar edema (non cardiogenic pulmonary edema) and atelectasis. Fluid that contains protein accumulates in the interstitial and alveolar spaces. In this acute phase, massive concentration of cytokines and lipid mediators are present in the lung. In response to proinflammatory mediators, leukocytes move into interstitial and alveoli. In addition, plasma protein accumulates in the air spaces with cellular debris and dysfunctional pulmonary surfactant to form hyaline membrane. Refractory hypoxemia occurs due to Severe V/Q mismatch and shunting of pulmonary capillaries. Respiratory alkalosis and an increase in cardiac output occurs in result of increased respiratory rate and heart rate as compensatory mechanism of Hypoxemia (Levy & Choi., 2012).
The patient has high temperature-sign of fever, a very fast pulse rate (tachycardia), and chest wheezing when listened to using a stethoscope (Harries, Maher, & Graham, 2004, p.
Shock that may be hypovolemic which can be one of the serious complications of dehydration...
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