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Subjective
No subjective data based on documents.
Objective
Atrial fibrillation w/ rapid ventricular
response, left axis deviation, pulmonary disease pattern, inferior infarction
BP 145/86
HR 110; Rhythm Afib
Upon arrival to the ER, her VS were BP 178/110, HR 114
Hgb 10.2
Hct 29.6
She has a history of Type 2 diabetes mellitus, hypertension, coronary artery disease,
chronic atrial fibrillation
Dorothy has no urinary output documented for the past 10 hours.
Intake includes 1100 ml of IV fluids and 3 cups of ice chips (~160 ml)
Strong hx of smoking and moderate life sytle.
Obese
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Problem
Excess Fluid Volume
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Long Term:
Client will remain free of edema, effusion, anasarca; weight appropriate for the
client during hospital stay.
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Monitor location and extent of edema; use a millimeter tape in the same area at
the same time each day to measure edema in extremities.
Generalized edema (e.g., in the upper extremities and eyelids) is associated with
decreased oncotic pressure often as a result of nephrotic syndrome. Measuring the
extremity with a millimeter tape is more accurate than using the 1 to 4 scale (Metheny, 2000). Heart failure and renal
failure are usually associated with dependent edema because of increased hydrostatic
pressure; dependent edema causes swelling in the legs and feet of ambulatory clients
and the presacral region of clients on bed rest. EBN: Dependent edema was found
to demonstrate the greatest sensitivity as a defining characteristic for excess
fluid volume (Rios et al, 1991).
Monitor daily weight for sudden increases; use same scale and type of clothing at
same time each day, preferably before breakfast. EB:
Measurement of body weight change is a safe technique to assess hydration status
(Armstrong, 2005). EB: Body weight could safely
be used to monitor for fluid overload when administering hyperhydration with high-dose
chemotherapy (Mank et al, 2003).
With head of bed elevated 30 to 45 degrees, monitor jugular veins for distention
in the upright position; assess for positive hepatojugular reflex.
Increased intravascular volume results in jugular vein distention, even in a client
in the upright position, and a positive hepatojugular reflex (Kasper et al, 2005).
Turn clients with dependent edema frequently (i.e., at least every 2 hours). Edematous tissue is vulnerable to ischemia and pressure
ulcers (Casey, 2004).
Teach client on diuretics to weigh self daily in
the morning and notify the physician of a change in weight of 3 pounds or more (Karch, 2004).
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R/T
Compromised regulatory mechanism
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Short Term:
Client will maintain clear lung sounds,
no evidence of dyspnea or orthopnea to be evaluated by the end of shift on xxxxx
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Monitor vital signs; note decreasing blood pressure, tachycardia, and tachypnea.
Monitor for gallop rhythms. If signs of heart failure are present, see the care
plan for Decreased Cardiac output. Heart failure
results in decreased cardiac output and decreased blood pressure. Tissue hypoxia
stimulates increased heart and respiratory rates.
Monitor lung sounds for crackles, monitor respirations for effort, and determine
the presence and severity of orthopnea. Pulmonary
edema results from excessive shifting of fluid from the vascular space into the
pulmonary interstitial space and alveoli. Pulmonary edema can interfere with the
oxygen/carbon dioxide exchange at the alveolar-capillary membrane (Metheny, 2000), resulting in dyspnea and orthopnea.
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