Laica A.

Luneta
BSN II

CASE SCENARIO
A client with Fluid Volume Excess
Dorothy is a 45-year-old Native American woman hospitalized with acute renal failure
that developed as a result of acute glomerulonephritis. She is expected to recover, but she has
very little urine output. Ms. Rainwater is a single mother of two teenage sons. Until her illness,
she was active in caring for her family, her career as a high school principal, and community
activities.

Assessment
Mike Penning, Ms. Rainwater’s nurse, notes that she is in the oliguric phase of acute
renal failure, and that her urine output for the previous 24 hours is 250 mL; this low input has
been constant for the past 8 days. She gained 1 lb (0.45kg) in the past 24 hours. Laboratory test
results from that morning are sodium, 155 mEq/L (normal 3.5 to 5.0 mEq/l); calcium, 7.6 mg/dL
(normal 8.0 to 10.5 mg/dL), and urine specific gravity 1.008 (normal 1.010 to 1.030). Ms.
Rainwater’s serum creatinine and blood urea nitrogen (BUN) are high; however, her ABGs are
within normal limits.
In his assessment of Ms. Rainwater’, Mike notes are the following:
· BP 160/92; P 102, with obvious neck vein distention; r 28, with crackles and wheezes;
head of bead elevated 30 degrees; T 98.6 F.
· Periorbital and sacral edema present 3+ pitting bilateral pedal edema; skin cool; pale; and
shiny.
· Alert, oriented; responds appropriately to questions
· Client states she is thirsty, slightly nauseated, and extremely tired.
Ms. Rainwater is receiving intravenous furosemide and is on a 24-hour fluid restriction of
500 mL plus the previous day’s urine output to manage her fluid volume excess.
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Fill in the following information needed base on the above case scenario
1. Nursing Diagnosis: Fluid Volume Excess
Related Cause : Excessive fluid intake
Expected Outcomes :
 Patient maintains HR 60 to 100 beats/min.
 Patient describes symptoms that indicate the needs of health provider
 Patient has stable weight and balanced intake and ouput

Planning and Implementation :
 Assess vital signs every 4hrs
 Measure intake and output every 4hrs
 Weight at 0600 and 1800 daily
Evaluation:
At the end of the shift of the nurse, evaluates the effectiveness of the plan of care and
continuous all diagnosis and intervention. Patient with Fluid volume excess had gained no
weight and the urinary output during the shift of the nurse is 170 ml . Vital signs are unchanged
but her crackles and wheezes has decreased slightly. Patient tolerated the bedside chair without
dyspnea or fatigue.
2. Risk for impaired gas exchange
Related Cause:
 Ventilation-perfusion imbalance
Expected Outcomes:
 Patient maintains optimal gas exchange as evidenced by usual mental status, unlabored
respirations at 12-20 per minute, oximetry results within normal range, blood gases
within normal range, and baseline HR for patient.
 Patient maintains optimal gas exchange as evidenced by usual mental status, unlabored
respirations at 12-20 per minute, oximetry results within normal range, blood gases
within normal range, and baseline HR for patient
 Patient verbalizes understanding of oxygen and other therapeutic interventions
 Patient participates in procedures to optimize oxygenation and in management
 regimen within level of capability/condition.

Planning and Implementation:

  After 4 hours of nursing interention, the patient will able to breathe normally and can
provide rest.
Evaluation:
 At the end of the shift nurse, patient will able to rest in appropriate. Patient breathe
normally. Patient also verbalize understanding of therapeutic interventions such as
oxygenation and ventilation.

Critical Thinking in the Nursing Process

1. What is the pathophysiological basis for Ms. Rainwater’s increased respiratory rate,
blood pressure, and pulse?
The pathophysiological basis for the patient’s increased respiratory rate, blood pressure
and pulse is respiratory distress. Respiratory failure happens when the capillaries, or tiny blood
vessels, surrounding your air sacs can't properly exchange carbon dioxide for oxygen. The
condition can be acute or chronic. With acute respiratory failure, you experience immediate
symptoms from not having enough oxygen in your body.
2. Explain how elevating the head 30 degrees facilitates respirations.
Head of bed elevation (HOBE) is a commonly used therapeutic intervention in mechanically
ventilated patients associated with a reduction in the incidence of ventilator-associated
pneumonia. HOBE has also been shown to improve oxygenation and hemodynamic
performance. When the client is halfway lying and halfway sitting in this position, gravity will
push the secretion from the lungs down to the bottom of the lung tissue allowing the client to
breathe more easily because he/she is only using the top half of the lungs. However, sitting or
partially lying down in this position also harms the patients’ lungs ability to function. This is
particularly true for the lower half of the lungs as secretion accumulates and fills the alveolar
sacs. In time, this can limit the expansion of the lungs making it harder for the patient to breathe.

3. Suppose Ms. Rainwater says “I would really like to have all my fluids at once instead of
spreading them out.” How would you reply, and why?
I would say that “Miss, if you want that to happen your case may worsen but on the
other hand if you will follow all the things that we will instruct you to do such as urinating and
excreting your body wastes that will help improve your health and wellness and will lead to
your fast recovery”

4. Outline a plan for teaching Ms. Rainwater about diuretics. (Use this format)
Nursing Diagnosis
Planning
 Maintain electrolytes levels within normal limits and normal fluid balance
 during drug therapy.
 Immediately report symptoms of hyperkalemia or hypokalemia and hypersensitivity.
Intervention:
 Monitor vital sign specially the blood pressure.
 Observe for sign of Hypersensitivity reactions.
 Observe for changes in level of consciousness, dizziness, fatigue and postural
hypotension.
Rationale :
 Reduction in blood volume due to diuretics therapy may produce changes in level of
consciousness.
 Allergies response may be life threatening.
 Diuretics reduce blood volume, resulting in lowered blood pressure.

Evaluation:
After the nursing interventions, the patient maintained fluid balance and normal electrolytes
levels.

5. Discuss the possible home care management for Ms. Rainwater.

Drink more fluids and electrolytes to prevent dehydration and to increase urine output
Ensure proper positioning to prevent respiratory distress.
6. Explain the fluid restriction guidelines in patient with fluid excess.
If a patient needs to change the liquids that they are taking in, their healthcare provider will let
them know. Their healthcare provider will also tell them the reason for the Fluid Restriction and
how much liquid they can drink per day. Since water is essential for all body functions, there is a
delicate balance to maintain enough hydration.It is important to work with your healthcare
provider.

7. Discuss the importance of diagnostic test and medical management in this particular
type
of client.
 Diagnostic tests are essential at every step. The diagnostic process is a complex, collaborative
activity that involves clinical reasoning and information gathering to determine a patient’s health
probleem. It contribute sto the protection of consumer health, and help to limit healthcare
spending by finding potential problems sooner.