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course task week 7 fluid imbalances

Nursing (Our Lady of Fatima University)

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1. HYPERVOLEMIA

A patient was admitted in the medical ward with chief complaints of shortness of breath. Further
assessment reveals the following findings:

• BP –140/90 mm Hg

• HR –111 bpm

• RR –24 cpm

• +2 bipedal edema

• Bibasilar crackles upon auscultation

The doctor initially ordered furosemide 20 mg ampule TIV every 8 hours and the following laboratory
tests: Complete Blood Count (CBC), Serum Sodium, Serum Potassium, Blood Urea Nitrogen, Serum
Creatinine, Total Protein, and Chest X-ray.

1. Write down three (3) priority nursing diagnoses for the patient and create a hypothetical
FDAR.

FOCUS DATA ACTION RESPONSE

• Patient was able to
exercise the deep
• Shortness breathing and
• Encourage deep
of breath coughing technique
breathing and
and was relieved
Ineffective Airway • RR of 24 coughing exercises.
from having
Clearance cpm • Maintain semi-
shortness of breath
• HR of 111 Fowler’s position
• Patient was able to
bpm • Monitor HR and RR
maintain a normal
RR of 18cpm and HR
of 90bpm
• Patient has clear
• Weigh client daily. lung sounds as
• Bibasilar
Observe for sudden manifested by the
crackles
weight gain. absence of
upon • Auscultate lung and pulmonary
Excess Fluid Volume auscultation heart sounds crackles.
• +2 bipedal • Elevate edematous • Patient has
edema extremities, and balanced intake and
handle with care output and stable
weight and an
absence of
edema
• BP of • Patient was able to
Hypertension 140/90 • Monitor BP maintain a normal
mmHg BP

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2. What laboratory test may give the hint to the doctor about the oncotic pressure of the
patient?

➢ The serum creatinine provides a sufficient screen for advanced renal insufficiency, and
the serum albumin permits a useful approximation of the plasma oncotic pressure.

3. Create a drug study for FUROSEMIDE specifying the following:

1. Drug classification

2. Mechanism of action

3. Indication (*for the case of the patient mentioned above)

4. Contraindication

5. Side effects

6. Nursing Considerations

MECHANISM
DRUG INDICATION CONTRAINDICATION SIDE EFFECTS NURSING CONSIDERATIONS
OF ACTION
Indicated in
Furosemide
adults for
works by
blocking the the
absorption of treatment
sodium, of edema
chloride, and associated
water from with • Increased
Furosemide congestive urination
the filtered
fluid in the heart • Dehydration • Assess
Generic • Muscle patient fluid
kidney failure, Lasix is
Name: Lasix cramps intake
tubules, cirrhosis of contraindicated in
causing a the liver, patients with • Itching or • Monitor daily
Drug
profound and renal anuria and in rash weight, I & O
Classification:
increase in the disease, patients with • Weakness • Monitor VS
Diuretics
output of including a • Dizziness before and
the history of • Diarrhea after
urine nephrotic hypersensitivity to • Constipatio administering
Dose: 20 mg
(diuresis). The syndrome. furosemide n the
onset of LASIX is • Spinning medication
Frequency: q
action after particularly Sensation
8 hours
oral useful
administration when an
is within one agent with
hour, and the greater
diuresis lasts diuretic
about 6-8
potential is
hours. desired.

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2. HYPOVOLEMIA

A teenage patient was rushed to the emergency department due to wrist laceration from a suicide
attempt. The patient is lethargic and has the following findings upon assessment:

• BP –80/50 mm Hg

• HR –110 bpm

• RR –25 bpm

The doctor initially ordered fluid resuscitation with PNSS 1L, to fast-drip 200 cc then the remaining fluid
to run for 6 hours. Stat blood typing was ordered, and 3 units of whole blood was ordered to be
transfused immediately after proper cross-matching. The patient was hooked to oxygen 8 liters per
minute via face mask.

1. What parameters will the nurse check while the patient is undergoing rapid fluid
resuscitation?

➢ The adequacy of fluid resuscitation is measured by clinical parameters, not simply by

following a predetermined formula calculation. The recording of vital signs is generally made
hourly but changes in a patient's condition may necessitate more frequent recordings. If a
reaction occurs, the fluids must be stopped immediately, and the reaction noted. Patients
receiving fluid infusions need to have regular checks of their blood pressure, temperature,
pulse, respiration, and mental state.

2. For a patient who will undergo a blood transfusion, enumerate the steps that the nurse should
prudently undertake while performing the procedure.
• Assess the client’s vital signs, physical examination including fluid balance and heart and
lung sounds and any unusual symptoms
• Verify doctor’s order for the number and type of units and the desired speed of
infusion. Note and schedule to administer pre-medication ordered by a physician
(usually 30 minutes prior to transfusion).
• Prepare the patient by introducing self, verifying the client’s identity, explaining the
procedure and its purpose, instructions on what to report by the client during the
procedure, providing privacy, and assisting to a comfortable position.
• If the client has an IV solution infusing, check whether the IV catheter and solution are
appropriate to administer blood.
• Perform hand hygiene and observe appropriate infection prevention procedures.
• Prepare the infusion equipment. Apply gloves and close all the clamps on the Y-set.
Spike into the saline solution and hang the container on the IV pole about 1 meter
above the venipuncture site.

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• Open the upper clamp on the saline solution tubing and squeeze the drip chamber until
it covers the filter and 1/3 of the drip chamber above the filter. Then prime the tubing
and close both clamps.
• Start the saline solution. If an IV solution incompatible with blood is infusing, stop the
infusion and discard the solution and tubing according to agency policy. Attach the
blood tubing primed with normal saline to the IV catheter. Open the saline and main
flow rate clamps and adjust the flow rate. Use only the main flow rate clamp to adjust
the rate. Allow a small amount of solution to infuse to make sure there are no problems
with the flow or with the venipuncture site.
• Obtain the correct blood component for the client. Check for
• the following:
a. Doctor’s order with the requisition

b. Requisition form and the blood bag label with a laboratory technician
(Client’s name, ID number, blood type and Rh group, blood donor number, and
expiration date) at the blood bank. Observe blood for abnormal color, RBC clumping,
gas bubbles, and extraneous material.

c. With another nurse, verify the doctor’s order, transfusion consent form, client
identification, blood unit identification, blood type, expiration date, compatibility, and
appearance.

d. If any of the information does not match exactly, notify the charge nurse and
the blood bank. Do not administer blood until discrepancies are corrected or clarified.
e. Sign the appropriate form with the other nurse according to agency policy.
f. Make sure that the blood is left at room temperature for no more than 30
minutes before starting the transfusion. Blood must be returned to the blood bank if it
has not been started.
• Prepare the blood bag. Invert the blood bag gently several times to mix the cells with
the plasma. Expose the port on the blood bag and spike the remaining Y-set into the
bag. Hang the bag on the IV pole.
• Establish the blood transfusion. Close the upper clamp below the saline solution and
open the upper clamp below the blood bag. Readjust the flow rate with the main clamp
3. List down three (3) priority nursing diagnoses for the patient and create a hypothetical FDAR.

FOCUS DATA ACTION RESPONSE

• Assess emotional and
psychological factors • The patient was able
Blood loss due to
Fatigue • Provide a quiet place to perform physical
wrist laceration
so the patient can rest activities
well.
• Patient was able to
Hypotension BP of 80/50 mmHg • Monitor BP
maintain a normal
BP
Tachypnea / • RR of 25 • Monitor HR and RR • Patient was able to
Tachycardia cpm maintain a normal RR

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• HR of 110 of 18cpm and HR of
bpm 90bpm

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