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) prioritynursing diagnoses for the patient and create a
hypothetical FDAR.
2. What laboratory test may give the hint to the doctor about the oncotic
pressure of the patient?
3. Create a drug study for FUROSEMIDE specifying the following:
1. Drug classification
2. Mechanism ofaction
3. Indication (*for the case of the patient mentioned above)
4. Contraindication
5. Side effects
6. Nursing Considerations

1.
FOCUS DATA ACTION RESPONSE

Ineffective airway HR- 111 bpm Instruct the patient to After nursing
clearance RR- 24 cpm slowly breathe intervention, the
patient was able to
Educate the patient maintain the RR of 20
to do pursed lip bpm
breathing method

Administer oxygen
(as ordered)
 Hypertension BP- 120/90 mmHG Assess VS every 30
mins

Provide calm
environment

Instruct patient on a
diet requirements

Instruct to patient
maintain a healthy
lifestyle

Fluid volume excess +2 bipedal edema Monitor clients weight After intervention, the
daily and the clients patient was able to
response during report absence of
diuretics edema

If prescribed, apple
ointment/cream

2.Advanced renal insufficiency can be detected with serum creatinine, and plasma
oncotic pressure can be roughly estimated with serum albumin.

DRUG ACTION INDICATI CONTR ADVERS NURSIN

ON AINDIC E G
ATION EFFECT INDICATI
ON
Furosemide Furosemide is Furosemi Contrain -dizziness -assess
ananthranilic de is dicated -headach pt fluid
Generic acid derivative indicatedi with e status
and a Potent
Name: diuretic. It n adults hyperse -fatigue
Lasix mainly inhibits patients nsitivity -pain -monitor
the reabsorpt for the and -hyperglyc daily
Classificatio ion of Na treatment anuria emia weight,
n: and chloride in of edema I&O,
Diuretics the ascending amount
loop of Henle
and in both
and
Dosage: the proximal location
20mg and the distal of
renal tubules. edema.
Frequency: Italso
8 hours interferes with -monitor
the bp and
chloride-bindin
Route: g cotransport pulse
TIV system, before
thereby and after
causing its administr
natriuretic ation
effect

2. HYPOVOLEMIA
A teenage patient was rushed to the emergency department due to wrist
laceration from a suicide attempt. The patient is lethargic and have the following
findings upon assessment:BP –80/50 mm HgHR –110 bpmRR –25 bpmThe
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?

▪ Fluid administration is beneficial only if it increases the stroke volume (SV) and
thereby, the cardiac output. Patients are considered fluid responsive if SV
increases by at least 10% after a fluid challenge of 500mL of crystalloid. Pulse
pressure variation, passive leg raising test, and SV variation are some reliable
markers for fluid responsiveness. In patients with massive blood loss, permissive
hypotension prevents progression to dilutional coagulopathy of trauma . In
severe and uncontrolled hemorrhagic shock, controlled resuscitation (MAP of 40
mmHg) is preferred. Two strategies were proposed to avoid clot disruption and
dilutional coagulopathy:delayed resuscitation strategy where fluid is given after
bleeding is controlled and permissive hypotension strategy, where fluid is given to
increase SBP without reaching norm tension. In penetrating trauma patients with
hypotension (prehospital SBP < 90 mmHg), delayed resuscitation shows better
survival rates compared to immediate resuscitation. Increased mortality is seen
with increased in-field procedures, supporting “scoop and run” and delayed fluid
resuscitation techniques. However, when PTT is long, simple life support
measures reduce mortality in severely injured patients even when conducted in
suburban and remote locations with long PTT.

2. For a patient who will undergo blood transfusion, enumerate the steps
that the nurse should prudently undertake while performing the procedure.

*Requesting blood, clearly indicating the reason for transfusion and

communicating the degree of urgency to the Blood Transfusion Laboratory.
*Providing full information on transfusion requests.
*Explaining to patients the risks, benefits and possible alternatives to blood
transfusion and providing written information where appropriate.
*Requesting collection of blood including arranging urgent transportation if
required.
*Obtaining red cells for transfusion via the electronic remote issue system,
ensuring that the right blood unit is correctly labeled for the intended patient and
that blood for only one patient is collected at each visit.
*Carrying out pre transfusion checks to ensure the right blood is transfused.
*Monitoring the patient during transfusion.Inclusion of medical staff in the
management of the patient if a transfusion reaction should occur.
*Reporting of transfusion reactions or other incidents to the Blood Transfusion
Laboratory.
*Documentation of indications for transfusion, number of units administered and
observations recorded in patients’ medical records.

3. List down three (3) priority nursing diagnoses for the patient and create a
hypothetical FDAR.
FOCUS DATA ACTION RESPONSE
Lethargic -Blood loss Provide a quiet After nursing
cause of wrist environment and intervention the
laceration from a cool room. patient was able
suicide attempt to perform
Teach strategies physical
for energy activities.
conservation.

Encourage pt to
participate in
physical therapy.
Tachypnea RR - 25 bpm Monitor vs every After nursing
2 hours. intervention
patient was able
Position client to to maintain
high fowler's normal range of
position. respiratory rate

Administer
oxygen as
ordered.

Observing
respiratory
status frequently.

Encourage
opportunities for
 rest and limit
physical
activities.
Hypotension BP- 80/50 Monitor vs After nursing
mmHg intervention
Teach the cause patient maintain
of fluid loss normal blood
pressure.
Elevate pt’s
lower extremities

3.THIRD SPACE EDEMA

A patient with portal hypertension secondary to chronic liver cirrhosis was admitted in
the surgical ward. The patient presented with emaciated body build, distended abdomen
with prominent veins, and jaundice. The doctor ordered paracentesis and the following
laboratory tests prior the procedure: Prothrombin time (PT), Activated Partial
Thromboplastin Time (APTT), Total Protein, Albumin-Globulin ratio, AST, ALT.
1. List down two (2) nursing diagnoses and create a hypothetical FDAR for the
patient.
2. Why is there a need to check the PT and APTT levels of the patient prior
paracentesis?
3. What is the rationale behind the order of checking the Total Protein,
Albumin-Globulin ratio?
4. Enumerate the following regarding the nursing role in assisting with
paracentesis:
● Position of choice
● Site of insertion
● At least three (3) nursing considerations.