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Excess Fluid Volume

The patient was experiencing excess fluid volume related to decreased plasma protein from proteinuria. Nursing interventions included measuring intake and output to monitor fluid balance, weighing the patient daily, monitoring vital signs and edema. After 8 hours, the patient's vital signs were normal and intake/output was almost equal. However, after 3 days some edema remained, indicating the fluid excess was still resolving.

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403 views2 pages

Excess Fluid Volume

The patient was experiencing excess fluid volume related to decreased plasma protein from proteinuria. Nursing interventions included measuring intake and output to monitor fluid balance, weighing the patient daily, monitoring vital signs and edema. After 8 hours, the patient's vital signs were normal and intake/output was almost equal. However, after 3 days some edema remained, indicating the fluid excess was still resolving.

Uploaded by

yudd
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Nursing Evaluation

Nursing Interventions
Rationale
diagnosis
Excess Fluid Measured I&O, noting Reflects circulating After 8 hours of nursing
Volume related to positive balance— volume status, interventions, the
decreased plasma
intake in excess of developing or resolving patients vital signs
protein secondary
to proteinuria output. Weigh daily, fluid shifts, and
remained within normal
and note gain more response to therapy.
range and I&O is
than 0.5 kg/day. Positive fluid balance
almost equal in
and weight gain often
  quantity.
reflects continuing fluid
Objective:    Monitored Blood
. retention.  
Pressure.
   Peripheral  edema   BP elevations are :
 
(Grade 2 pitting usually associated with
After 3 days of nursing
edema on both upper fluid volume excess but
interventions, Grade 2
may not occur because
and lower    Assessed
pitting edema is still
of fluid shifts out of the
extremities) respiratory status,
vascular space. present on upper
noting increased
   Proteinuria: +1 extremities, but on
respiratory rate and   Indicative of
lower extremities, only
   Decreased dyspnea. pulmonary congestion
the right foot was noted
Hgb/Hct or edema.
   Provided frequent
to have grade 1 pitting
   BP- 140/70mmHG mouth care and   Decreases sensation
edema.
occasional ice chips. of thirst, especially
 
because fluid intake
   Assessed degree of
restricted and on NPO.
peripheral and
dependent edema.   Fluids shift into

  tissues as a result of
sodium and water
retention, decreased
albumin, and increased
antidiuretic hormone
(ADH).
Faculty of nursing and health Science
MEDICAL SURGICAL 334\335
Care plan

subject:care plan of Edema

.Prepared by:saja fareed ayyash

.Presented to:Hala Kasbari


.Student No:1202190

.Semester:Spring 2014

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