Question

George, 88 years old, is suffering from congestive heart failure. He was admitted to the hospital with a diagnosis of extracellular fluid volume excess. He was frightened and slightly confused and dyspneic on exertion.

1. what symptoms does the nurse expected to find when performing the assessment on this patient?
2. what manifestation of extracellular fluid volume excess does the nurse anticipate finding?
3. When developing a plan of care for the patient, which interventions should the nurse include?

Answer 1

-The Symptoms the nurse expected to find when performing the assessment on this patient are-

Pain areas: in the chest

Cough: can be dry or with phlegm

Respiratory: fast breathing, shortness of breath at night, shortness of breath on exercise, or shortness of breath on lying down

Gastrointestinal: water retention or bloating

Also common: excess urination at night, palpitations, swollen feet, swollen legs, or weight gain.

-Manifestation Of Extracellular Fluid Volume Excess the nurse anicipate Finding is -

• Palpitations
• Congestive cardiac failure
• Swollen legs
• Shortness of Breath
• Swollen body

-The plan of Care for the patient and the Nursing Intervention the nurse should include is -

Nursing Interventions	Rationale
Nursing Assessment
Note heart sounds.	S1 and S2 may be weak because of diminished pumping action. Gallop rhythms are common (S3and S4), produced as blood flows into noncompliant chambers.
Palpate peripheral pulses.	Decreased cardiac output may be reflected in diminished radial, popliteal, dorsalis pedis, and post tibial pulses.
Monitor BP.	In early, moderate, or chronic HF, BP may be elevated because of increased SVR. In advanced HF, the body may no longer be able to compensate, and profound hypotension may occur.
Inspect skin for pallor, cyanosis.	Pallor is indicative of diminished peripheral perfusion secondary to inadequate cardiac output. Cyanosis may develop in refractory HF. Dependent areas are often blue or mottled as venous congestion increases.
Monitor urine output, noting decreasing output and concentrated urine.	Kidneys respond to reduced cardiac output by retaining water and sodium. Urine output is usually decreased during the day because of fluid shifts into tissues but may be increased at night because fluid returns to circulation when patient is recumbent.
Note changes in sensorium: lethargy, confusion, disorientation, anxiety, and depression.	May indicate inadequate cerebral perfusion secondary to decreased cardiac output.
Assess for abnormal heart and lung sounds.	Allows detection of left-sided heart failure that may occur with chronic renal failure patients due to fluid volume excess as the diseased kidneys are unable to excrete water.
Assess mental status and level of consciousness.	The accumulation of waste products in the bloodstream impairs oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness.
Monitor results of laboratory and diagnostic tests.	Results of the test provide clues to the status of the disease and response to treatments.
Monitor oxygen saturation and ABGs.	Provides information regarding the heart’s ability to perfuse distal tissues with oxygenated blood
Therapeutic Interventions
Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs.	Makes more oxygen available for gas exchange, assisting to alleviate signs of hypoxia and subsequent activity intolerance.
Implement strategies to treat fluid and electrolyte imbalances.	Decreases the risk for development of cardiac output due to imbalances.
Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for toxicity.	Digitalis has a positive isotropic effect on the myocardium that strengthens contractility, thus improving cardiac output.
Encourage periods of rest and assist with all activities.	Reduces cardiac workload and minimizes myocardial oxygen consumption.
Assist the patient in assuming a high Fowler’s position.	Allows for better chest expansion, thereby improving pulmonary capacity.
Teach patient the pathophysiology of disease, medications	Provides the patient with needed information for management of disease and for compliance.
Reposition patient every 2 hours	To prevent occurrence of bed sores
Elevate legs, avoiding pressure under knee. Encourage active and passive exercises. Increase activity as tolerated.	Decreases venous stasis, and may reduce incidence of thrombus or embolus formation