fluid balance- HESI case study
The nurse plans to assess Clara for orthostatic vital sign changes. What action will the nurse take first?
Position Clara in a supine position
Orthostatic vital signs are measured in three different positions: lying sitting and standing. So placing pt in supine position should be first
The nurse takes the first blood pressure measurement. After recording the first blood pressure measurement, what action will the nurse take?
Count the client’s radial pulse rate
Both the BP and pulse rate are typically measured in each position lying, sitting and standing
Since Clara has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when Clara moves from a lying to a standing position?
Blood pressure. Fluid volume deficit often occurs with orthostatic hypotension and tachycardia. Because the client may experience diziness with orthostatic hypotension the nurse should take additional safety precautions
In addition to obtaining Clara’s vital signs, the nurse performs additional assessments. For ongoing evaluation of Clara’s fluid volume status, it is most important to obtain which assessment data?
Daily weights provide the most important dataabout fluid volume status
The nurse continues to assess the client and observes that Clara’s skin tents when a fold of skin over her sternum is pinched. What action should the nurse implement?
Document the presence of inelastic skin turgor
Skin turgor is best assessed in the elderly by gently pinching a fold of skin over the sternum.
Clara’s daughter reports that her mother usually weighs about 150 lbs. and is 5 feet, 4 inches in height. The nurse weighs Clara and obtains a measurement of 65 kg. The nurse explains to Clara’s daughter that Clara has lost approximately how many pounds?
7= 65 kg 2×2 = 143. 150 lbs.-143= 7lbs
The nurse then explains that Clara’s weight loss represents approximately how many liters of fluid loss?
3 (1 kg is equivalent to 1 L)
The nurse discusses factors that contributed to Clara’s fluid volume deficit with Clara and her daughter. Which problem often occurs in the elderly and may have contributed to the fluid volume deficit Clara is experiencing?
Decreased hepatic blood flow
decreased hepatic flow commonly occurs in the elderly. This decreases drug metabolism, which allows drugs to remain in the body longer and produces a greater drug effect
The nurse is aware that the elderly often experience an increase in the amount of free, unbound drug molecules, which has the potential to increase the pharmacological effects of the drug. Which lab test will the nurse monitor to determine if this may be a factor contributing to Clara’s problem?
serum protein= drug molecules may be distributed through the body bound to plasma protein molecules. A decrease in serum protein levels is an indication that there may be an increase in free, unbound drug molecules in the bloodstream
The nurse starts an intravenous line to administer fluids. The prescription states, “3% Normal Saline to infuse at 100 ml/hour.” The client’s most recent serum sodium level is 135 mEq/L. What action should the nurse take?
Consult with the healthcare provider about the prescription. (Normal Sodium levels 136-145 mEq/L; 3% sodium chloride has a hypertonic concentration; normal saline is 0.9% sodium chloride)
3% saline is a hypertonic solution which can pull fluid from the interstitial and intracellular spaces into the bloodstream. It is usually prescribed for severe hyponatremia( sodium<115 mEq/L) Since Clara is already expereiencing a fluid deficit, the IV solution could worsen her condition. The nurse should consult with the healthcare provider about this presciption.
A short while later, a prescription for 0.9% Normal Saline at 100 ml/hour is received. Clara’s primary nurse is at lunch, so another nurse hangs the solution. When checking Clara upon returning from lunch, the primary nurse observes that a solution of 5% Dextrose and 0.9% Normal Saline is infusing at 125 ml/hour. What action should the primary nurse implement?
Change the currently infusing solution to 0.9% Normal Saline and change the rate to 100 ml/hour. Two errors have occured the wrong solution and the wrong rate of administration. These errors shold both be corrected
After hanging the correct IV solution at the correct rate of infusion, the nurse discusses the error with the nurse who hung the first IV solution. Together, the nurses complete a variance (incident) report. What additional action should the primary nurse take?
Notify the healthcare provider of the error in treatment that occurred. Since the prescription was not initially followed, the healthcare provider should be notified in case a change in treatment plan is warranted
The nurse who made the errors is very upset about writing a variance (incident) report and states, “I’ve never made an error before. What if I get fired?” How should the primary nurse respond?
“Variance reports are used to find ways to prevent further errors.” Variance reports are used by the risk management department of healthcare agencies to look for patterns that contribute to errors so that preventative measures can be institututed
Later that day, Clara’s IV pump alarm sounds. The nurse notes that the IV is not infusing in the right antecubital area, and the alarm indicates an obstruction is present. The nurse determines that all the clamps are open and there are no kinks in the tubing. What intervention should the nurse take next?
Straighten the joint above the site. Obstruction is often cause by the client’s movement resulting in a bend in the client’s proximal joint. Therefore, this non invasive procedure should be the next action taken by the nurse
The nurse resolves the obstruction, and the IV solution begins to infuse. The next day the nurse observes that the IV insertion site is inflamed and tender. The label on the IV site indicates the current IV has been in place for 36 hours. What action should the nurse take?
Remove the IV and restart it in a different location. The client is experiencing PHLEBITIS, which can lead to further complications if left untreated. Since the nurse has the responsibility to take action when IV site complications occur, the IV should be discontinued, action should be taken for the inflammation according to agency policy, and a new IV should be started at a different site
The nurse used the nursing process in deciding to remove Clara’s IV and restart it in a new location. When assessing the IV site, what step of the nursing process did the nurse use?
Analyze the data. The nurse analyzes the assessment data to determine if characteristics occur that define a problem. A problem is then stated, a goal is established and interventions are planned and implemented.
Which problem did the nurse identify as most pertinent in that situation?
Risk for injury (thrombus formation). Phlebitis is an inflammatory problem. The phlebitis at the IV site places Clara at high risk for thrombus formation. So, the nurse identified this problem, established the goal that the risk for injury will be reduced, and implemented the interventions of removing the IV and providing care at the site of inflammation.
Clara continues to receive 0.9% Normal Saline at a rate of 100 ml/hour. She is stronger and has started taking oral food and fluids well. She receives a regular no-added-salt diet. Her breakfast includes one cup of scrambled eggs, one bowl of oatmeal, a fresh orange, and a carton of milk. In addition to the milk, which item should be measured as fluid intake?
Only the milk. Oral fluid intake includes only foods that are LIQUID AT ROOM TEMPERATURE!
Oral fluid intake includes only foods that are liquid at room temperature. When Clara was first admitted, the healthcare provider did not include intake and output measurement in the initial prescriptions, but the primary nurse initiated this assessment activity.
Continue the measurement of the client’s fluid intake and output. Since Clara is till receiving a significant amount of volume of IV fluid, she remains at risk for fluid volume alterations. Tee nurse may initiate and maintain intake and output measurement without a prescription for the healthcare provider
Clara’s intake and output measurements indicate her intake is greater than her output. The nurse is concerned that Clara may develop fluid volume excess. Which assessment is important for the nurse to perform?
Auscultate the client’s breath sounds. Fluid volume excess often causes abnormal breath sounds. Fluid collection in the lungs can impair oxygen exchange and result in hypoxemia.
The nurse also observes that Clara’s feet and ankles are swollen. When the nurse presses a finger over the client’s ankle (bony prominence), a 4 mm indentation appears. How will the nurse document this finding?
2+ pitting edema present around ankles and feet. This documentation concisely describes the degree of indentation and its location
Clara has abnormal breath sounds, bilateral pitting edema, and jugular vein distention. Which change in Clara’s pulse will the nurse anticipate?
Increase in rate and volume. As fluid volume increases to tyhe point of fluid volume excess, the client will develop tachycardia and a 3+ bounding pulse
Further findings include oxygen saturation level of 90%, serum sodium of 140 mEq/L, and serum potassium of 3 mEq/L. The nurse reports the findings to the healthcare provider and receives several prescriptions.Which prescription should the nurse question?
Potassium chloride 40 mEq IV push now. Clara’s potassium is low. She needs potassium replacement but potassium chloride should never be administered IV push. A prescription for potassium chloride diluted in an IV solution to be administered over several hours should be obtained from the healthcare provider.
It is important for the nurse to monitor what lab value
Serum Potassium may cause a significant hypokalemia. Use of hydrochlorothiazide may also result ina decrease in serum magnesium and sodium and an increase in serum calcium and glucose
Before Clara’s discharge, the nurse provides client teaching related to the prescribed hydrochlorothiazide (HydroDIURIL). Clara’s fluid volume excess improves and the prescription for hydrochlorothiazide (HydroDIURIL) 12.5 mg PO daily is restarted. The nurse will emphasize the importance of taking this medication only once a day, on what schedule?
With breakfast to reduce the likelihood of nocturia, the client should take diuretic in the morning. Take it with food to reduce adverse SE like nausea
Since Clara is receiving a diuretic that contributes to the loss of potassium, the nurse must provide dietary teaching. Which food(s) selected by the client indicate an understanding of potassium-rich foods? (Select all that apply.)
baked potato, grapefruit, chicken breast. :
Dark Leafy Greens (Spinach)
Baked Potatoes (With Skin)
Baked Acorn Squash
Yogurt (Plain, Skim/Non-Fat)
In preparing to administer the hydrochlorothiazide, the nurse notes that the prescribed dose is 12.5 mg, and the tablet available is 25 mg. What action should the nurse take?
Observe the tablet to see if it is scored. A scored tablet can safely be divided so the the client may receive the prescribed does.
Upon entering Clara’s room with the medication, the nurse checks Clara’s identification band. Clara states, “You take care of me every day. Why do you keep looking at my identification?” What is the best response by the nurse?
“This is a double-check to ensure that no errors occur.” The response provides the best client teaching. The client can participate in the plan of acre more actively if explanations for interventions are provided