Question

27th PN 200 Fundamentals of Nursing II Concept Map: Hypovolemia/ Deficient Fluid Volume Charles West, a 70 y/o man was brought to the Emergency Department at 4:30 AM by his wife. She told the emergency room triage nurse that he has a lot of "dark red" diarrhea for the past 3 days and last night. When he became very dizzy, disoriented and weak this morning, she decided to bring him to the hospital. Mr. West's vital signs were B/P 70/- (diastolic blood pressure inaudible) Pulse 110 weak and easily obliterated, and respirations 24. A 16-gauge IV catheter was inserted and Lactated Ringer's infusion at 125 m/L per hour was started. . Two years ago he experienced a cardiac arrest that was attributed to hypokalemia. He also has a long history of hypertension and arthritis. Fifteen years ago he was diagnosed with a peptic ulcer. An endoscopy showed a 25mmX15mm duodenal ulcer with adherent clot. The ulcer was cauterized and Mr. West was admitted to the Medical intensive care unit for treatment of his volume deficit. You are the admitting nurse. As you are making him comfortable, Mrs. West gives you a paper bag filled with the bottles of the medications Mr. West has been taking. Vasotee 5mgm po bid Coumadin 5mgm po qd Digoxin 0.125 mg po qd KCL 20 mEq po bid Tolimentin 400mgm po tid (non-steroid NSAID) Doing a quick assessment, you find a pale man who is sleepy but arousable and oriented. He is still dizzy, hypertensive and tachycardia. You hear S3 and S 4 heart sounds. Peripheral pulses are present and trace pedal edema is present. Lung sounds are clear. Bowel sounds are present, gastric tenderness is noted and the liver margin is 4cm below the costal margin. Mr. West receives a total of 4 units of PRBC's, 5 units of FFP (fresh frozen plasma) and many units of crystalloid solution to keep his systolic B/P above 90mmHg. As soon as you get a chance, you look at Mr. West's' admission lab results: 90mg/dl 2.1 8.4 BUN Creatinine Hgb Het WBC PT INR 25% 16,000 23.4 4.2 1/20.

disreguard the hypovolemia please it was posted by mistake

Answer 1

Hypervolemia

nursing diagnosis

1. Risk for impaired skin integrity related to fluid retention and edema

interventions

• Assess skin integrity of the patient especially at bony prominences and grading of edematous ankles and feet
• Keep patients lower limbs lifted by keeping pillow underneath
• Turn the patient every 2 hrly
• provide back care
• avoid vigorous massaging of bony prominences

positive outcome

• patient will have intact skin integrity

negative outcome

• patient will have broken skin integrity

evaluation

patient’s skin and mucous membranes are intact. edema of the patient’s feet and ankle is resolved

2. Risk for impaired gas exchange related to pulmonary congestion

interventions:

• assess patient respiratory system for shortness of breath and crackles
• prop up the patient
• restrict fluid intake as per order

positive outcome

• patient will have normal breathing pattern

negative outcome

• patient will have worsened breathing pattern

evaluation

patient’s respiratory rate is within normal limit and there is no abnormal breath sound.