Mary Reese

Nursing 217

Med/Surg Nursing Diagnosis

Jan 2016

Fluid volume excess r/t impaired kidney function

AEB +1 pitting edema, SOBE, I>O, &

Long Term Goal

Pt will be normovolemic

Outcome Criteria
Pt will show no pitting edema within
48 hrs.

Pts intake will be +/- 200 ml of

output within 48 hrs.

Rationale

Evaluation

Independent Intervention
Assess peripheral edema q 4h.

Interventions

The pt is a 48 y.o. female admitted with increasing

SOB and peripheral edema over the last five
months. She has a history of uncontrolled DM,
HTN, obesity, smoking, and has been diagnosed
with CKD stage 3. Due to her risk factors
(uncontrolled DM, HTN, obesity & smoking), the
microvasculature of her kidneys has been
damaged, impairing their ability to make urine. If
the body cannot make urine, then fluid
accumulates in the vascular space and eventually
spills over into the interstitial spaces, causing
edema. Therefore, assess edema as a means to
monitor for FVE. Edema may be seen in the
extremities, the sacrum, the abdomen and the periorbital area, and is classified as pitting or nonpitting.

Unmet
Pt has +1 pitting
edema in the lower
extremities, bil. As
diuretic therapy is
continued for this pt,
the pitting edema
should resolve.
Continue to monitor.

Independent Intervention
Monitor I&O q4h.

The pt is a 48 y.o. female admitted with increasing

SOB and peripheral edema over the last five
months. She has a history of uncontrolled DM,
HTN, obesity, smoking, and has been diagnosed
with CKD stage 3. Due to her risk factors
(uncontrolled DM, HTN, obesity & smoking), the
microvasculature of her kidneys has been
damaged, impairing their ability to make urine. If
the body cannot make urine, then urine output will
decrease, fluid will accumulate in the vascular
space and eventually, FVE occurs. Therefore,
monitor urine output as a means to watch for
developing FVE. Intake should be within 200 ml of
urine output.

Unmet
Reinforce with the pt
that the MD ordered
urine to be collected
& that it is needed to
monitor kidney
status. If pt continues
to be noncompliant,
provide a bedside
commode.


Outcome Criteria
Pts weight will not increase by
more than 2# in 2 days.

Pts lung sounds will be clear in all

fields within 48 hrs.

Interventions
Independent Intervention
Monitor daily weight.

Independent Intervention
Assess LS q4h.

Rationale

Evaluation

The pt is a 48 y.o. female admitted with increasing

SOB and peripheral edema over the last five
months. She has a history of uncontrolled DM,
HTN, obesity, smoking, and has been diagnosed
with CKD stage 3. Due to her risk factors
(uncontrolled DM, HTN, obesity & smoking), the
microvasculature of her kidneys has been
damaged, impairing their ability to make urine. If
the body cannot make urine, then urine output will
decrease, fluid will accumulate in the vascular
space, and FVE occurs. As FVE progresses,
overall body weight will increase since the body is
unable to adequately eliminate fluids through
diuresis. Therefore, assessing a daily weight is a
way to assess FVE. An increase of 2# or more in
2 days should be reported to the MD.

Unmet
Assessing daily
weight has not been
ordered for this pt,
but can be done
without an order, so
this should be
implemented right
away. However, to
ensure that the pts
wt is assessed each
day, collaborate with
the MD to add daily
weight to the active
orders.

The pt is a 48 y.o. female admitted with increasing

SOB and peripheral edema over the last five
months. She has a history of uncontrolled DM,
HTN, obesity, smoking, and has been diagnosed
with CKD stage 3. Due to her risk factors
(uncontrolled DM, HTN, obesity & smoking), the
microvasculature of her kidneys has been
damaged, impairing their ability to make urine. If
the body cannot make urine, then urine output will
decrease and fluid will accumulate in the vascular
space, causing FVE. The excess fluid will
eventually spill over into the interstitial space,
including that of the abdomen and into the alveoli,
causing adventitious lung sounds. Therefore,
assessing lung sounds is a way to monitor for FVE.

Partially met
Pts L lung is clear in
all fields; there are
rales in the R lower
lobe. As diuretic
therapy is continued,
the pts fluid volume
will decrease and
fluid in the alveoli will
resolve. Continue to
monitor.


Pts LS will be clear within 48 hrs.
K level will be > 3.5 and < 5.0 at all
times. SBP will be 90 and 130
mm Hg at all times.

K will be >3.5 and <5.0 within 48

hrs.

Bibliography

Dependent Intervention
Administer Lasix 40 mg IVP bid.

Dependent Intervention
Monitor K+ daily.

The pt is a 48 y.o. female admitted with increasing

SOB and peripheral edema over the last five
months. She has a history of uncontrolled DM,
HTN, obesity, smoking, and has been diagnosed
with CKD stage 3. Due to her risk factors
(uncontrolled DM, HTN, obesity & smoking), the
microvasculature of her kidneys has been
damaged, impairing their ability to make urine. If
the body cannot make urine, urine output
decreases and fluid accumulates in the vascular
space, causing FVE and eventually spills over into
the interstitial spaces, causing edema. Diuretics
such as Lasix are used to promote diuresis, which
in turn alleviates edema, decreases volume in the
vascular space, normalizes fluid volume and
decreases blood pressure. Since Lasix is a loop
diuretic, K+ will also be excreted, so the K+ level
needs to be monitored to ensure it is within
parameters, as K+ is necessary for muscle
contractions, including that of the heart.

Partially Met
Pts L lung is clear in
all fields; there are
rales in the R lower
lobe. As diuretic
therapy is continued,
the pts fluid volume
will decrease and
fluid in the alveoli will
resolve. On admit,
the pts K+ level was
not within
parameters, but after
24 hrs on the
prescribed diuretics,
the K+ level is now
4.8. Pts BP =
128/80. Continue to
monitor.

The pt is a 48 y.o. female admitted with increasing

SOB and peripheral edema over the last five
months. She has a history of uncontrolled DM,
HTN, obesity, smoking, and has been diagnosed
with CKD stage 3. Pts with CKD often have
hyperkalemia resulting from the kidneys being
unable to effectively filter the blood and excrete K+
in the urine. While CKD pts are prescribed
diuretics to decrease fluid volume and control
blood pressure, diuretics are also used to promote
excretion of K+ in the urine and bring K+ levels
within parameters. However, since K+ is important
in muscle contractions, including those of the
heart, it is important to tightly maintain K+ within
normal parameters to prevent dysrhythmias.

Met
After 24 hrs on
diuretic therapy this
pts K+ = 4.8.

Lewis, Dirksen, Heitkemper, & Bucher. (2014). Medical-Surgical Nursing. St. Louis, Missouri: Elsevier, 1107-1114.