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ati book:Fluid imbalances Ch.57

Terms in this set (48)

Fluid volume excess (FVE) is the isotonic retention
of water and sodium in high proportions.
● FVE is often referred to as hypervolemia because
of the resulting increased blood volume.
● Severe FVE can lead to pulmonary edema and heart failure.
Assessment findings
● Vital signs: Tachycardia, bounding pulse, hypertension,
tachypnea, increased central venous pressure
● Neuromusculoskeletal: Confusion, muscle weakness
● GI: Weight gain, ascites
● Respiratory: Dyspnea, orthopnea, crackles
● Other findings: Edema, distended neck veins
Laboratory findings
● Decreased Hct
● Serum sodium within the expected reference range
● Decreased Electrolytes
● Decreased BUN, and creatinine
● Arterial blood gases
● Respiratory alkalosis: decreased PaCO2 (less than
35 mm Hg), increased pH (greater than 7.45)
● Urine specific gravity less than 1.010
● Observe respiratory rate, symmetry, and effort.
● Auscultate breath sounds in all lung fields. Lung
sounds can be diminished with crackles.
● Monitor for shortness of breath and dyspnea.
● Check ABGs, SaO2, CBC, and chest x‑ray results.
● Position the client in semi‑Fowler's position.
● Measure the client's weight daily at same
time of day using the same scale.
● Monitor and document edema (pretibial, sacral, periorbital).
● Monitor I&O.
● Implement prescribed restrictions for fluid and sodium intake.
● Provide fluids in a small glass to promote the
perception of a full glass of fluid.
● Set 1‑ to 2‑hr short‑term goals for the fluid restriction
to promote client control and understanding.
● Administer supplemental oxygen as needed. Reduce IV flow rates.
● Administer diuretics (osmotic, loop) as prescribed.
● Monitor and document circulation to the extremities.
● Reposition the client at least every 2 hr.
● Support arms and legs to decrease dependent edema.