Nursing Diagnoses: Fluid Volume excess R/T decreased cardiac output aeb diminished LS, bilateral

lower leg edema Long Term Goal: Patient will restore normal fluid balance

Intervention 1. Assess lung sounds Q 4hrs

2. Measure patients weight Q shift

3. Record patients intake and output Q 2 hrs

Rationale 1. Listen to the lungs anterior and posterior for any abnormal sounds. Look for any SOB or SOBE. Edema results from excessive shifting of fluid from vascular space into the pulmonary interstitial space and alveoli, resulting in dyspnea and orthopnea. NDH p. 395 2. Use same scale and type of clothing at same time each day, preferably before breakfast. Accurate daily weights provide the easiest measurement of volume status. An increased of 1kg is equal to 1000mL of fluid retention. (Provided the person has maintained usual dietary intake and has not been NPO) Lewis p.310 3. The use of 24-hour intake and output records gives valuable information regarding fluid and electrolyte issues. Sources of excessive intake or fluid loss can be identified on an

Outcome Criteria 1. Patient will have clear lung sounds anterior and posterior within 48 hrs.

Evaluation 1. Unmet- Patients lung sounds are diminished in bases anterior and posterior

2. Patient will maintain body weight within 2lbs every day

2. Met- Patient did not gain or lose more than 2 lbs daily.

3. Patient will excrete more than 30mLs of urine output Q hr

3. Met- Patient voided > 30mL/hr daily I: 1076mL O:1350mL

4. Elevate legs when in bed Q shift

5. Administer Lasix 20mg IV once

6. Teach patient importance of low sodium diet Q shift

accurately record intake-and-output flow sheet. Intake should include oral, IV and tube feedings and retained irrigants. Output includes urine, excess perspiration, wound or tube drainage, emesis and diarrhea. Lew p.310 4. Elevation of edematous extremities helps promote venous return and fluid reabsorption. Protect edematous tissues from prolonged pressure ulcers. Lewis P.311 5. Lasix is a diuretic used for edema due to HF, hepatic impairment or renal disease. It inhibits the reabsorption of sodium and chloride from the loop of henle and distal renal tubule. It increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium. DDG p.609 6. Teaching the patient and having her verbalize understanding and the importance of diet, increases the likelihood of compliance after discharge. A high sodium diet will sodium in the blood stream, which will retain water. An increase in water

4. Patient will keep legs elevated in bed until edema in lower legs is resolved

5. Patient will have decreased edema in lower legs within 24 hrs

5. Met- Patients edema in lower legs decreased from 2+ pitting to 1+ pitting within 24hrs

6. Patient will verbalize and demonstrate understanding of a low sodium diet Q shift

6. Unmet- Patient states she does not want to change her diet at all. Further teaching needed

causes and increase in pressure. An increase in pressure causes HTN, which make the heart work much harder to pump effectively.