Nursing diagnosis and interventions for fluid volume excess…

INSTRUCTION FOR FOLLOW-UP REVIEWS Follow-up Posting (at least 2) SLO 3 Posts demonstrate above average analysis/synthesis of the topic and other posts. Adds substantive comments that advance the discussion by building on others’ posts. Use References from Literature SLO 5 Utilized at least one scholarly source for each follow-up post. APA Format SLO 5 Correct APA citations in the References at the bottom of follow-up posts. Sources cited in the correct format in the body of posts. Sources cited in text are listed in the References at the bottom of follow-up posts. Sources are within 5 years or less of publication 1. First follow-up review: Physical Assessment Julie noted that Mrs Jones was short of breath after ambulating a short distance to the restroom, which was a probable indication of respiratory distress. Bilateral 3+ edema in Mrs. Jones lower extremities is suggestive of fluid retention and may be related to heart failure or renal problems. Her oxygen saturation fell to 88 per cent after ambulation and the possibility of impaired gas exchange with fluid accumulation or respiratory compromise is indicated. Julie also heard wheezing in her lungs, which could indicate bronchospasm or the accumulation of fluid that affects the airways. These findings jointly point out to the fact that Mrs. Jones is probably suffering from excess of fluid in her body, and respiratory distress, both of which require immediate attention if she is not to get worse in her health (American Heart Association, 2017). Primary Nursing Diagnosis The main nursing diagnosis for Mrs. Jones is Fluid Volume Excess related to impaired cardiac function and poor diuretic action. This is proven by 3+, shortness of breath, and an O2 saturation of 88%. The diagnosis is made on the physical signs of fluid retention and difficulty in breathing when there is minimal exertion. Mrs. Jones’s current medication regimen, which includes Lasix (furosemide), has not been enough to control her fluid overload, which is likely contributing to her illness. The aim is to care for the excess fluid retention and enhance the respiratory function by adjusting the diuretic treatment and observing the changes in edema or oxygenation (Shin & Baek, 2019). Nursing Diagnosis Aligning with Safety Mrs Jones is also at risk for Impaired Gas Exchange secondary to fluid in her lungs and an oxygen saturation of 88% This risk is critical as the hypoxia and respiratory distress are a higher risk for complications such as acute respiratory failure. Fluid accumulation in the lungs may make it hard for the patient to breathe and prevents them from exchanging oxygen and carbon dioxide properly. This risk should be dealt with as soon as possible to ensure continued good oxygenation and prevent further deterioration of respiration. Regular monitoring of oxygen saturation along with interventions to increase lung function are key in improving her safety and preventing further deterioration (American Heart Association, 2017). Patient Goals/Outcomes For Fluid Volume Excess diagnosis, the goal is for Mrs. Jones to demonstrate a decrease in edema and improve her oxygen saturation – greater than 90% – by the end of the shift. This outcome is realistic and measurable – looking at improving fluid retention and oxygenation on observation. A reduction in swelling in the lower extremities will indicate a reduction in edema and increased oxygen saturation will indicate that her lungs are able to maintain adequate oxygen levels. Monitoring of vital signs and oxygen saturation will be important to monitor progress towards this goal. For the Risk for Impaired Gas Exchange diagnosis, the goal is to have the patient maintain oxygen saturation levels of 90% or greater at rest and without the signs of shortness of breath or wheezing by the end of shift. This goal addresses the concern of safety directly and creates a clear goal of improving oxygenation and respiratory function. Achieving this outcome would mean that the interventions are successfully easing the fluid overload and the respiratory distress, and Mrs. Jones would be able to breathe easily and retain a better level of oxygen (Shin & Baek, 2019). Nursing Interventions To address Fluid Volume Excess the important intervention is regular monitoring of vital signs which includes blood pressure, heart rate, respiratory rate and oxygen saturation at defined intervals. This allows early detection of changes in Mrs. Jones fluid status, respiratory function and to take preventative action in maintaining the patient at a better state. It is also important to evaluate the severity of edema by checking the circumference of her ankles and legs at least twice a shift. This is an objective measure that can be used to monitor the effectiveness of any interventions and make decisions regarding additional treatment, such as adjusting the dosage of diuretic (American Heart Association, 2017). For Risk for Impaired Gas Exchange, encourage the patient to be on oxygen therapy as ordered. Supplemental oxygen can raise the level of saturation and alleviate the shortness of breath, raising the overall respiratory status. In addition, it is important to position the patient upright in a high Fowler’s position to facilitate lung expansion and decrease work of breathing. This positioning optimizes the ventilation and increases the gas exchange by providing optimal alignment of the lungs and the diaphragm, thus enhancing the respiratory efficiency (Shin & Baek, 2019). References American Heart Association. (2017). Heart failure: Overview and facts. Retrieved from Shin, S., & Baek, S. (2019). The use of diuretics in heart failure. Heart Failure Clinics, 15(1), 57-64. 2. Second follow-up review: During her initial assessment, Julie gathered several important findings that showed Mrs. Jones was having trouble with breathing and fluid balance. Mrs. Jones became short of breath after walking a short distance, and her oxygen saturation dropped to 88% after activity. Julie also noted wheezing in the lungs and significant swelling in both ankles. These findings suggest fluid buildup and poor tolerance for activity, which require immediate nursing attention. The highest-priority nursing diagnosis is impaired gas exchange, related to fluid in the lungs, as evidenced by shortness of breath, wheezing, and low oxygen saturation with activity. The goal is for Mrs. Jones to maintain an oxygen saturation of at least 92% at rest and with movement within 24 hours. Nursing interventions include keeping Mrs. Jones in an upright position to improve lung expansion and monitoring respiratory rate and oxygen saturation before and after activity to assess breathing status (Makic et al., p.448). Another key nursing diagnosis is excess fluid volume, related to the bodys inability to manage fluids, as evidenced by lower-extremity swelling and increased shortness of breath. The goal is for Mrs. Jones to show decreased ankle swelling and improved breathing within 48 hours. Interventions include elevating her legs while resting to reduce swelling and monitoring intake, output, and daily weight to evaluate fluid changes (Makic et al., p.439) A safety-related nursing diagnosis is risk for falls, related to weakness and shortness of breath during activity. The goal is for Mrs. Jones to remain free from falls during her hospital stay. Nursing interventions include assisting her during ambulation and bathroom use and ensuring the call light is within reach with reminders to ask for help before getting out of bed ((Makic et al., p.393). Reference Makic, M. B. F., & Martinez-Kratz, M. R. (2023). Ackley and ladwigs nursing diagnosis handbook: An evidence-based guide to planning care. Elsevier.