Nursing Assessment and Care for a Patient with Fluid Volume Overload

QUESTION

Mr. Jones is a 68-year old patient with a history of congestive heart failure (CHF).
The patient has been admitted to the intensive care unit directly from his
physician’s office this a.m. because of severe dyspnea and orthopnea.

Patient Information:

Height: 72 inches

Weight: 180 lbs.

Notes:

Charles Jones is a 68-year-old male with a history of congestive heart failure (CHF), who was admitted to the intensive care unit from a physician’s office. Upon admission the patient had severe dyspnea and orthopnea. Auscultation of the lungs revealed rales that are noted bilaterally in lower lobes. The patient is on oxygen 4 L/min and the saturation is on average 92-94%. Patient has received IV Lasix of 160 mg over 20 minutes IV piggy back. Total urine output is 800 mL over the past 4 hours. His BP is stable 102/78 and he has 3+ bilateral lower extremity edema. Mr. Jones is oriented to place, time, and person, and he denies any pain.

Prior medical history: Mr. Jones has had hypertension for the last 10 years, and was diagnosed with atrial fib and congestive heart failure 5 years ago. He has hyperlipidemia. He had been smoking 1 pack a day for 20 years, but quit smoking 2 years ago. He is a social drinker only. No known drug allergies, immunizations current with annual flu vaccine. Recent medical history: Mr. Jones was seen in his physician’s office this morning. He presented with a 12 lb weight gain, severe dyspnea, O2 saturation of 87% on room air, orthopnea and lower extremity edema. Dr. Smith admitted Mr. Jones from the office with diagnosis of severe decompensated heart failure (DHF). An echocardiogram upon admission reveals high filling pressures and ejection fraction (EF) of 20%.

Lab:

BNP: 4600

Hct: 11.3

HGB: 11.3

Glucose: 122

BUN: 54

Creatinine: 1.6

1. Write a nursing note and list all data that supports this patient was experiencing fluid volume overload.

2. What cues need follow up? What findings are most concern?

3. Based on your identified cues, what possible disease processes exist?

4. What are the priority concerns or highest risk/complication?

5. What potential interventions are needed for this patient?

6. When would administering furosemide, a loop diuretic, be contraindicated when caring for a patient with fluid overload?

ANSWER

Nursing Assessment and Care for a Patient with Fluid Volume Overload

Introduction

This nursing note addresses the case of Mr. Jones, a 68-year-old male admitted to the intensive care unit due to severe dyspnea and orthopnea related to congestive heart failure (CHF). The note highlights the patient’s medical history, presenting symptoms, physical examination findings, and relevant laboratory results. This information supports the assessment that the patient is experiencing fluid volume overload.

 Nursing Note: Fluid Volume Overload

Date and Time: [Specify]

Patient: Charles Jones, 68-year-old male

Presenting Symptoms
Severe dyspnea and orthopnea
Lower extremity edema (3+ bilateral)
Weight gain of 12 lbs
Rales noted bilaterally in lower lobes upon lung auscultation
Oxygen requirement of 4 L/min with average saturation of 92-94%

Medical History
Hypertension (10 years)
Atrial fibrillation and congestive heart failure (5 years)
Hyperlipidemia
Former smoker (quit 2 years ago)
Social drinker
No known drug allergies
Up-to-date with immunizations, including annual flu vaccine

Relevant Findings
Echocardiogram: High filling pressures, ejection fraction (EF) of 20%
Laboratory Results:
B-type natriuretic peptide (BNP): 4600
Hematocrit (Hct): 11.3
Hemoglobin (HGB): 11.3
Glucose: 122
Blood urea nitrogen (BUN): 54
Creatinine: 1.6

Cues Needing Follow-Up and Findings of Concern

Cues Needing Follow-Up
Weight gain of 12 lbs
Severe dyspnea and orthopnea
Lower extremity edema (3+ bilateral)
Rales on lung auscultation
Low oxygen saturation levels (92-94%)

Findings of Concern
Low hematocrit (Hct) and hemoglobin (HGB) levels (11.3)
Elevated BNP (4600)
Elevated BUN (54) and creatinine (1.6)

Possible Disease Processes

Based on the identified cues, possible disease processes include:
Acute decompensated heart failure (ADHF)
Cardiogenic pulmonary edema
Fluid volume overload secondary to CHF exacerbation

Priority Concerns or Highest Risk/Complication

The priority concerns include:
Impaired gas exchange due to severe dyspnea and orthopnea
Fluid overload leading to pulmonary congestion and compromised cardiac function
Potential for worsening renal function due to elevated BUN and creatinine levels

Potential Interventions

Administer supplemental oxygen to maintain oxygen saturation above 92%.
Implement strict fluid monitoring, including intake and output measurement.
Initiate a diuretic regimen, such as furosemide, to promote diuresis and reduce fluid overload.
Elevate the head of the bed to facilitate breathing and reduce orthopnea.
Monitor vital signs, including blood pressure, heart rate, and respiratory rate, regularly.
Assess lung sounds frequently and document any changes.
Collaborate with the healthcare team to adjust medication dosages and interventions based on ongoing assessment findings.

Contraindications for Furosemide Administration

Administering furosemide, a loop diuretic, would be contraindicated when caring for a patient with fluid overload if the patient has:
Known hypersensitivity or allergy to furosemide or sulfonamide derivatives.
Profound electrolyte imbalances, such as severe hypokalemia, which could be exacerbated by the diuretic.
Anuria or significantly impaired renal function, as the diuretic may not be effective in promoting diuresis.

Conclusion

This nursing note provides a comprehensive overview of Mr. Jones’ clinical presentation and supports the assessment of fluid volume overload. It emphasizes the importance of vigilant monitoring, prompt interventions, and collaboration among the healthcare team to address the patient’s symptoms and manage the underlying condition. By implementing appropriate interventions and closely monitoring the patient’s response, the goal is to alleviate symptoms, optimize cardiac function, and improve overall outcomes for Mr. Jones.