NCLEX: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client: ASSESSMENT OF THE ADULT CLIENT

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

Assessment is the process of gathering a comprehensive data-base about the client’s present, past, and potential health problems, as well as a description of the client as a whole in his or her environment. It includes a comprehensive nursing history, a physical examination, and laboratory/x-ray data, and it concludes with the formulation of nursing diagnoses.

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The Health Insurance Portability and Accountability Act of 1996 (HIPAA) strengthened the privacy protections for consumers. Communications are confidential, and the client needs to give permission for other family members to remain in the room—particularly when asking sensitive questions on pregnancies, abortions, drug use, or multiple sex partners.

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Physiological Integrity: Nursing Care of the Adult Client: Subjective Data

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

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Nursing History

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Focus topic: Physiological Integrity: Nursing Care of the Adult Client

The nursing history obtains data for planning and implementing nursing actions.

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I. GENERAL HEALTH INFORMATION: reason for admission; duration of present illness; previous hospitalization; history of illnesses; diagnostic procedures before admission; allergies—type and severity of reactions; medications taken at home—over-the-counter (OTC) and prescription medications, and alternative/complementary therapies.

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II. INFORMATION RELATIVE TO GROWTH AND DEVELOPMENT: age; menarche—age at onset; heavy menses; dysmenorrhea; vaginal discharge; date of last Pap smear; pregnancies; abortions; miscarriages; last menstrual period; history of sexually transmitted infections (STIs).

III. INFORMATION RELATIVE TO  PSYCHOSOCIAL FUNCTIONS: feelings (anger, denial, fear, anxiety, guilt, lifestyle changes); language barriers; cultural needs; family support; spiritual needs; religious preference; history of trauma/rape;  job status; current stressors.

IV. INFORMATION RELATIVE TO NUTRITION: appetite—normal, changes; dietary habits; food  preferences or intolerances; difficulty swallowing or chewing; dentures; use of caffeine/alcohol; weight changes; excessive thirst, hunger, sweating.

V. INFORMATION RELATIVE TO FLUID AND GAS TRANSPORT: difficulty breathing; shortness  of breath; home O2 use; history of cough/smoking; colds; sputum; swelling of extremities; chest pain; palpitations; varicosities; excessive bruising; blood transfusions; excessive bleeding.

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VI. INFORMATION RELATIVE TO PROTECTIVE FUNCTIONS: skin problems—rash, itch; current treatment; unusual hair loss.

VII. INFORMATION RELATIVE TO COMFORT, REST, ACTIVITY, MOBILITY: usual activity (activities of daily living [ADLs]); present ability and restrictions; rest and sleep pattern; weakness; joint or muscle stiffness, pain, or swelling; occupation; interests.

VIII. INFORMATION RELATIVE TO  ELIMINATION: bowel habits; changes—constipation, diarrhea; ostomy; emesis; nausea; voidin —retention, frequency, dysuria, incontinence.

IX. INFORMATION RELATIVE TO SENSORY/ PERCEPTUAL FUNCTIONS: pain—verbal report, acute/chronic, treatment, quality, location, precipitating factors, duration; limitations in vision (glasses), hearing, touch, smell; orientation to person, place, time; confusion; headaches; fainting; dizziness;  convulsions.

Objective Data

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Focus topic: Physiological Integrity: Nursing Care of the Adult Client

I. GENERAL —provides information on the client as a whole.

A. Race, sex, apparent age in relation to stated age.

B. Nutritional status—well hydrated and developed or obesity, cachexi —include weight.

C. Apparent health status—general good health or mild, moderate, severe debilitation.

D. Posture and motor activity —erect, symmetrical,  balanced gait and muscle development, or ataxic, circumducted, scissor, or spastic gait; slumped or bent-over posture; scoliosis, lordosis, kyphosis; mild, moderate, or hyperactive motor responses.

E. Behavior—alert; oriented to person, time, place; hears and comprehends instructions, or tense,  anxious, angry; uses abusive language; slightly or largely unresponsive; delusions, hallucinations.

F.  Odors—noncontributory, or acetone, alcohol, fetid breath, incontinent of urine or feces.

II. PHYSICAL ASSESSMENT —requires knowledge  of normal findings, organization, and keen senses (i.e., visual, auditory, touch, smell). For abnormal findings, refer to the Assessment section of each health problem discussed.

A. Components

  •  Inspection —uses observations to detect deviations from normal.
  •  Auscultation —used to perceive and interpret sounds arising from various organs, particularly heart, lungs, and bowel.
  •  Palpation —used to assess for discomfort, temperature, pulsations, size, consistency, and texture.
  • Percussion —technique used to elicit vibrations produced by underlying organ structures; used less frequently in nursing practice.
    a. Flat—normal percussion; note over muscle or bone.
    b. Dull—normal percussion; note over organs such as liver.
    c. Resonance—normal percussion; note over lungs.
    d. Tympany—normal percussion; note over stomach or bowel.

B. Approach—head to toe

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  • General appearance—well or poorly developed or nourished. Color (black, white, jaundiced, pale). In distress (acutely or chronically)?
  •  Vital signs —blood pressure (which arm or both, orthostatic change); pulse (regular or irregular, orthostatic change); respirations (labored or unlabored, wheeze); temperature (axillary, rectal, temporal [forehead], tympanic membrane, or oral); weight; height (Factors Affecting Vital Signs).
  • Skin, hair, and nails —pigmentation, scars, lesions, bruises, turgor. Describe or draw rashes.
    a. Skin color:
    (1) Red—fever, allergic reaction, carbon monoxide (CO)       poisoning, burn.
    (2) White (pallor)—excessive blood loss, fright.
    (3) Blue (cyanosis)—hypoxemia, peripheral vasoconstriction, shock.
    (4) Mottled—cardiovascular embarrassment, shock.
    b. Skin temperature:
    (1) Hot, dry—excessive body heat (heatstroke).
    (2) Hot, wet—reaction to increased internal or external temperature.
    (3) Cool, dry—exposure to cold.
    (4) Cool, clammy—shock.
  • Head—scalp, skull (configuration), scars, tenderness, bruits.
  • Neck —suppleness. Trachea, larynx, thyroid, blood vessels (jugular veins, carotid arteries).
  • Nodes—any cervical, supraclavicular, axillary, epitrochlear, inguinal lymphadenopathy? If so, size of nodes (in centimeters), consistency (firm, rubbery, tender), mobile or fixed.
  • Eyes:
    a. External eye.Conjunctivae, sclerae, lids, cornea, pupils (including reflexes), visual fields, extraocular motions.
    b. Fundus. Disk, blood vessels, pigmentation.
  • Ears —shape of pinnae, external canal, discharge, tympanic membrane, acuity, air conduction versus bone conduction (Rinne test), lateralization (Weber test).
  • Nose —nares (symmetry), septum, mucosa, polyps, discharge, flaring.
  • Mouth and throat—lips, teeth (loose, dental hygiene, odor), tongue (size, papillation, position), buccal mucosa, palate, tonsils, oropharynx.
  • Chest
    a. Inspection. Contour, symmetry, expansion, retractions.
    b. Palpation.Expansion, rib tenderness, tactile fremitus.
    c. Percussion. Diaphragmatic excursion, dullness.
    d. Auscultation. Crackles, rubs, wheezes, egophony, pectoriloquy.
    (1) Use diaphragm or bell. Normal sounds over alveol—vesicular. Large airway or abnormal sounds— bronchial or bronchovesicular. Adventitious sounds—crackles or wheezes.
    (2) Crackles—discontinuous noises heard on auscultation; caused by popping open of air spaces; usually associated with increased fluid in the lungs; formerly called rales and rhonchi.(3)Wheezes—high-pitched, whistling sounds made by air flowing through narrowed airways.
    (4) Stridor —harsh, high-pitched, heard during inspiration and expiration; life threatening.

Physiological Integrity: Nursing Care of the Adult Client

  • Breasts —symmetry, retraction, lesions, nipples (inverted, everted), masses, tenderness, discharge.
  • Heart:
    a. Inspection. Point of maximal impulse (PMI), chest contour.
    b. Palpation.Point of maximal impulse (PMI), thrills, lifts, thrusts.
    c. Auscultation. Heart sounds, gallops, murmurs, rubs. Use diaphragm for high-pitched sounds of normal heart sounds (S1 and S2) and bell for abnormal sounds (S3 and S4).
  • Abdomen:
    a. Inspection. Scars (draw these), contour, masses, vein pattern.
    b. Auscultation. Bowel sounds, rubs, bruits. Use diaphragm. Auscultate after inspection and before palpation and percussion. Listen to each quadrant for at least 1 minute. If bowel sounds are present, they will be heard in lower right quadrant (area of ileocecal valve). Hypoactivity—every minute; normal — every 15 to 20 seconds; hyperactivity —about every 3 seconds.
    c. Percussion—organomegaly, hepatic dullness.
    d. Palpation —tenderness, masses, rigidity, liver, spleen, kidneys.
    e. Hernia —femoral, inguinal, ventral, umbilical.
  • Genitalia:
    a. Male.Penile lesions, discharge, scrotum, testes. Circumcised?
    b. Female.Labia, discharge, odor, Bartholin’s and Skene’s glands, vagina, cervix. Bimanual examination of internal genitalia.
  • Rectum —perianal lesions, sphincter tone, tenderness, masses, prostate, stool color, occult blood.
  • Extremities—pulses (symmetry, bruits, perfusion). Joints (mobility, deformity). Cyanosis, edema. Varicosities. Muscle mass. Grips equal.
  • Back —contour of spine, tenderness. Sacral edema.
  • Neurological:
    a. Mental status. Alertness, memory, judgment, mood.
    b. Cranial nerves (I–XII) ( Cranial nerves and their distributions.).
    c. Cerebellum. Gait, finger-nose, heel-shin, tremors.                                                                                                                                                                         d. Motor. Muscle mass, strength; deep tendon reflexes. Pathological or primitive reflexes.                                                                                                                     e. Sensory. Touch, pain, vibration. Heat and cold as indicated.

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III. ROUTINE LABORATORY STUDIES —for normal ranges.

A. Hematology:

  • Complete blood count—detects presence of anemia, infection, allergy, and leukemia.
  • Prothrombin time—increase may indicate liver disease or cancer.
  • Serology (Venereal Disease Research Laboratories [VDRL])—determines presence of syphilis; false-positive result may indicate collagen dysfunction.

B. Urinalysis:

  • Specific gravity—measures ability of kidney to concentrate urine. Fixed specific gravity indicates renal tubular dysfunction.
  • Protein—indicates glomerular dysfunction.
  • Albumin, white blood cells (WBCs), and pus—indicate renal infection.
  • Sugar and acetone—presence indicates metabolic disorder.

C. Chest x-ray—detects tuberculosis or other pulmonary dysfunctions, as well as changes in size or configuration of heart.

D. Electrocardiogram (ECG or EKG)—detects rhythm and conduction disturbances, presence of myocardial ischemia or necrosis, and ventricular hypertrophy.

E. Blood chemistries—detect deviation in electrolyte balance, presence of tissue damage, and adequacy of glomerular filtration.

 

IV. PREVENTIVE CARE

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Checkup visits recommended every 1 to 3 years until age 65 and then yearly thereafter.

B. Individuals with special risk factors may need more frequent and additional types of preventive care.

  •  Diabetes—eye, foot examinations; urine, blood sugar tests.
  •  Drug abuse—AIDS, tuberculosis (TB) tests; hepatitis immunization.
  •  Alcoholism —influenza, pneumococcal immunizations; TB test.
  •  Overweight—blood sugar test, triglycerides, blood pressure.
  •  Homeless, recent refugee or immigrant—TB test.
  •  High-risk sexual behavior—AIDS, syphilis, gonorrhea, chlamydia (every year for women who are sexually active), hepatitis tests.
  •  Pregnancy —rubella blood test (prior to first pregnancy).
  •  Cancer—colonoscopy, mammography, x-ray.

Physiological Integrity: Nursing Care of the Adult Client

C. Adult immunizations—prevention of disease and reduction in the severity of disease (2011 Recommended Adult Immunization Schedule). Assessment is followed by analysis of data and formulation of a nursing diagnosis. Possible nursing diagnoses are given in the following sections.

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Physiological Integrity: Nursing Care of the Adult Client: GROWTH AND DEVELOPMENT

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

Young Adulthood (20 to 30 Years of Age)

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

I. STAGE OF DEVELOPMENT—PSYCHOSOCIAL STAGE: intimacy versus isolation.

II. PHYSICAL DEVELOPMENT

A. At the height of bodily vigor.

B. Maximum level of strength, muscular development, height, and cardiac and respiratory capacity; also, period of peak sexual capacity for men.

III. COGNITIVE DEVELOPMENT

A. Close to peak of intelligence, memory, and abstract thought.

B. Maximum ability to solve problems and learn new skills.

IV. SOCIALIZATION

A. Has a vision of the future and imagines various possibilities for self.

B. Defines and tests out what can be accomplished.

C. Seeks out a mentor to emulate as a guiding, though transitional, figure; the mentor is usually a mixture of parent, teacher, and friend who serves as a role model to support and facilitate the developing vision  of self.

D. Grows from a beginning to a fuller understanding of own authority and autonomy.

E. Transfers an interest into an occupation or profession; crucial work choice may be made after one has knowledge, judgment, and self-understanding, usually at the end of young adulthood; when the choice is deferred beyond these years, valuable time is lost.

F. Experiments with and chooses a lifestyle.

G. Forms mature peer relationships with the opposite sex.

H. Overcomes guilt and anxiety about the opposite sex and learns to understand the masculine and feminine aspects of self, as well as the adult concept of roles.    

I. Learns to take the opposite sex seriously and may choose someone for a long-term relationship.

J. Accepts the responsibilities and pleasures of parenthood.

 

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client: Adulthood (31 to 45 Years of Age)

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

I. STAGE OF DEVELOPMENT—PSYCHOSOCIAL STAGE: generativity versus self-absorption.
II. PHYSICAL DEVELOPMENT

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Gradual decline in biological functioning, although in the late 30s the individual is still near peak.

B. Period of peak sexual capacity for women occurs during the mid-30s.

 C. Distinct sense of bodily decline occurs around 40 years of age.

 D. Circulatory system begins to slow somewhat after 40 years of age.

III. COGNITIVE DEVELOPMENT

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Takes longer to memorize.

B. Still at peak in abstract thinking and problem-solving.

C. Generates new levels of awareness.

D. Gives more meaning to complex tasks.

IV. SOCIALIZATION

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Achieves a realistic self-identity.

B. Perceptions are based on reality.

C. Acts on decisions and assumes responsibility for actions.

D. Accepts limitations while developing assets.

E. Delays immediate gratification in favor of future satisfaction.

F. Evaluates mistakes, determines reasons and causes, and learns new behavior.

G. Struggles to establish a place in society.

  • Begins to settle down.
  • Pursues long-range plans and goals.
  • Has a stronger need to be responsible.
  • Invests self as fully as possible in social structure, including work, family, and community.

H. Seeks advancement by improving and using skills,

Physiological Integrity: Nursing Care of the Adult Client: Middle Life (46 to 64 Years of Age)

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

I. STAGE OF DEVELOPMENT—PSYCHOSOCIAL STAGE: continuation of generativity versus self-absorption.

II. PHYSICAL DEVELOPMENT

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Failing eyesight, especially for close vision, may be one of the first symptoms of aging.

B. Hearing loss is very gradual, especially for low sounds; hearing for high-pitched sounds is impaired more readily.

C. There is a gradual loss of taste buds in the 50s and gradual loss of sense of smell in the 60s, causing the individual to have a diminished sense of taste.

D. Muscle strength declines because of decreased levels of estrogen and testosterone; it takes more time to accomplish the same physical task.

E. Lung capacity is impaired, which adds to decreased endurance.

F. The skin begins to wrinkle, and hair begins graying.

G. Postural changes take place because of loss of calcium and reduced activity.

III. COGNITIVE DEVELOPMENT

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A.Memory begins to decline slowly around age 50 years.

B.It takes longer to learn new tasks, and old tasks take longer to perform.

C.Practical judgment is increased due to experiential background.

D.May tend to withdraw from mental activity or overcompensate by trying the impossible.

IV. SOCIALIZATION

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A.The middle years can be very rewarding if previous stages have been fulfilled.

B.The years of responsibility for raising children are over.

C.Husbands and wives usually find a closer bond.

D.There is less financial strain for those with steady employment.

E.Individuals are usually at the height of their careers; the majority of leaders in their field are in this age group.

F.Self-realization is achieved.

  • There is more inner direction.
  • There is no longer a need to please everyone.
  • Individual is less likely to compare self with others.
  • Individual approves of self without being dependent on standards of others.
  • There is less fear of failure in life because past failures have been met and dealt with.

Physiological Integrity: Nursing Care of the Adult Client: Early Late Years (65 to 79 Years of Age)

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

I. STAGE OF DEVELOPMENT—PSYCHOSOCIAL STAGE: ego integrity and acceptance versus despair and disgust.
II. PHYSICAL DEVELOPMENT

A.Continues to decrease in vigor and capacity.

B.Has more frequent aches and pains.

C.Likely to have at least one major illness.

III. COGNITIVE DEVELOPMENT

A.Mental acuity continues to slow down.

B.Judgment and problem-solving remain intact, but the processes may take longer.

C.May have problems in remembering names and dates.

IV. SOCIALIZATION

A.Individual is faced with the reality of the experience of physical decline.

 B.Physical and mental changes intensify the feelings of aging and mortality.

C.Increasing frequency of death and serious illness among friends, relatives, and associates further reinforces the concept of mortality.

D.Constant reception of medical warnings to follow certain precautions or run serious risks adds to general feeling of decline.

E.Individual is less interested in obtaining the rewards of society and is more interested in using own inner resources.

F.Individuals feel that they have earned the right to do what is important for self-satisfaction.

G.Retirement allows time for expression of own creative energies.

H.Overcomes the splitting of youth and age; gets along well with adolescents.

I.Learns to deal with the reality that only old age remains.

J.Provides moral support to grandchildren; more tolerant of grandchildren than was of own children.

 K.Tends to release major authority of family to children while holding self in the role of consultant.

Physiological Integrity: Nursing Care of the Adult Client: Later Years (80 Years of Age and Older)

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

I. STAGE OF DEVELOPMENT—PSYCHOSOCIAL STAGE: continuation of ego integrity and acceptance versus despair and disgust.
II. PHYSICAL DEVELOPMENT

A.Additional sensory problems occur, including diminished sensation to touch and pain.

B.Increase in loss of muscle tone occurs, including sphincter (urinary and anal) control.

C.Individual is insecure and unsure about orientation to space and sense of balance, which may result in falls and injury.

III. COGNITIVE DEVELOPMENT

A.Has better memory for the past than the present.

B.Repetition of memories occurs.

C.Individual may use confabulation to fill in memory gaps.

D.Forgetfulness may lead to serious safety problems, and individual may require constant supervision.

E.Increased arteriosclerosis may lead to mental illness (dementia and other cognitive disorders).

IV. SOCIALIZATION

A.Few significant relationships are maintained; deaths of friends, family, and associates cause isolation.

 B.Individual may be preoccupied with immediate bodily needs and personal comforts; the gastrointestinal tract frequently becomes the major focus.

C.Individuals see that they can provide others with an example of wisdom and courage.

 D.Individuals come to terms with themselves.

E.Individuals are concerned with own mortality.

F.Individuals come to terms with the process of dying and prepare for own death.

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Physiological Integrity: Nursing Care of the Adult Client: FLUID AND ELECTROLYTE IMBALANCES

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

Imbalances in fluid and electrolytes may be due to changes in the total quantity of either substance (deficit or excess), protein deficiencies, or extracellular fluid volume shifts. Clients who are older and very young are particularly susceptible.

I. FLUID VOLUME DEFICIT (dehydration): mechanism that influences fluid balance and sodium levels; decreased quantities of fluid and electrolytes may be caused by deficient intake (poor dietary habits, anorexia, and nausea), excessive output (vomiting, nasogastric suction, and prolonged diarrhea), or failure of regulatory mechanism that influences fluid balance and sodium levels.

A.Pathophysiology: water moves out of the cells to replace a significant water loss; cells eventually become unable to compensate for the lost fluid, and cellular dehydration begins, leading to circulatory collapse.

B.Risk factors:                                                                                                                                                                                                                                       

  • No fluids available.
  • Available fluids not drinkable.
  • Inability to take fluids independently.
  • No response to thirst; does not recognize the need for fluids.
  • Inability to communicate need; does not speak same language.
  • Aphasia.
  • Weakness, comatose.
  • Inability to swallow.
  • Psychological alterations.
  • Overuse of diuretics.
  • Increased vomiting.
  • Fever.
  • Wounds, burns.
  • Blood loss.
  • Endocrine abnormalities (e.g., diabetes insipidus).
  • Diarrhea.

 C.Assessment:

  • Subjective data:
    a. Thirst.
    b. Behavioral changes: apprehension, apathy, lethargy, confusion, restlessness.
    c. Dizziness.
    d. Numbness and tingling of hands and feet.
    e. Anorexia and nausea.
    f. Abdominal cramps.
  • Objective data:
    a. Sudden weight loss of 5%.
    b. Vital signs:
    (1) Decreased BP; postural changes.
    (2) Increased temperature.
    (3) Irregular, weak, rapid pulse.
    (4) Increased rate and depth of respirations.
    c. Skin: cool and pale in absence of infection; decreased turgor.
    d. Urine: oliguria to anuria, high specific gravity.
    e. Eyes: soft, sunken.
    f. Tongue: furrows.
    g. Laboratory data:
    (1) Blood—increased hematocrit and blood urea nitrogen (BUN).
    (2) Urine—decreased 17-ketosteroids; increased specific gravity, dark-colored urine.

 D. Analysis/nursing diagnosis:

  • Fluid volume deficit related to inadequate fluid intake.

E. Nursing care plan/implementation:

  • Goal: restore fluid and electrolyte balance— increase fluid intake to hydrate client.
    a. IVs and blood products as ordered; small, frequent drinks by mouth.
    b. Daily weights (same time of day) to monitor progress of fluid replacement.
    c. I&O, hourly outputs (when in acute state).                                                                                                                                                                                      d. Avoid hypertonic solutions (may cause fluid shift when compensatory mechanisms begin to function).
  • Goal: promote comfort.
    a. Frequent skin care (lack of hydration causes dry skin, which may increase risk for skin breakdown).
    b. Position: change every hour to relieve pressure.
    c. Medications as ordered: antiemetics, antidiarrheal.
  • Goal: prevent physical injury.
    a. Frequent mouth care (mucous membrane dries due to dehydration; therefore, client is at risk for breaks in mucous membrane, halitosis).
    b. Monitor IV flow rate—observe for circulatory overload, pulmonary edema related to potential fluid shift when compensatory mechanisms begin or client is unable to tolerate rate of fluid replacement.
    c. Monitor vitals, including level of consciousness (decreasing BP and level of consciousness indicate continuation of fluid loss).
    d. Prepare for surgery if hemorrhage present (internal bleeding can only be relieved by surgical intervention).

F. Evaluation/outcome criteria:

  • Mentally alert.
  • Moist, intact mucous membranes.
  • Urinary output approximately equal to intake.
  • No further weight loss.
  • Gradual weight gain.

II. FLUID VOLUME EXCESS (fluid overload): most common cause is an increase in sodium; excessive quantities of fluid and electrolytes may be due to increased ingestion, tube feedings, intravenous infusions, multiple tap-water enemas, or a failure of regulatory systems, resulting in inability to excrete excesses

A. Pathophysiology: hypo-osmolar water excess in extracellular compartment leads to intracellular water excess because the concentration of solutes in the intracellular fluid is greater than that in the extracellular fluid. Water moves to equalize concentration, causing swelling of the cells. The most common cause is an increase in sodium.

B. Risk factors:

  • Excessive intake of electrolyte-free fluids.
  • Increased secretion of antidiuretic hormone (ADH) in response to stress, drugs, anesthetics (Diabetes Insipidus (DI) Versus Syndrome of Inappropriate Antidiuretic Hormone (SIADH)).
  • Decreased or inadequate output of urine.
  • Psychogenic polydipsia.
  • Certain medical conditions: tuberculosis; encephalitis; meningitis; endocrine disturbances; tumors of lung, pancreas, duodenum; heart failure.
  • Inadequate kidney function or kidney failure.

Physiological Integrity: Nursing Care of the Adult Client

C. Assessment:

  • Subjective data:
    a. Behavioral changes: irritability, apathy, confusion, disorientation.
    b. Headache.
    c. Anorexia, nausea, cramping.
    d. Fatigue.
    e. Dyspnea.
  • Objective data:
    a. Vital signs: elevated blood pressure.
    b. Skin: warm, moist; edema—eyelids, facial, dependent, pitting.
    c. Sudden weight gain of 5 lb.
    d. Pink, frothy sputum; productive.
    e. Constant, irritating cough.
    f. Crackles in lungs.
    g. Pulse: bounding.
    h. Engorgement of neck veins in sitting position.
    i. Urine: polyuria, nocturia, pale color.
    j. Laboratory data:
    (1)Blood—decreasing hematocrit, BUN.
    (2)Urine—decreasing specific gravity.

D. Analysis/nursing diagnosis:

  • Fluid volume excess related to excessive fluid intake or decreased fluid output.

E. Nursing care plan/implementation:

  • Goal: maintain oxygen to all cells.                                                                                                                                                                                                    a. Position: semi-Fowler’s or Fowler’s to facilitate improved gas exchange.                                                                                                                                         b. Vital signs: prn, minimum q4h.
    c. Fluid restriction.                                                                                                                                                                                                                          
  • Goal: promote excretion of excess fluid.
    a. Medications as ordered: diuretics.
    b. Monitor electrolytes, especially Mg++, K+.
    c. If in kidney failure: may need dialysis; explain procedure.
    d. Assist client during paracentesis, thoracentesis, phlebotomy.
    (1) Monitor vital signs to detect shock.
    (2) Prevent injury by monitoring sterile technique.
    (3) Prevent falling by stabilizing appropriate position during procedure.
    (4) Support client psychologically.
  • Goal: obtain/maintain fluid balance.
    a. Daily weights; 1 kg = 1,000 mL fluid.
    b. Measure: all edematous parts, abdominal girth, I&O.
    c. Limit: fluids by mouth, IVs, sodium.
    d. Strict monitoring of IV fluids.
  • Goal: prevent tissue injury.
    a. Skin and mouth care as needed.
    b. Evaluate feet for edema and discoloration when client is out of bed.
    c. Observe suture line on surgical clients (potential for evisceration due to excess fluid retention).
    d. IV route preferred for parenteral medications; Z track if medications are to be given IM (otherwise injected liquid will escape through injection site).
  • Goal: health teaching.
    a. Improve nutritional status with low-sodium diet.
    b. Identify cause that put client at risk for imbalance, methods to avoid this situation in the future.
    c. Desired and side effects of diuretics and other prescribed medications.
    d. Monitor urinary output, ankle edema; report to health-care manager when fluid retention is noticed.
    e. Limit fluid intake when kidney/cardiac function impaired.

F. Evaluation / outcome criteria :

  • Fluid balance obtained.
  • No respiratory, cardiac complications.
  • Vital signs within normal limits.
  • Urinary output improved, no evidence of edema.
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