The next patient is a 76-year-old patient who presents with a chief complaint: \

Question

The next patient is a 76-year-old patient who presents with a chief complaint: "I can't sleep at night—I can't lie down, I get so out of breath." She is sitting in high Fowler's position on the exam table. She has a history of heart problems. She is diagnosed with acute exacerbation of congestive heart failure, and the preceptor identifies a nursing diagnosis of Fluid Volume Excess. The physician gives the following orders: • NS at 125 mL/hr, Use infusion pump • Furosemide (Lasix) 80 mg IV now • Potassium citrate (K-Lyte) 10 mEq orally now and q4h × 2 doses • O2 2–5 LPM to keep O2 sat greater than 92% 1. Which order should the nurse question? Why? 2. What is the term should the nurse use to document the patient's chief complaint regarding her breathing? 3. Besides the respiratory difficulty exhibited by the patient, what specific manifestations of fluid volume excess would the nurse look for on assessment? 4. What assessments and outcome data will the nurse use to determine if the interventions to reduce the fluid volume excess have been effective? The patient was diuresed and is ready for discharge. Discharge orders include a low-sodium (2000 mg/day) diet and a fluid restriction of 1500 mL/day. 5. Describe discharge teaching necessary to help her manage her fluid restriction of 1500 cc per day. The next patient is a 76-year-old patient who presents with a chief complaint: "I can't sleep at night—I can't lie down, I get so out of breath." She is sitting in high Fowler's position on the exam table. She has a history of heart problems. She is diagnosed with acute exacerbation of congestive heart failure, and the preceptor identifies a nursing diagnosis of Fluid Volume Excess. The physician gives the following orders: • NS at 125 mL/hr, Use infusion pump • Furosemide (Lasix) 80 mg IV now • Potassium citrate (K-Lyte) 10 mEq orally now and q4h × 2 doses • O2 2–5 LPM to keep O2 sat greater than 92% 1. Which order should the nurse question? Why? 2. What is the term should the nurse use to document the patient's chief complaint regarding her breathing? 3. Besides the respiratory difficulty exhibited by the patient, what specific manifestations of fluid volume excess would the nurse look for on assessment? 4. What assessments and outcome data will the nurse use to determine if the interventions to reduce the fluid volume excess have been effective? The patient was diuresed and is ready for discharge. Discharge orders include a low-sodium (2000 mg/day) diet and a fluid restriction of 1500 mL/day. 5. Describe discharge teaching necessary to help her manage her fluid restriction of 1500 cc per day.

Explanation / Answer

1) The nurse can raise her doubt on the IV fluid, because as per the order the patient is about yo get 2400ml of IV.NS at 4 th hourly,where the patient is already hypervolemic

2)The nurse can document as dyspnea , which means the patient is having difficulties in breathing

3)she can assess for the following

4)Assessing for oxygen saturation maintain a nice

Reduced symptoms

Good out put due yo diuretics administration

Reduced dyspnea ,able to lie supine than Fowler position

Improved activities

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