Her fluid intake is 700 ml since last 7 hours out of which 700 ml completed and commenced another 1000ml commenced at 7am in morning urine out put is 180 ml in last 7 hour Nursing diagnosis- Fluid volume excess related to excessive fluid build-up in the extractcellular fluid space secondary to edema as evidenced by obstruction of the lungs. Goal is to increase urinary output and decrease edema. Question: What would be rational behind it
Kngwarreye is a 60 yr old Anmatyerre woman from Urpuntia in
Central Australia. She has been referred and admitted to hospital for
exacerbation of her COPD. She is currently receiving increased regular
salbutamol, oral steroids in addition to her regular medications and
intensive respiratory physiotherapy rehabilitation before returning to her
community in the next week.
u Hx COPD, cor pulmonale
u It is 0800 and you attend to undertake her observations. She looks at
you vaguely and asks where she is. However, after a moment she
seems fine. She seems a bit agitated and says she doesn’t want
breakfast because she feels like she needs to vomit.
P: Provoking Factors: coughing and taking a deep breath
Palliative Factors: Nothing makes me feel better
Q: aching
R: Everywhere
S: “not too severe, I just don’t
feel right”.
T: “I woke up during the night
feeling hot all over”.
BP: 104/68 mmHg
• HR: 112bpm
• RR: 26 bpm
• Temp: 38.1°C
• Sp02: 87% on RA
Cardiac
Assessment
findings
u Pulse – Regular, rapid and
palpable
u JVP - not visible
u Peripheries are warm
u Pale
u CXR - Nil evidence of enlarged
cardiac shadow or lung changes pre-
operatively.
u ECG – Sinus Tachycardia
Respiratory
Assessment
• Dyspnoeic
• Increased Work of
breathing
• Generalised Bilateral
crackles
• Decreased lung sounds L
side
• Chest Xray – Extensive L
sided chest consolidation all
fields.
Neurological assessment
• LOC: A&O x3
• PERRLA
• Motor and sensory function
intact
GCS: 15- but slow to respond
BGL: 4.1 mmol/L
UA: negative
Her fluid intake is 700 ml since last 7 hours out of which 700 ml completed and commenced another 1000ml commenced at 7am in morning urine out put is 180 ml in last 7 hour
Nursing diagnosis-
Fluid volume excess related to excessive fluid build-up in the extractcellular fluid space secondary to edema as evidenced by obstruction of the lungs.
Goal is to increase urinary output and decrease edema.
Question: What would be rational behind it ( 200 words)?
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