Fluid Overload?

Nursing Students Student Assist

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Patient with Right Sided Heart Failure complaints of palpitation. Unknown amounts of fluid ingested. Foods high in Sodium were eaten, that with soups too. There is distention of neck vein. T:36.0 AX. BP: 140/70 PR: 132 RR: 20. Skin is cold to touch. Murmurs RSB 2nd ICS, LSB 2nd ICS, and LSB 4rth ICS, Grade 4 Blowing, Low pitched. No S3 or S4 noted. Presents with Oliguria and devoid of perspiration. No adventitious breathe sounds heard, respiration is quiet and unlabored. Last dose of Furosemide 20 mg (1/2 tab) taken last 8 am. Patient presents with anxiety. ECG tracing unavailable.

What is happening?

What should be done?

Regards,

Feeveer

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Specializes in Family Medicine, Medical Intensive Care.

Let us know what you think first.

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Tell us what you think is happening, and we'll let you know if you're on the right track.

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I am not sure. However I am inclined to think it really is Fluid Overload... Although I think there is also presence of arrythmia though I'm not sure... Is there something wrong with my assessment? I feel uneasy... I need help...

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Specializes in Family Medicine, Medical Intensive Care.

It's okay. Take a deep breath!

The first thing to do is to look up the pathophysiology of right-sided heart failure. This will help you understand what can cause right-sided heart failure and its associated signs and symptoms. Some pathophysiology text books may tell you what the common treatment modalities are.

The second thing to do is to use the nursing process. You've already performed the first step (assessment). So, what is the second step? This will guide you in the direction of knowing what to do for the patient.

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