Published Mar 3, 2014
For my patient care packet my patient's priority problem is fluid volume excess. I'm suppose to include what my priority focused assessment is for this problem. I believe it would be cardiovascular and that I would assess the blood pressure, heart rate, and jugular vein distention. Am I on the right track? Any ideas on what else I would assess?
cayenne06, MSN, CNM
don't forget the lymphatic system and I & O. What other systems might be affected by fluid overload?
SopranoKris, MSN, RN, NP
It depends. Is the fluid volume excess due to renal failure? Heart failure? Administration of IV fluids?
What about lungs? Where is the excess fluid going?
Definitely need to assess lungs. And possibly the skin. Sometimes with an excess, the skin starts weeping. If that's the case, you need to assess the skin, especially for breakdown because of the moisture. And as PP said, what's the cause of the excess? That will point you in the right direction of what to assess.
And it's not part of the physical assessment, but don't forget to monitor electrolytes with fluid volume excess.
Think about the places where fluid tends to accumulate. Depending on the cause and gender, this can vary. JVD, HR and BP would all mean that the fluid is still in the vascular system, which may or may not be the case. What do the labs look like? Which ones do you think might be off if they're overloaded with fluids, depending on the cause? How might one cause lead to some labs being off, but not others? Which ones would be affected by this patient's diagnosis/es?
Have you learned about measuring edema yet?
nurseprnRN, BSN, RN
And remember that I&O is not the most accurate measure of fluid balance. What is, and why?
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