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[Ambermarie777]

What lab values are most indicative of fluid volume excess as caused by SIRS????? Thank you for your help.

[kgh31386, BSN, MSN, RN]

Well before anyone goes off on you about doing your own hw and not just giving you the answer...what have you come up with? And what can you tell me about how SIRS affects your labs?

[Ambermarie777]

So far I know that SIRS is a different form of fluid overload than fluid overload caused by IV overload. I have a care plan i have been working on and I am trying to tie in a the fluid overload factor into one of my nursing diagnosis. I looked in the NANDA and there are no Ns Dx for Sepsis or Sirs. So this leaves me to compartmentalize my nursing diagnosis. One for septicemia, fluid excess, and respiratory failure. So I am just having a hard time trying to find a way to tie things together. None of my lab values are abnormal that indicate fluid overload atleast so far as i have found in my lab studies and diagnostics text book. My patient has definite edema all over including periorbital edema.

[Nurse Kyles, BSN, RN]

Think of the manifestations of your client. What organs are involved? If all of the fluid is in the tissues, where is it not? If there is decreased fluid in the vasculature, how will that manifest? Think about what you know about"normal" fluid volume excess. Would these manifestations be the same if the fluid is in the tissues vs vasculature? If there is decreased fluid in vasculature are the kidneys being perfused? How would that manifest?

I am no expert, but that is just my train of thought. Hope it sends you in the right direction!

It might be best to look up shock-SIRS-MODS section in your med-surg book. Good Luck!

[nurseprnRN, BSN, RN]

"i looked in the nanda and there are no ns dx for sepsis or sirs "

there is no nursing diagnosis for mi, or cva, or esrd, or diabetes, or for any medical diagnosis. so, you didn't look in the nanda book for it. or if you did, you aren't clear on what you should be using it for.

many nursing students think there is a big list somewhere where column a is the medical diagnosis and column b is the nursing diagnosis. this is wrong-headed for several reasons. one is that nursing diagnoses are made by nurses using the nursing process (which i know you don't have a good handle on yet but we're trying to help), not dependent on a medical diagnostic process. nursing diagnosis is in no way subservient to or inferior to medical diagnosis.

yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

for example, if i admit a 55-year-old with diabetes and heart disease, i recall what i know about dm pathophysiology. i'm pretty sure i will probably see a constellation of nursing diagnoses related to these effects, and i will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. i might find readiness to improve health status, or ineffective coping, or risk for falls, too. these are all things you often see in diabetics who come in with complications. they are all things that nursing treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. but i can't put them in any individual's plan for nursing care until *i* assess for the symptoms that indicate them, the defining characteristics of each.

according to the american college of chest physicians and the society of critical care medicine,[/url] there are different levels of sepsis:

• systemic inflammatory response syndrome (sirs). defined by the presence of two or more of the following findings:
  
  • body temperature 38 °c (100 °f) (hypothermia or fever).
    
  • heart rate > 90 beats per minute.
    
  • respiratory rate > 20 breaths per minute or, on blood gas, a paco2 less than 32 mm hg (4.3 kpa) (tachypnea or hypocapnia due to hyperventilation).
    
  • white blood cell count mm3 or > 12,000 cells/mm3 ( 12 × 109 cells/l), or greater than 10% band forms (immature white blood cells). (leukopenia, leukocytosis, or bandemia).
    

  [*]sepsis. defined as sirs in response to a confirmed infectious process. infection can be suspected or proven (by culture, stain, or polymerase chain reaction (pcr)), or a clinical syndrome pathognomonic for infection. specific evidence for infection includes wbcs in normally sterile fluid (such as urine or cerebrospinal fluid (csf)); evidence of a perforated viscus (free air on abdominal x-ray or ct scan; signs of acute peritonitis); abnormal chest x-ray (cxr) consistent with pneumonia (with focal opacification); or petechiae, purpura, or purpura fulminans.

  [*]severe sepsis. defined as sepsis with organ dysfunction, hypoperfusion, or hypotension.

  [*]septic shock. defined as sepsis with refractory arterial hypotension or hypoperfusion abnormalities in spite of adequate fluid resuscitation. signs of systemic hypoperfusion may be either end-organ dysfunction or serum lactate greater than 4 mmol/l. other signs include oliguria and altered mental status. patients are defined as having septic shock if they have sepsis plus hypotension after aggressive fluid resuscitation (typically upwards of 6 liters or 40 ml/kg of crystalloid solution).

so... what do you assess with this patient? what do you see? when you think about the pathophysiology, where might you look in nanda 2009-2011 (which every student should have) for possible nursing diagnoses related to that?