AUBREY ROSE A.

VIDON

BSN 3Y1-2 September 4, 2020

COURSE TASK #2

QUESTION:

1. HYPERVOLEMIA

A patient was admitted in the medical ward with chief complaints of shortness of breath. Further
assessment reveals the following findings:

 BP –140/90 mm Hg
 HR –111 bpm
 RR –24 cpm
 +2 bipedal edema
 Bibasilar crackles upon auscultation

The doctor initially ordered furosemide 20 mg ampule TIV every 8 hours and the following
laboratory tests: Complete Blood Count (CBC), Serum Sodium, Serum Potassium, Blood Urea
Nitrogen, Serum Creatinine, Total Protein, and Chest X-ray.

1. Write down three (3) priority nursing diagnoses for the patient and create a hypothetical
FDAR.
2. What laboratory test may give the hint to the doctor about the oncotic pressure of the
patient?
3. Create a drug study for FUROSEMIDE specifying the following:
1. Drug classification
2. Mechanism of action
3. Indication (*for the case of the patient mentioned above)
4. Contraindication
5. Side effects
6. Nursing Considerations

ANSWER:

1. Three Nursing Diagnosis:

 Hypertension
 Ineffective Airway Clearance
 Fluid Volume Excess
Date/Hour Focus Progress Notes
9/3/20 Hypertension Data:
9:00 PM  Blood Pressure of 140/90 mmHg

Action:
 Administered furosemide 20mg
ampule TIV every 8 hours as per
doctor’s order
 Encourage restriction of sodium
and fat
 Support active patient control of
condition

Response:
 Blood Pressure is at less than
140/90 mmHg
 No complications
 Has palpable peripheral pulses

Date/Hour Focus Progress Notes

9/3/20 Ineffective Airway Clearance Data:
9:00 PM  Shortness of breath
 Respiratory rate of 24 breaths per
minute
 Bibasilar crackle upon
auscultation

Action:
 Teach the patient the proper
ways of coughing and breathing
(e.g. take a deep breath, hold for
2 seconds, and cough 2 or 3
times in succession)
 Encourage patient to increase
fluid intake to 3 liters per day
within the limits of cardiac
reserve and renal function
 Give medication as prescribed,
such as antibiotic, mucolytic
agents, bronchodilators,
expectorants, noting
effectiveness and effects.
 Provide oral care every 4 hours
 Educate patient coughing, deep
breathing, and splinting
techniques

Response:
 The patient maintained airway
patency, clear breath sounds
 The patient expectorated retained
secretions and maintained normal
breathing pattern

Date/Hour Focus Progress Notes

9/4/2020 Fluid Volume Excess Data:
 +2 bipedal edema

Action
 Limit sodium intake as prescribed
 Take diuretics as prescribed.
 Elevate edematous extremities,
and handle with care.
 Place the patient in a semi-
Fowler’s or high-Fowler’s
position.
 Administer IV fluids through an
infusion pump, if possible.

Response:
 Patient has balanced intake and
output and stable weight.
 Patient maintains HR 60 to 100
beats/min
 Patient has clear lung sounds as
manifested by absence of
pulmonary crackles.
 Patient verbalizes awareness of
causative factors and behaviors
essential to correct fluid excess.

2. The serum creatinine provides a sufficient screen for advanced renal insufficiency, and
the serum albumin permits a useful approximation of the plasma oncotic pressure.

3. Drug Study of Furosemide:

Drug Mechanism of Action Indication

Classification
 Diuretics  Furosemide, like other loop  Indicated in adult patient for
diuretics, acts by inhibiting the treatment of edema
the luminal Na-K-Cl associated with congestive
cotransporter in the thick heart failure and
ascending limb of the loop hypertension.
of Henle, by binding to the
chloride transport channel,
thus causing sodium,
chloride and potassium
loss in urine.

Contraindication Side Effects Nursing Considerations

 Furosemide is  Increased urination  Assess fluid status
contraindicated  Muscle cramps  Monitor daily weight, intake
in patients with  Itching or rash and output ratios, amount
anuria. It should  Weakness and location of edema,
be used  Dizziness lung sound, skin turgor,
cautiously in any  Diarrhea and mucous membranes.
patient with renal  Stomach pain Monitor BP and pulse
disease such as before and during
 Constipation
severe renal administration.
impairment or
renal failure.

2. HYPOVOLEMIA

A teenage patient was rushed to the emergency department due to wrist laceration from a
suicide attempt. The patient is lethargic and has the following findings upon assessment:

 BP –80/50 mm Hg
 HR –110 bpm
 RR –25 bpm

The doctor initially ordered fluid resuscitation with PNSS 1L, to fast-drip 200 cc then the
remaining fluid to run for 6 hours. Stat blood typing was ordered, and 3 units of whole blood was
ordered to be transfused immediately after proper cross-matching. The patient was hooked to
oxygen 8 liters per minute via face mask.

1. What parameters will the nurse check while the patient is undergoing rapid fluid
resuscitation?
2. For a patient who will undergo blood transfusion, enumerate the steps that the nurse
should prudently undertake while performing the procedure.
3. List down three (3) priority nursing diagnoses for the patient and create a hypothetical
FDAR.

ANSWER:

1. Fluid administration is beneficial only if it increases the stroke volume (SV) and thereby, the
cardiac output. Patients are considered fluid responsive if SV increases by at least 10% after a
fluid challenge of 500 mL of crystalloid. Pulse pressure variation, passive leg raising test, and
SV variation are some reliable markers for fluid responsiveness. In patients with massive blood
loss, permissive hypotension prevents progression to dilutional coagulopathy of trauma . In
severe and uncontrolled hemorrhagic shock, controlled resuscitation (MAP of 40 mmHg) is
preferred. Two strategies were proposed to avoid clot disruption and dilutional coagulopathy:
delayed resuscitation strategy where fluid is given after bleeding is controlled and permissive
hypotension strategy, where fluid is given to increase SBP without reaching normotension. In
penetrating trauma patients with hypotension (prehospital SBP < 90 mmHg), delayed
resuscitation shows better survival rates compared to immediate resuscitation. Increased
mortality is seen with increased in-field procedures, supporting “scoop and run” and delayed
fluid resuscitation techniques. However, when PTT is long, simple life support measures reduce
mortality in severely injured patients even when conducted in suburban and remote locations
with long PTT.

2.

 Requesting blood, clearly indicating the reason for transfusion and communicating the
degree of urgency to the Blood Transfusion Laboratory.
 Providing full information on transfusion requests
 Explaining to patients the risks, benefits and possible alternatives to blood transfusion
and providing written information where appropriate
 Requesting collection of blood including arranging urgent transportation if required
 Obtaining red cells for transfusion via the electronic remote issue system, ensuring that
the right blood unit is correctly labeled for the intended patient and that blood for only
one patient is collected at each visit
 Carrying out pre transfusion checks to ensure the right blood is transfused
 Monitoring the patient during transfusion
 Inclusion of medical staff in the management of the patient if a transfusion reaction
should occur
 Reporting of transfusion reactions or other incidents to the Blood Transfusion Laboratory
 Documentation of indications for transfusion, number of units administered and
observations recorded in patients’ medical records

3.

 Acute Pain
 Decrease Cardiac Output
 Hypovolemic Shock
Date/Hour Focus Progress Notes
9/4/20 Acute Pain Data:
9:00 PM  Wrist laceration

Action:
 Foresee the need for pain relief.
 Get rid of additional stressors or sources
of discomfort whenever possible.
 Determine the appropriate pain relief
method.
 Provide analgesics as ordered,
evaluating the effectiveness and
inspecting for any signs and symptoms
of adverse effects.

Response:
 Patient displays improved well-being
such as baseline levels for pulse, BP,
respirations, and relaxed muscle tone or
body posture.
 Patient uses pharmacological and
nonpharmacological pain-relief
strategies.
 Patient displays improvement in mood,
coping.

Date/Hour Focus Progress Notes

9/4/20 Ineffective Tissue Perfusion Data:

9:00 PM  Severe blood loss.
 Weak, thready pulse
 Altered mental status.
 Shallow respirations.
Action:
 Assess for rapid changes or continued
shifts in mental status.
 Observe for pallor, cyanosis, mottling,
cool or clammy skin. Assess quality of
every pulse.
 Record BP readings for orthostatic
changes (drop of 20 mm Hg systolic BP
or 10 mm Hg diastolic BP with position
changes).
 Provide oxygen therapy if indicated.
 Administer IV fluids as ordered.

Response:
 Patient maintain maximum tissue
perfusion to vital organs, as evidenced
by warm and dry skin, present and
strong peripheral pulses, vitals within
patient’s normal range, balanced I&O,
absence edema, normal ABGs, alert
LOC, and absence of chest pain.

Date/Hour Focus Progress Notes

9/4/20 Decreased Cardiac Output Data:
 Blood loss
 Change in level of consciousness.
 Tachycardia.
 Decreased blood pressure.

Action:
 Assess the client’s HR and BP, including
peripheral pulses. Use direct intra-
arterial monitoring as ordered.
 Monitor oxygen saturation and arterial
blood gasses.
 Monitor the client’s central venous
pressure (CVP), pulmonary artery
diastolic pressure (PADP), pulmonary
capillary wedge pressure, and cardiac
output/cardiac index.
 Assess for any changes in the level of
consciousness.
 Administer fluid and blood replacement
therapy as prescribed.
 Use a fluid warmer or rapid fluid infuser.

Response:
 Patient is normovolemic as evidenced by
HR 60 to 100 beats per minute, systolic
BP greater than or equal to 90 mm Hg,
absence of orthostasis, urinary output
greater than 30ml/hr, and normal skin
turgor.

3. THIRD SPACE EDEMA

A patient with portal hypertension secondary to chronic liver cirrhosis was admitted in the
surgical ward. The patient presented with emaciated body build, distended abdomen with
prominent veins, and jaundice. The doctor ordered paracentesis and the following laboratory
tests prior the procedure: Prothrombin time (PT), Activated Partial Thromboplastin Time (APTT),
Total Protein, Albumin-Globulin ratio, AST, ALT.

1. List down two (2) nursing diagnoses and create a hypothetical FDAR for the patient.
2. Why is there a need to check the PT and APTT levels of the patient prior paracentesis?
3. What is the rationale behind the order of checking the Total Protein, Albumin-Globulin
ratio?
4. Enumerate the following regarding the nursing role in assisting with paracentesis:
 Position of choice
 Site of insertion
 At least three (3) nursing considerations

ANSWER:

1. Two nursing diagnoses

 Excess Fluid Volume
 Risk for Injury

Date/Hour Focus Progress Notes

9/4/20 Excess Fluid Volume Data:
9:00 PM
 Excess sodium/fluid intake
 Edema, anasarca, weight gain
 Intake greater than output, oliguria,
changes in urine specific gravity
 Dyspnea, adventitious breath
sounds, pleural effusion
 BP changes, altered CVP
 JVD, positive hepatojugular reflex
 Altered electrolyte levels

Action:

 Measure I&O, weigh daily, and note

gain of more than 0.5 kg/day.
 Monitor BP (and CVP if available).
Note JVD and abdominal vein
distension.
 Measure abdominal girth.
 Encourage bedrest when ascites is
present.
 Administer salt-free albumin/plasma
expanders as indicated.

Response:
 Stabilized fluid volume, with balanced
I&O, stable weight, vital signs within
patient’s normal range, and absence
of edema.

Date/Hour Focus Progress Notes

9/4/20 Risk for Injury Data:
9:00 PM  Portal hypertension
 Abnormal blood profile; altered
clotting factors (decreased
production of prothrombin,
fibrinogen, and factors VIII, IX, and
X; impaired vitamin K absorption;
and release of thromboplastin)

Action:
 Monitor pulse, BP (and CVP if
available).
 Closely assess for signs and
symptoms of GI bleeding: check all
secretions for frank or occult blood.
Observe color and consistency of
stools, NG drainage, or vomitus.
 Observe for presence of petechiae,
ecchymosis, bleeding from one or
more sites.
 Use small needles for injections.
Apply pressure to small bleeding and
venipuncture sites for longer than
usual.

Response:
 Maintain homeostasis with absence
of bleeding
 Demonstrate behaviors to reduce
risk of bleeding.
2. Prothrombin Time (PT) which measures the integrity of the extrinsic system as well as
factors common to both systems and Partial Thromboplastin Time (PTT), which
measures the integrity of the intrinsic system and the common components. The partial
thromboplastin time (PTT; also known as activated partial thromboplastin time (aPTT)) is
a screening test that helps evaluate a person's ability to appropriately form blood clots. It
measures the number of seconds it takes for a clot to form in a sample of blood after
substances (reagents) are added. In patients without clinical evidence of active bleeding,
routine labs such as prothrombin time (PT), activated partial thromboplastin time (aPTT),
and platelet counts may not be needed prior to the procedure.
3. Proteins are important building blocks of all cells and tissues. They are important for
body growth, development, and health. They form the structural part of most organs and
make up enzymes and hormones that regulate body functions. This test measures the
amount of protein in your blood.

Two classes of proteins are found in the blood, albumin and globulin:
 Albumin is made by the liver and makes up about 60% of the total protein.
Albumin keeps fluid from leaking out of blood vessels, nourishes tissues, and
transports hormones, vitamins, drugs, and substances like calcium throughout
the body.
 Globulins make up the remaining 40% of proteins in the blood. The globulins are
a varied group of proteins, some produced by the liver and some by the immune
system. They help fight infection and transport nutrients.

The test also compares the amount of albumin with globulin and calculates what is
called the A/G ratio. A change in this ratio can provide your healthcare practitioner with a
clue as to the cause of the change in protein levels.

Total protein levels in the blood may increase or decrease, to a greater or lesser degree,
with various conditions.

Total protein levels may decrease in conditions that:

 Interfere with production of albumin or globulin proteins, such as malnutrition or
severe liver disease
 Increase the breakdown or loss of protein, such as kidney disease (nephrotic
syndrome)
 Increase or expand the volume of plasma, the liquid part of blood (diluting the
blood), such as congestive heart failure
Total protein levels may increase with conditions that cause:
 Abnormally high production of protein (e.g., inflammatory disorders, multiple
myeloma)
 Dehydration
4.

Position of Choice Site of Insertion Nursing Considerations

The patient is placed in the The insertion sites may be 1. Reassure the patient
supine position and slightly midline or through the oblique during the procedure.
rotated to the side of the transverses muscle, which is Checks of blood
procedure to further minimize lateral to the thicker rectus pressure, heart rate
the risk of perforation during abdominus muscles. and respiratory rate,
paracentesis. Because the and temperature
cecum is relatively fixed on monitoring, and
the right side, the left-lateral observe for any signs
approach is most commonly of complications, such
used. as leakage of ascetic
fluid, infection, bladder
and bowel perforation
and bleeding.
2. Observe the
characteristic and
amount of fluid
aspirated.
3. Measure his/her
abdominal girth for
comparison with the
baseline
measurement.