Assessment:
Objectives:
- Edema on lower and upper peripheral part of the body
- Reduce or eliminate causative and contributing factors.
- Assess Mrs. Moto's dietary intake and her habits that may contribute to fluid retention. Be specific; record her daily and weekly intake of food and fluids. Assess Mrs. Moto's weekly diet for inadequate protein or excessive sodium intake. Discuss likes and dislikes of foods that provide protein.
- Teach Mrs. Moto to plan a weekly menu that provides protein at an affordable price. Teach her to decrease salt intake. Read labels for sodium content. Avoid convenience and canned and frozen foods. Cook without salt; use spices like lemon, basil, tarragon, mint to add flavor. Use vinegar in place of salt to flavor soups, stews, etc. Ascertain whether Mrs. Moto may use salt substitute.
- Assess for evidence of dependent venous pooling or venous stasis. Encourage alternating periods of horizontal rest with legs elevated with vertical activity or standing; this may be contraindicated in congestive heart failure. Keep the edematous extremity elevated above the level of the heart whenever possible (unless contraindicated by heart failure).
- Elevate Mrs. Moto's legs whenever possible, using pillows under them but avoid pressure points, especially behind the knees. Discourage leg and ankle crossing. Reduce constriction of vessels.
- Assess clothing for proper fit and constrictive areas. Instruct Mrs. Moto to avoid panty-girdles/garters, knee-high stockings, and leg crossing and to practice elevating her legs when possible. Consider using antiembolism stockings or Ace bandages; measure her legs carefully for stockings/support hose. Measure circumference of her calf and her thigh. Consider both measurements when choosing stockings, matching measurements with a size requirement chart that accompanies the stockings. Apply stockings while Mrs. Moto is lying down like in the morning before arising. Check her extremities frequently for adequate circulation and evidence of constrictive areas.
- Assess for venous pressure points associated with casts, bandages, and tight stockings. Observe circulation at edges of casts, bandages, and stockings. For casts, insert soft material to cushion pressure points at the edges. Check circulation frequently. Shift body weight in the cast to redistribute weight within, unless contraindicated. Encourage Mrs. Moto to do this every 15 to 30 minutes while awake to prevent venostasis. Encourage Mrs. Moto to wiggle her toes and isometric exercise of unaffected muscles within the cast. If she cannot do this alone, assist her at least hourly to shift body weight.
- Keep her extremity elevated on pillows. If the edema is marked, the arm should be elevated but not in adduction, be careful because this position may constrict her axilla. Her elbow should be higher than her shoulder. Her hand should be higher than her elbow. Measure Mrs. Moto's blood pressure in her unaffected arm. Do not give injections or start IV fluids in her affected arm. Protect her affected limb from injury. Teach Mrs. Moto to avoid using strong detergents, carrying heavy bags, holding cigarettes, injuring cuticles or hangnails, reaching into hot ovens, wearing jewelry or a wristwatch, or using Ace bandages. Advise Mrs. Moto to apply lanolin or a similar cream, often daily, to prevent dry, flaky skin. Encourage Mrs. Moto to wear a Medic-Alert tag engraved with Caution: lymphedema arm—no tests/no needle injections. Caution Mrs. Moto to visit a physician if her arm becomes red, swollen, or unusually hard.
- Inspect Mrs. Moto's skin for redness and blanching. Reduce pressure on her skin areas; pad chairs; use knee-high stockings and footstools. Prevent dry skin. Use soap sparingly. Rinse off soap completely. Use a lotion to moisten skin.
- Initiate health teaching and referrals, as Indicated. Give clear verbal and written instructions for all medications: what, when, how often, why, side effects; pay special attention to drugs that directly influence fluid balance. Write down instructions for diet, activity, and use of Ace bandages, stockings, and so forth. Have Mrs. Moto demonstrate the instructions. With severe fluctuations in edema, have her weigh herself every morning and before bedtime daily; instruct the Mrs. Moto to keep a written record of weights. For less severe illness, she may need to weigh herself only once daily and record the weight.
- Consider home care or visiting nurses referral to follow at home.
- Taut, shiny skin
- Weight gain
- Weight gain
Diagnosis:
Excess fluid volume related to compromised regulatory mechanisms secondary to:acute renal failure.
Planning:
After 8 hours of nursing intervention, the patient will exhibit decreased edema on lower peripheral part of the body. The patient will enumerate the causative factors of excess fluid volume and will enumerate methods of preventing edema.
Interventions:
- Identify contributing and causative factors about Mrs. Moto's situation.- Reduce or eliminate causative and contributing factors.
- Assess Mrs. Moto's dietary intake and her habits that may contribute to fluid retention. Be specific; record her daily and weekly intake of food and fluids. Assess Mrs. Moto's weekly diet for inadequate protein or excessive sodium intake. Discuss likes and dislikes of foods that provide protein.
- Teach Mrs. Moto to plan a weekly menu that provides protein at an affordable price. Teach her to decrease salt intake. Read labels for sodium content. Avoid convenience and canned and frozen foods. Cook without salt; use spices like lemon, basil, tarragon, mint to add flavor. Use vinegar in place of salt to flavor soups, stews, etc. Ascertain whether Mrs. Moto may use salt substitute.
- Assess for evidence of dependent venous pooling or venous stasis. Encourage alternating periods of horizontal rest with legs elevated with vertical activity or standing; this may be contraindicated in congestive heart failure. Keep the edematous extremity elevated above the level of the heart whenever possible (unless contraindicated by heart failure).
- Elevate Mrs. Moto's legs whenever possible, using pillows under them but avoid pressure points, especially behind the knees. Discourage leg and ankle crossing. Reduce constriction of vessels.
- Assess clothing for proper fit and constrictive areas. Instruct Mrs. Moto to avoid panty-girdles/garters, knee-high stockings, and leg crossing and to practice elevating her legs when possible. Consider using antiembolism stockings or Ace bandages; measure her legs carefully for stockings/support hose. Measure circumference of her calf and her thigh. Consider both measurements when choosing stockings, matching measurements with a size requirement chart that accompanies the stockings. Apply stockings while Mrs. Moto is lying down like in the morning before arising. Check her extremities frequently for adequate circulation and evidence of constrictive areas.
- Assess for venous pressure points associated with casts, bandages, and tight stockings. Observe circulation at edges of casts, bandages, and stockings. For casts, insert soft material to cushion pressure points at the edges. Check circulation frequently. Shift body weight in the cast to redistribute weight within, unless contraindicated. Encourage Mrs. Moto to do this every 15 to 30 minutes while awake to prevent venostasis. Encourage Mrs. Moto to wiggle her toes and isometric exercise of unaffected muscles within the cast. If she cannot do this alone, assist her at least hourly to shift body weight.
- Keep her extremity elevated on pillows. If the edema is marked, the arm should be elevated but not in adduction, be careful because this position may constrict her axilla. Her elbow should be higher than her shoulder. Her hand should be higher than her elbow. Measure Mrs. Moto's blood pressure in her unaffected arm. Do not give injections or start IV fluids in her affected arm. Protect her affected limb from injury. Teach Mrs. Moto to avoid using strong detergents, carrying heavy bags, holding cigarettes, injuring cuticles or hangnails, reaching into hot ovens, wearing jewelry or a wristwatch, or using Ace bandages. Advise Mrs. Moto to apply lanolin or a similar cream, often daily, to prevent dry, flaky skin. Encourage Mrs. Moto to wear a Medic-Alert tag engraved with Caution: lymphedema arm—no tests/no needle injections. Caution Mrs. Moto to visit a physician if her arm becomes red, swollen, or unusually hard.
- Inspect Mrs. Moto's skin for redness and blanching. Reduce pressure on her skin areas; pad chairs; use knee-high stockings and footstools. Prevent dry skin. Use soap sparingly. Rinse off soap completely. Use a lotion to moisten skin.
- Initiate health teaching and referrals, as Indicated. Give clear verbal and written instructions for all medications: what, when, how often, why, side effects; pay special attention to drugs that directly influence fluid balance. Write down instructions for diet, activity, and use of Ace bandages, stockings, and so forth. Have Mrs. Moto demonstrate the instructions. With severe fluctuations in edema, have her weigh herself every morning and before bedtime daily; instruct the Mrs. Moto to keep a written record of weights. For less severe illness, she may need to weigh herself only once daily and record the weight.
- Consider home care or visiting nurses referral to follow at home.
- Provide literature concerning low-salt diets; consult with a dietitian if necessary.
Evaluation:
After 8 hours of nursing intervention, the patient was exhibited decreased edema on lower peripheral part of the body. The patient was enumerated the causative factors of excess fluid volume and was enumerated methods of preventing edema.
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