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NCP 1

The patient presented with massive ascites, right lung cancer with metastasis to the brain, and fluid volume excess. Nursing diagnoses included fluid volume excess related to ascites. Goals were to stabilize fluid volume, decrease edema, and maintain normal vital signs within 8 hours. Interventions included monitoring vitals and edema, maintaining fluid balance, restricting oral fluids, encouraging rest and activity, and collaborating on treatment of the underlying causes including diet restrictions, diuretics, and dialysis if needed. The patient's fluid volume and edema were partially stabilized but further interventions were still needed.

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205 views5 pages

NCP 1

The patient presented with massive ascites, right lung cancer with metastasis to the brain, and fluid volume excess. Nursing diagnoses included fluid volume excess related to ascites. Goals were to stabilize fluid volume, decrease edema, and maintain normal vital signs within 8 hours. Interventions included monitoring vitals and edema, maintaining fluid balance, restricting oral fluids, encouraging rest and activity, and collaborating on treatment of the underlying causes including diet restrictions, diuretics, and dialysis if needed. The patient's fluid volume and edema were partially stabilized but further interventions were still needed.

Uploaded by

Charm Tanya
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Assessment

S: Ang bigat ng
tiyan ko. Nasusuka
ako dahil
pakiramdam ko
sobra akong busog,
grabe pa manas ko
sa katawan.
O:

BP: 130/90
PR: 92bpm
RR: 24
T: 36.0
Dx result:
massive
ascites, R
lung cancer
CT scan:
metastasis to
brain
Diet: H2o
restriction and
avoid high
sodium diet
Assisted
Paracentesis
with 1800 mL
aspirate
Abdominal
Girth of117
cm
With pitting
edema grade

Explanation of the
Problem
Cancer cells can
block the
lymphatic system
which help drain
off excess fluid. If
some of these
lymphatic
channels are
blocked, the
system can't drain
efficiently and fluid
can build up. Also,
if cancer cells have
spread to the
lining of the
abdomen, they
can irritate it and
cause fluid to build
up.
Fluid volume
excess, or
hypervolemia,
occurs from an
increase in total
body sodium
content and an
increase in total
body water. This
fluid excess
usually results
from compromised
regulatory
mechanisms for

Goals
STO:
After 8 hours of
nursing
interventions,
patient will :
a.demonstrate
stabilized fluid
volume and
decreased pitting
edema of 1 to 2
and abdominal
girth of 40-70cm.
b.Vital signs of
Blood pressure:
90/60 mm/Hg to
120/80 mm/Hg.
Breathing: 12 - 18
breaths per
minute. Pulse: 60
- 100 beats per
minute.
c.perceive the
reason for fluid
restriction of 300
to 500 ml and will
avoid high sodium
diet foods such as
canned foods,
frozen meals,
snack foods, and
seasoned side
dishes.

INTERVENTIONS
Independent
Monitor vital signs as well
as CVP, if available.

Assess for presence and


location of edema
formation.

RATIONALE
Tachycardia and
hypertension are common
manifestations.
Tachypnea usually present
with or without dyspnea.
Elevated
CVP may be noted before
dyspnea and adventitious
breath
sounds occur. Hypertension
may be a primary disorder
or
occur secondary to other
associated conditions such
as heart
failure (HF).
Adventitious sounds
(crackles) and extra heart
sounds (S3) are indicative
of fluid excess, possibly
resulting in rapid
development of pulmonary
edema. Edema can be
either a cause or a result of
various pathological
conditions reflecting four
competing forces: blood
hydrostatic and osmotic
pressures and interstitial
fluid hydrostatic and
osmotic pressures. The
dynamic interaction of

Evaluation
STO is partially
met since the
patient
manifested :
a.demonstr
ate
stabilized
fluid
volume and
decreased
pitting
edema of 2
.
b.perceive
the reason
for fluid
restriction
of 300 to
500 ml and
will avoid
high
sodium diet
foods such
as canned
foods,
frozen
meals,
snack
foods, and
seasoned
side dishes.

3 noted on
both upper
and lower
extremities
With crackles
noted on both
lung fields
upon
auscultation
Nursing Diagnosis:
Fluid Volume Excess
related to ascites

sodium and water


as seen in this
case because of
the metastasis of
the cancer cells
which originated
from the lungs.
Reference:
Doenges, M.E.
(2010). Nurses
Pocket Guide.
Diagnoses,
Prioritized
interventions and
Rationales. F.A.
Davis Compay.
Philadelphia.

LTO
After a series of
Nursing
Interventions the
patient will be
able to have :
a. No presence of
pitting edema on
both upper and
lower extremities
b.Normal
Abdominal girth
of 46 cm
c.No presence of
crackles on both
lung fields.
d. Normal Vital
signs of Blood
pressure: 120/80
mm/Hg.
Breathing: 18
breaths per
minute. Pulse: 60
beats per minute.

Note presence of neck and


peripheral vein distention,
along with pitting edema,
and dyspnea.
Maintain accurate I&O.
Note decreased urinary
output and positive fluid
balance on 24-hour
calculations.
Weigh, as indicated. Be
alert for acute or sudden
weight gain.
Give oral fluids with
caution. If fluids are
restricted, set up a 24-hour
schedule for fluid intake.

these four forces allows


fluid to shift from one body
compartment to another.
Edema may be generalized
or localized in dependent
areas. Elderly clients may
develop dependent edema
with relatively little excess
fluid.
Signs of cardiac
decompensation and HF.
Decreased renal perfusion,
cardiac insufficiency, and
fluid shifts may cause
decreased urinary output
and edema formation.
One liter of fluid retention
equals a weight gain of 1
kilogram (2.2 pounds).

Monitor infusion rate of


parenteral fluids closely;
administer via control
device, as necessary.
Encourage coughing and
deep-breathing exercises.

e.no presence of
Ascites.
Maintain semi-Fowlers

Fluid restrictions, as well as


extracellular shifts, can
aggravate drying of mucous
membranes, and client may
desire more fluids than are
prudent.
Rapid fluid bolus or
prolonged excessive
administration potentiates
volume overload and risk of
cardiac decompensation.

position if dyspnea or
ascites is present.

Turn or reposition, and


promote early ambulation,
where possible. Provide
skin care at regular
intervals.
Encourage rest periods.
Schedule care to provide
frequent rest periods.

Provide safety precautions


as indicated, such as use
of side rails, bed in low
position, frequent
observation, and soft
restraints, if required to
prevent client injury.
Collaborative
Assist with identification
and treatment of
underlying cause.

Pulmonary fluid shifts


potentiate respiratory
complications.
Gravity improves lung
expansion by lowering
diaphragm and shifting fluid
to lower abdominal cavity.
Reduces pressure and
friction on edematous
tissue, which is more prone
to breakdown than normal
tissue.
Limited cardiac reserves
result in fatigue and activity
intolerance. Rest,
particularly lying down,
favors diuresis and
reduction of edema.
Fluid shifts may cause
cerebral edema and
changes in mentation,
especially in the geriatric
population.
Note: Restraints must be
used as infrequently as
possible, and be limited to
a specified time period with
client under close
supervision (Dugdale,
2012).
Refer to listing of

predisposing and
contributing factors to
determine treatment needs.

Monitor laboratory studies,


such as sodium,
potassium, BUN, and
arterial blood gases
(ABGs), as indicated.

Provide balanced protein,


low-sodium diet. Restrict
fluids, as indicated.
Administer diuretics: loop
diuretic such as
furosemide (Lasix),
thiazide diuretic such as
hydrochlorothiazide
(Esidrix), or potassiumsparing diuretic such as
triamterene (Direnium),
amiloride (Midamore),
spironolactone
(Aldactone).

Replace potassium losses,


as indicated.

Extracellular fluid shifts,


sodium and water
restriction, and renal
function all affect serum
sodium levels. Potassium
deficit may occur with
kidney dysfunction or
diuretic therapy. BUN may
be increased as a result of
renal dysfunction. ABGs
may reflect metabolic
acidosis.
If serum proteins are low
because of malnutrition or
gastrointestinal (GI) losses,
intake of dietary proteins
can enhance colloidal
osmotic gradients and
promote return of fluid to
the vascular space.
Restriction of sodium or
water decreases
extracellular fluid retention.
To achieve excretion of
excess fluid, either a single
thiazide diuretic or a

Prepare for and assist with


dialysis or ultrafiltration, if
indicated.

combination of agents may


be selected, such as
thiazide and
spironolactone. The
combination can be
particularly helpful when
two drugs have different
sites of action, allowing
more effective control of
fluid excess.
Potassium deficit may
occur, especially if client is
receiving potassiumwasting diuretic. This can
cause lethal cardiac
dysrhythmias if untreated.
May be done to rapidly
reduce fluid overload,

http://www.macmillan.org.uk/Cancerinformation/Livingwithandaftercancer/Symptomssideeffects/Othersymptomssideeffects/Ascites.aspx
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick22.html

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