Which of the following nursing diagnoses might apply to a patient with hypertonic FVE?
A. Ineffective airway clearance
B. Potential for decreased cardiac output
C. Ineffective breathing pattern
D. Potential for increased cardiac output
Correct Answer: B. Potential for decreased cardiac output
Potential for decreased cardiac output is a nursing diagnosis associated with hypertonic FVE. Assess for bounding peripheral pulses and S3. These assessment findings are signs of fluid overload. Check for distended neck veins and ascites. Monitor abdominal girth to follow any ascites accurately. Distended neck veins are caused by elevated CVP. Ascites occur when fluid accumulates in extravascular spaces.
Option A: Assess for crackles in the lungs, changes in respiratory pattern, shortness of breath, and orthopnea. These signs are caused by an accumulation of fluid in the lungs.
Option C: Review the patient’s history to determine the probable cause of the fluid imbalance. Such information can assist in direct management. History may include increased fluids or sodium intake.
Option D: Monitor input and output closely. Dehydration may be the result of fluid shifting even if overall fluid intake is adequate. In some patients with heart failure, the weight may be a poor indicator of fluid volume status. Poor nutrition and decreased appetite over time result in a decrease in weight, which may be accompanied by fluid retention even though the net weight remains unchanged.
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