A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial infarction who was admitted two (2) days ago. The nurse would plan to do which of the following next?
A. Review the intake and output records for the last two (2) days.
B. Change the time of diuretic administration from morning to evening.
C. Request a sodium restriction of one (1) g/day from the physician.
D. Order daily weight starting the following morning.
Correct Answer: A. Review the intake and output records for the last 2 days.
Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Monitor intake and output. Note decreased urinary output and positive fluid balance on 24-hour calculations. Decreased renal perfusion, cardiac insufficiency, and fluid shifts may cause decreased urinary output and edema formation.
Option B: Diuretics should be given in the morning whenever possible to avoid nocturia. To achieve excretion of excess fluid, either a single thiazide diuretic or a 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.
Option C: Strict sodium restrictions are reserved for clients with severe symptoms. Monitor laboratory studies, such as sodium, potassium, BUN, and arterial blood gasses (ABGs), 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.
Option D: Weigh the client daily. Observe for sudden weight gain. One liter of fluid retention equals a weight gain of 1 kilogram (2.2 pounds). Auscultate lung and heart sounds. Adventitious sounds (crackles) and extra heart sounds (S3) are indicative of fluid excess, possibly returning in the rapid development of pulmonary edema.
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