University of Newcastle: NURS2101 Mr. Fraser Hypervolemia Care Plan

This assignment focuses on a nursing care plan for Mr. Ron Fraser, a patient experiencing hypervolemia. The plan begins with an introduction defining hypervolemia and its common causes, such as kidney and heart problems. The assignment then identifies abnormal cues like high blood pressure (160/90), increased pulse (110bpm), low temperature (34C), low oxygen saturation (89%), and an elevated respiratory rate (28). It discusses risk factors, including excessive sodium intake and kidney issues, and links them to the patient's blood test results. The pathophysiology section explains how the Hartmann’s solution and kidney problems contribute to fluid imbalances, leading to symptoms like pulmonary edema, increased blood pressure, and edema. The care plan outlines goals, including balanced fluid volume and reduced edema, and proposes nursing actions such as monitoring fluid intake and output, assessing edema, encouraging deep breathing, and promoting physical exercise. Rationales for each action are provided, supported by relevant research. The care plan emphasizes the importance of monitoring and intervention to prevent complications and improve the patient's condition. References from various sources are provided to support the findings.

Name of patient: Mr Ron Fraser
Chosen Scenario number: Scenario 3 A - Altered fluid balance (Hypervolaemia)
List the cluster of cues related to the above priority problem in the identified scenario situation. Clearly indicate the cues which are abnormal and provide the
normal ranges (with referencing) for comparison where appropriate.
Introduction
Hypervolemia is a condition of having too much water in the body. The condition is common to patients with chronic conditions such as diabetes, kidney and heart
problems. Patients with hypervolemia have a high blood pressure which is as a result of fluid entering the lungs which also reduces the ability to breath and hence body
organs may not get sufficient oxygen making the oxygen saturation rate to decrease Eltzschig et.al 2018. With law oxygen saturation, the breaths increase as the body
organs try to get oxygen from the environment. The fluid also causes speed up the heart rate, consequently harming the size of the heart. The fluid in the lungs raises
the blood pressure forcing the heart to work harder and having a pulse rate of more than 72bpm.
Abnormal cue Normal value Reference
Blood pressure 160/90 120/80 -139/89 Elliott, & Lawton, (2018).
Pulse 110bpm 60-100bpm (Hart,2015).
Temperature 34C 36.1 -37.2C (Ridley, et.al .2018).
Oxygen saturation 89%, 95-100 % (Morgan et .al 2017)
Respiratory rate of 28 Normal is 12-20 RR (Winland-Brown, & Klause. (2017).

Process information – Discuss Risk Factors and Contributing factors
Individuals who take an excess intake of sodium from their diet, are susceptible of getting hypervolemia condition. This is because when there is too much sodium in the
body, it may equally require a lot of water to retain it. In most cases, the condition occurs when there is a problem of removing excess water in the body. Therefore, one an
individual takes a high content of sodium salt in the body, there are chances of retaining much water into the body (Kazory, A. 2017).. From the hospital, Fraser’s blood
test indicated Na 130 mmol/L, K 5.5mmol/L, Cl 90mmol/L, Urea 14.0mm/L, Creatinine 150umol/L, eGFR 40, Alb 26 , meaning that he was taking a lot of salt in his diet
which is a major contributing factor of hypervolemia condition .
Seeing that that Mr. Fraser had a kidney problem, this is also a contributing factor to the hypervolemia. According to the recent study, it indicates that the condition highly
prevalent to patients with the kidney disease. This is because kidney helps in regulation of amount sodium and water in the body. In addition, Kidney has role of
maintaining osmoregulation in the body by determining the fluid to be maintained and the one to be execrated Therefore, if the kidney is damaged there will be poor
control of water and sodium in the body and hence much of the water will be retained in the body resulting to hypervolemia (Sahutoglu et.al 2018).
Mr. Fraser had gone through surgery and was given various mediation such as the given 2x 250 mL boluses of Hartmann’s, which made his pressure increase. Such
medication caused hormonal imbalance in his body risking to hypervolemia condition. Fraser has been increasing his urine output day by day. His urine output increased to
30ml. This is are clear signs of nephrotic syndrome. This condition causes excess fluid in the body due to Serum hypoleukemia. When the serum drops, the oncotic
pressure makes fluid to accumulate in the tissues of the intestines leading to edema. Edema is also a risk factor in hypervolemia (Ray, et.al, 2015).
Process information – Discuss Pathophysiology associated with the abnormalities and link to the present symptom (cues) with referencing
Mr. Fraser was given 2x 250 mL boluses of Hartmann’s solution on the evening of his first post-operative day. The Hartmann’s solution was used to regulate and maintain
patient fluid balance by replacing the lost fluid or fluid resuscitation. This is usually done by adding sodium lactate solution. When there is insufficient fluid in the body the
cognitive brain function becomes impaired (Frost, 2015). The blood is therefore concentrated which makes the kidneys to retain water, consequently, the urine output

reduces. When the blood concentration is high it makes the heart work more to maintain the blood pressure. But after administration of Hartmann’s solution, the body
regains fluid balance and the body can work normally since the Sodium ions make the body tissues hypotonic making the fluid flow into the tissues and the rest of the
body.
The blood pressure of the patient is 160/90. This is a result of increasing the heartbeat which is 110 bpm. When there is excess fluid in the body it may cause pulmonary
edema, which occurs when the fluid enters the air sacks of the lungs. Therefore, there rises a problem with gaseous exchange. leading to respiratory failure. The body
organs are unable to get sufficient oxygen due to this condition. This gives the reason why the patient has crackles in the lung’s field auscultation. When the lungs cannot
produce enough oxygen to the body organs, the saturation rate decreases and the respiratory rate increases since the body does not get enough oxygen from the lungs
(Prasad, et.al 2018). The patient experiencing high blood pressure due to the excess fluid in the bloodstream increases the rate at which the heartbeats. And may harm the
heart muscles. This gives the reason why the blood pressure is 160/90 and the heartbeat is 110bpm.
The fluid balance chart shows a positive balance and a gain of weight his ankles are puffy. He is tired and lethargic and does not want to get up. This happens as a result of
Edema which occurs due to the accumulation of the fluid in the body tissues causing the pedal edema. It is caused by venous edema as a result of capillary filtration,
retaining protein fluid in the venous system.
If the condition remains untreated it results in painful swelling of the foot, walking difficulties, skin ulcers, and reduced blood circulation. Individuals with fluid retention
in their bodies are often faced with the challenge of weight gain (Chen, & Zeng, 2020). This is because when water accumulates in the body it causing bloating in most
parts of the abdomen arms and even legs. This adds more weight to the body of more than 1-2 pounds a day. One gets a feeling of general weakness and short breath,
ad Goal of care including
SMART outcome criteria
Priority Nursing actions (4) including specific
detail
Rationales for each action (4) explained
with in text reference

Altered fluid balance
(Hypervolaemia)
Related to:
Compromised regulatory
mechanism
Excess fluid, sodium
intake.
Excess urination.
Evidenced by:
crackles in all lung fields
on auscultation
He has a pitting oedema
to mid calves and in
sacral area
his blood pressure
increased slowly to
120/80.
he is complaining of
The patient is expected to
have a balanced fluid volume,
with a balanced weight and
reduce edema signs. This can
be done regulating amount
salt intake of the patient.
Making regular exercises is
equally helpful to the patient
in reducing weight of the
fluid in the body. (Blowey,
2016).
Help the patient understand
self-care management by
following proper dietary
procedures. Which can by
eating food with high content
of caffeic acid such as
Cucumber and coffee. (Hall,
et.2019)
The patient will demonstrate
Can monitor the intake or the output. Record the
reduced urinary output and note the positivity of
the fluid balance within 24-hour. This will ensure
accurate record of the patient output in order to
know any deficits. The fluid balance chart is very
effective in the monitoring process. In addition, it
will help in preventing excess fluid or any
occurrence of body dehydration (Liaw et.al 2018).
Scrutinize the presence or where edema is located
and formed. This will help in its management and
taking necessary precaution for the patient, which
may either be administration of furosemide
Lasix or provide self-management strategies
(Thanakitcharu, et.al 2014).
Help the patient in deep breathing and coughing
exercises. This will help air movement down to
the bottom areas of the body. It will assist in
oxygen circulation and reduces the risk of further
When there is a decreasing renal perfusion,
the cardiac imbalance and fluid change, may
reduce urinary output and formation of
edema (Malbrain, et.al2018). Therefore,
proper monitoring of the patient fluid
reduces the overall body condition such as
pulse rate, higher respiratory rate and blood
pressure.
It is important to note Edema may be formed
due to pathological conditions in the
independent areas (Daruich et.al 2018).
Scrutinizing the formation of the edema by
identifying the signs and symptoms will help
manage other related issues of edema.
The pulmonary fluid from the cough may

breathlessness appropriate procedures for
monitoring fluid status and
mitigate reoccurrence. By
using prescription diuretic
pills, they can help in
reducing excess water.
Alternatively taking
magnesium supplements will
help will be very effective in
managing body (Jahnen-
Dechent & Ketteler, 2012)
.
lungs complications. Such as pneumonia (Çelik, &
Özer, 2020).
Encourage patient to have physical exercising.
Muscle movement of the affected part of the
edema assists in pumping the excess fluid to the
heart. More over the exercise reduce swelling
(Ratchford, & Evans, 2017)
shift respiratory complications (Rose, et.al
2017) as well allowing more oxygen to flow
to the body organs to avoid hypoxia. Hence
the body organs will work effectively.
Physical exercises help relieve the excess
fluid in the lungs, legs. This can be done by
putting legs on pillows or raising them
above the heart when just lying down
(Hoaas et.al 2016).
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