Primary Nursing Diagnosis

Fluid volume excess (total body) related to excessive serum protein loss and resultant volume shifts out of vascular bed

OUTCOMES. Fluid balance; Hydration; Circulation status; Cardiac pump effectiveness

INTERVENTIONS. Fluid monitoring; Fluid/electrolyte management; Fluid resuscitation; Intravenous therapy; Circulatory care

H PLANNING AND IMPLEMENTATION Collaborative

Edema is controlled by restricting salt to 2 to 3 g/day. Dietary alterations also include a highprotein diet with restrictions of cholesterol and saturated fat. If the patient has accompanying renal insufficiency, restriction of dietary protein may complicate the dietary plan. The amount of protein lost in the urine needs to be added to the calculated protein restriction to arrive at the total daily protein intake. Most patients need nutritional consultation with a dietitian to identify an appropriate diet within the restrictions. Involve the patient, parents, or significant others in the meal selection to ensure that the diet is appealing to the patient. Discuss the optimal fluid intake for the patient with the physician so that the patient is well hydrated and yet does not have continued fluid retention.

Other collaborative interventions are primarily pharmacologic. In spite of the excessive edema, patients need to be monitored for dehydration and hypokalemia, particularly when they are on diuretic therapy. Patients need to maintain an adequate fluid intake and a diet high in potassium (unless they have renal insufficiency).

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Rationale

Prednisone (Orasone)

1 mg/kg per day PO until <3 g protein per day in urine

Glucocorticoid

Decreases permeability of glomerulus to protein; initiated as soon as possible after the diagnosis of NS is confirmed

Cyclophosphamide (Cytoxan)

2 mg/kg per day PO for 8 wk

Antineoplastic

For patients who respond poorly to glucocorticoids

Other Drugs: The physician may prescribe diuretics if respiratory compromise from edema occurs or if edema causes tissue breakdown. Some patients may also receive parenteral albumin to raise the oncotic pressure within the vascular bed. To prevent thromboembolic complications, many patients are given anticoagulant therapy with heparin and warfarin. Acute thrombolytic episodes may require fibrinolytic agents such as streptokinase or surgical thrombectomy.

Independent

Focus on maintaining the patient's fluid balance, promoting skin care, preventing nosocomial infection, and providing supportive measures. To maintain the patient's skin integrity, turn the patient every 2 hours. Observe the skin closely for areas of breakdown until the edema resolves. Use an egg-crate mattress or specialty bed to limit irritation to skin pressure points, and encourage the patient or parents to avoid tight-fitting clothing and diapers.

Note that both the medications and the disease process may lead to immunosuppression. Implement scrupulous infection control measures, such as hand washing, sterile technique with invasive procedures, and clean technique for all noninvasive procedures to reduce the chance of infection. Do not assign patients to rooms with other patients who have infectious processes. Encourage visitation, but ask visitors with infections to wait until they are infection free before visiting. To limit the risk of blood clotting, encourage the patient to be as mobile as possible considering his or her underlying condition. If the patient is bedridden, use active and passive range-of-motion exercises at least every 4 hours and have the patient wear compression boots when immobile in bed.

662 Neurogenic Bladder

Note that some patients have a disturbed body image because of the side effects of steroid therapy (moon face, increased facial and body hair, abdominal distension, and mood swings). Encourage the patient to express these feelings and note that they are temporary until the condition resolves and the steroids are discontinued. If the patient desires, limit visitation to immediate family only until the patient resolves the anxiety over the body image disturbance.

Weight Loss All Star

Weight Loss All Star

Are you looking to lose weight or even just tone up? What is stopping you from having the body you want and help you feel great at the same time? I created Weight Loss All-Star for all those wanting to lose weight, and keep the weight off. I know how hard it is to do diets and stick with them, and get the motivation to get up and exercise.

Get My Free Ebook


Post a comment