Nursing Student Asked:

A 60-year-old female patient with a history of congestive heart failure (CHF) is admitted with complaints of shortness of breath and edema. Upon assessment, the nurse notes pitting edema in the lower extremities, lung crackles, and jugular vein distention. The healthcare provider orders an infusion of 0.9% normal saline at 75 mL/hour, and the nurse is to monitor the patient’s fluid balance closely. Over the next 24 hours, the patient’s total fluid intake is 2200 mL, and the total urine output is 1800 mL. Based on this information, calculate the patient’s fluid balance. Additionally, what clinical signs should the nurse monitor for that indicate worsening fluid overload? Provide the fluid balance in mL (enter numerical values only).

Step 1: Calculate the Patient’s Fluid Balance

Fluid balance is calculated by subtracting the total output (urine) from the total intake (oral and IV fluids).

[ \text{Fluid Balance (mL)} = \text{Total Intake (mL)} - \text{Total Output (mL)} ]

Given:

• Total intake: 2200 mL
• Total output: 1800 mL

[ \text{Fluid Balance (mL)} = 2200 , \text{mL} - 1800 , \text{mL} ]

[ \text{Fluid Balance (mL)} = 400 , \text{mL} ]

Step 2: Interpretation of Fluid Balance

The patient has a positive fluid balance of 400 mL, meaning that more fluid has been taken in than excreted. In a patient with congestive heart failure, a positive fluid balance can exacerbate symptoms of fluid overload, such as pulmonary edema and increased systemic edema.

Step 3: Clinical Signs of Worsening Fluid Overload

The nurse should closely monitor for the following clinical signs that may indicate worsening fluid overload:

• Increased Shortness of Breath: Worsening pulmonary edema can lead to increased respiratory distress.
• Worsening Edema: Especially pitting edema in the extremities, indicating fluid retention.
• Crackles in Lungs: These may become more pronounced or spread to additional lung fields.
• Increased Jugular Venous Distention (JVD): Indicative of increased central venous pressure.
• S3 Heart Sound: An S3 gallop may be auscultated, suggesting heart failure.
• Hypertension: Fluid overload can lead to elevated blood pressure.
• Weight Gain: A sudden increase in weight over a short period is a key indicator of fluid retention.

Conclusion

• Fluid Balance: 400 mL (positive balance)
• Clinical Monitoring: The nurse should monitor for increased shortness of breath, worsening edema, lung crackles, JVD, an S3 heart sound, hypertension, and rapid weight gain.

GoodNurse Explanation

This question focuses on fluid and electrolyte balance, a critical aspect of nursing care, particularly in patients with conditions like congestive heart failure. A positive fluid balance indicates that the patient is retaining more fluid than they are excreting, which can worsen symptoms of heart failure.

In clinical practice, nurses play a vital role in monitoring fluid balance and recognizing signs of fluid overload early to prevent complications. This requires not only understanding how to calculate fluid balance but also being vigilant in assessing the patient for clinical indicators of worsening fluid status.

It's important to remember that fluid management in heart failure patients is a delicate balance. Too much fluid can exacerbate heart failure, while too little fluid can lead to dehydration and reduced cardiac output. Accurate monitoring and timely intervention are essential to maintain patient safety and promote optimal outcomes.