Nursing Care Plan for Patient with Peripheral Fluid Retention

Nursing Care Plan for Patients with Edema

The patient being discussed in this nursing care plan will be referred to as Mrs. Eileen Sparks. She is 80 years old, of German decent, speaks very little English, and currently resides in the Richmond, Vancouver area. Mrs. Spark’s husband, Ian Sparks, died five years ago. They had met in Berlin and immigrated to Canada in their late 20’s. They had one son named Robert, who currently resides in North Vancouver.

Mrs. Sparks was admitted to the hospital on September 4th, 2019 for acute back pain, secondary to a lumbar fracture sustained during a fall that was left untreated. Her health history includes: cataracts, hyperthyroid, hypertension, gastric esophageal reflux disease, psoriasis, shingles, and aortic stenosis. Allergies include: ciprofloxacin, penicillin, acetaminophen/codeine, and tetracyclines. The patient was on a soft diet with fluids. According to PT and OT assessment, Mrs. Sparks was a two person assist from the bed to sitting position and from sitting to standing position, as well as a two person assist with a walker. When mobilizing the patient, it was noted that her leg strength and range of motion was quite limited, and she had difficulty understanding how to use the walker effectively. This posed challenges regarding mobility and fall risk. Due to her back injury, any movement (rolling in bed, laying down in bed from a sitting position, etc.) caused her a lot of pain. In turn, she was taking opioid analgesics. Opioids reduce nervous system activity and slow muscle contractions in the gastro-intestinal tract (GI tract) which results in the intestinal walls absorbing more fluid (Rausch & Jansen, 2012). Additionally, movement is one of the body’s natural mechanisms of moving food through the GI tract (Bodian, 2019). In turn, her pain level and lack of movement, combined with the side effects of opioid treatment, resulted in incontinence of urine and constipation.

During the patient’s head to toe assessment, vital signs were stable. Respirations were found to be easy and regular. A heart murmur could be heard at the pulmonic area, commonly heard in those diagnosed with aortic stenosis (Alpert, 1990). Capillary refill was less than three seconds bilaterally in both feet and hands. Dorsalis pedis pulses were strong bilaterally. Bowel sounds were heard in all four quadrants of the abdomen. Abdomen was slightly distended, but soft when palpated. When examining the patient’s legs, swelling was noticed in the left calf. When palpating the swollen area, grade two pitting (3-4 mm rebound in 15 seconds) was noted in the left calf. The circumference of the calves was measured halfway down the length of the calves. The left calf was found to be 20”, while the right calf was 17”. The left calf was hot to the touch and the patient complained of non-radiating pain, rated 4/10 on a pain scale, when palpated. No heat or pain was noted in the right calf. Patient reported that a pain level of 2/10 would be tolerable in her calf. Edema is caused by an increase in hydrostatic pressure. In those with heart failure or high blood pressure, the heart muscles can be remodelled resulting in harder, thicker tissue that is less effective at pumping blood around the body. This leads to decreased renal perfusion, followed by an increase in renin and aldosterone production, which ultimately causes the body to retain more sodium and fluid (Pellicori et al., 2015). Mrs. Sparks reported an overall pain level of 8/10. Her ability to remain coherent while in so much pain showed extreme resilience. Mrs. Sparks did not say much to anyone as there was a language barrier present. She napped for most of the day and seemed in the greatest of spirits when her son came to visit once a week. Once discharged, she planned to move in with her son and have daily home supports.

Based on the patient’s health history and assessment, the nursing diagnosis this care plan will focus on is: Actual increased fluid retention, (secondary to hypertension and heart failure), related to lack of mobilization, evidenced by bilateral pitting, tenderness, and heat and pain localized in the left calf. This diagnosis was prioritized because peripheral edema is a sign of reduced cardiac output (Pellicori et al., 2015), and it is important to try and get blood pumping more effectively back to the heart. Additionally, it was a discomfort for the patient and comfort is always something that should be prioritized.

There are many interventions that can be used to try and reduce fluid retention. The first being pharmacological interventions. The use of diuretics and angiotensin converting enzyme inhibitors (ACE inhibitors) are first line treatments for patients presenting with peripheral edema, especially due to heart failure. Loop diuretics (e.g. Lasix) inhibit the reabsorption of sodium and fluid in the loop of henle, thus decreasing retained fluid. Thiazide diuretics and mineral corticosteroid receptor antagonists are also commonly prescribed in combination as well. ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II, thus decreasing the amount of circulating aldosterone which leads to the excretion of fluid and sodium (Pellicori et al., 2015). Mrs. Spark was prescribed Lasix and Lisinopril by the hospital physician. Providing these medications to the patient as prescribed in the medication administration record will be a very important intervention in helping to reduce fluid retention. A review by Pellicori et al. (2015), found that 25% of patients have difficulty adhering to a medication schedule. As Mrs. Sparks will most likely have to continue taking these medications once discharged from the hospital, education regarding the importance of taking the medication, as well as side effects and interactions to be aware of will be a necessary step of this intervention. Due to the language barrier, this will include educating Mrs. Sparks’ son or having Mrs. Sparks’ son translate the importance of drinking lots of fluids to reduce the chance of dehydration and constipation, reporting symptoms of hypokalemia (i.e. constipation, arrhythmias, muscle weakness, fatigue), and to refrain from taking non-steroidal anti-inflammatories (Redman, 2019).

The second intervention is compression therapy. Compression stockings apply pressure to the legs preventing the buildup of fluid and reducing inflammation (Alguire & Scovell, 2019). They should be applied in the morning in order to prevent buildup of fluid throughout the day, and taken off before bed. Stockings should be properly fitted. They do have the potential to cause tenderness and pain. If this is the case, they can instead be put on before the patient wants to walk around, or sit in their chair. A stocking donner could also be used if the patient has trouble putting the stockings on themselves (Sterns, 2019). If stockings are not tolerated, stretchable bandages (Simon, 2014) and pneumatic compression devices (Trayes et al., 2013) are alternative forms of compression therapy that could be used. Compression stockings acts as a good long-term intervention as they can continue to be used upon discharge (Simon, 2014). However, compression therapy can be contraindicated in patients with heart failure. In turn, it will be important to ensure the ankle-brachial index is less than 0.7 (Simon, 2014)., and consult with the physician before initiating.

The third intervention is elevation. Elevation can be achieved by placing a few pillows under the patient’s legs or by raising the foot of the bed so the legs are above heart level. Elevation allows gravity to naturally move fluid from the legs, back into systemic circulation (Procter, 2018). According to Sterns (2019), this has been proven to be an effective treatment to reduce peripheral edema when performed for 30 minutes, four times a day. When Mrs. Sparks is in bed, her legs should be elevated above her heart as much as possible.

The fourth intervention is exercise. Walking is the body’s way of stimulating the skeletal muscle to move blood from the lower extremities back to the heart. This reduces venous congestion, as well as any fluid pooling that has occurred (Alguire & Scovell, 2019). Working with PT and OT, it will be important to help Mrs. Sparks mobilize at least twice a day with her walker in order to get her blood circulating. As Mrs. Sparks can be resistant to mobilizing, it will be important to educate her on the therapeutic effects movement and exercise have on reducing the swelling in her legs and ultimately, helping improve her cardiac output.

The fifth intervention is diet. Sodium binds to water in the body and in turn, increased sodium can result in fluid retention. It is beneficial for patients suffering from hypertension and heart failure to eat a diet that is moderate in sodium (Pellicori et al., 2015). While in the hospital, Mrs. Sparks will be receiving meals planned by the dietician. However, education should be provided regarding the importance of a low sodium diet, and foods that are high and low in sodium.

The sixth intervention is foot massage. A study by Coban and Sirin, as referenced by Simon (2014), found that in a controlled trial, a test group who received 20-minute foot massages for five consecutive days saw reduced leg circumference compared to the control group. They stated that, “the manipulation of soft tissue foot massage moves extravascular fluid without disturbing intravascular fluid.” (Simon, 2014, p. 9). In turn, a 20-minute foot massage should be given to Mrs. Sparks once a day.

The final interventions involve monitoring the swelling and performing regular pain assessments. Mrs. Sparks’ edematous tissue was radiating heat. She complained that it was tender to the touch and rated the pain level at 4/10. In turn, it will be important to assess her pain level and potentially administer PRN acetaminophen if deemed appropriate. Additionally, it will be important to monitor for increased/decreased fluid retention. This can be achieved by measuring the circumference of the calves (halfway down the length of the calf) at the start of each shift and comparing to previous measurements. This will allow you to know if the interventions are working and/or if the swelling is getting worse.

An example of the implementation of the nursing care plan is as follows:

Time / Nursing Action

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07.00-07.15 / H/T assessment (including measurement of calves, & pain assessment)

07.15-07.20 / Put on compression socks and elevate the legs with pillows - Opportunity to educate on the importance of elevation in reducing swelling

08.00-08.15 / Administer meds (including any diuretics, and ACE inhibitors on order. PRN acetaminophen if needed); Education regarding medications

08.45-09.15 / Breakfast – Opportunity to provide education about low sodium diet. If pain medications were provided, re-assess pain level

09.30-09.45 / Bed bath – Opportunity to provide a 20-minute foot massage

11.00-11.30 / Exercise with PT

11.30 -11.35 / Move to chair (ensure stockings are on)

12.00-12.30 / Lunch – Opportunity to provide education about low sodium diet

14.00-14.30 / Walk with patient around the ward (as much as tolerated) – Opportunity to educate on the importance of exercise

14. 30-14. 35 / Move to bed – Elevate legs with pillows, measure calves, perform pain assessment.

**Medication might be administered at more times during the day depending on the orders. Whenever pain medications are administered, pain will be re-assessed 30 minutes later.

The following criteria will be used to assess the nursing diagnosis. The patient will be able to tolerate walking the full loop of the ward by the time of discharge. The patient’s left calf will show decreased fluid retention with a calf measurement of 17” by the time of discharge. The patient will report a pain level of 2/10 by the end of the shift. The patient and/or the patient’s son will be able to articulate understanding of the education provided by the end of each shift. This will be measured by their ability to articulate the importance of taking medications on time; and the importance of compression therapy, exercise, elevation, and diet on decreasing fluid retention.

Through the implementation of this care plan, one would hope that Mrs. Sparks pain, as well as the fluid retention in her calves, would be reduced. This could have positive impacts on her ability to perform activities of daily living. The education provided would also give the patient, as well as her support system, the information they need in order to help prevent this issue from getting any worse once discharged. Additionally, this issue is a symptom of a more serious medical condition so by treating the fluid retention, you are indirectly treating the cardiac output issue at the same time, which will increase the overall health of the patient (Pellicori et al., 2015).

References

1. Alguire, P.C., & Scovell, S. (2019). Overview and management of lower extremity chronic venous disease. In J.F. Eidt, & J.S. Mills, Sr. (Ed.), Uptodate. Retrieved November 3, 2019, from https://www.uptodate.com/contents/overview-and-management-of-lower-extremity-chronic-venous-disease?csi=235adc50-2f53-44c3-8220-1d96047cfdef&source=contentShare
2. Alpert, M.A. (1990). Systolic murmurs. In H.K. Walker, & J.W. Hurst (Ed.), Clinical methods: the history, physical, and laboratory examinations. 3rd Edition (Chapter 26). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK345/
3. Bodian, C.H. (2019). 4 positive effects of exercise on the digestive system. In L. Maloney (Ed.), Livestrong. Retrieved November 3, 2019, from https://www.livestrong.com/article/356356-immediate-effects-of-exercise-in-the-digestive-system/
4. Pellicori, P., Kaur, K., & Clark, A.L. (2015). Fluid management in patients with chronic heart failure. Cardiac Failure Review, 1(2), 90-95.
5. Procter, L.D. (2018). Low blood pressure. Merck Manual Consumer Version. Retrieved November 3, 2019, from https://www.merckmanuals.com/en-ca/home/heart-and-blood-vessel-disorders/low-blood-pressure-and-shock/low-blood-pressure
6. Rausch, T., & Jansen, T. (2012). Gastrointestinal side effects of opioid analgesics. US Pharmacist, 37(12), 36-39.
7. Redman, K. (2019). Introduction to Cardiac Pharmacology [PDF Document]. Retrieved from Lecture Notes Online Website: https://canvas.ubc.ca/courses/42589/files/5688566?module_item_id=1428310
8. Simon, E.B. (2014). Leg edema assessment and management. Medsurg Nursing. 23(1), 44-53.
9. Sterns, R.H. (2019). Patient education: edema (swelling) (beyond basics). In J.P. Forman (Ed.), Uptodate. Retrieved November 3, 2019, from https://www.uptodate.com/contents/edema-swelling-beyond-the-basics/print
10. Trayes, K.P., Studdiford, J.S., Pickle, S., Tully, A.S. (2013). Edema: diagnosis and management. American Family Physician, 88(2), 102-110B.