A nurse is planning care for a client with acute kidney injury. The nurse should recognize that which assessment data best supports the nursing diagnosis of Excess Fluid Volume?

Condition Most Likely Experiencing: Heart failure.

The client presents with signs and symptoms consistent with heart failure, including cardiomegaly, bibasilar pleural congestion on chest x-ray, elevated BNP level, and vital signs indicating hypertension (BP 146/98 mm Hg), tachycardia (pulse rate 106/min), and tachypnea (respirations 24/min). Additionally, the client is prescribed medications commonly used to manage heart failure, such as digoxin and carvedilol, and is receiving a diuretic (furosemide) to address fluid overload associated with heart failure.
Action to Take:

Elevate the head of the bed: Elevating the head of the bed helps reduce venous return to the heart, decreasing preload and potentially alleviating symptoms of heart failure, such as dyspnea and orthopnea. It can also help prevent aspiration in clients with compromised cardiac function. Encourage intake of a low-sodium diet: A low-sodium diet is essential in managing heart failure as it helps reduce fluid retention and edema by decreasing fluid volume overload. Sodium restriction helps minimize fluid accumulation, which is crucial in preventing exacerbations of heart failure.
Parameter to Monitor:

Urinary output: Monitoring urinary output is important in assessing fluid balance and response to diuretic therapy in clients with heart failure. Decreased urinary output may indicate worsening heart failure or inadequate response to diuretic therapy, whereas increased output may suggest over-diuresis or improvement in heart failure symptoms.
Blood pressure: Monitoring blood pressure helps assess the effectiveness of treatment in managing heart failure and controlling hypertension, a common comorbidity. Hypertension can exacerbate heart failure, so monitoring blood pressure trends helps guide adjustments in medication therapy to achieve optimal blood pressure control and improve cardiac function.

A. Inform the health care provider that there is a probable leak in the drainage system: Bubbling in the water seal chamber of a chest drainage system during client breathing is an expected finding and indicates air movement in and out of the pleural space. It does not necessarily indicate a leak in the drainage system. Documenting the observation and assessing the client for other signs of complications would be appropriate before informing the healthcare provider.

B. Encourage the client to breathe deeply so the water seal will stabilize: Deep breathing by the client will not stabilize the water seal. The bubbling occurs due to air movement in and out of the pleural space during respiration and is a normal finding.

C. Inform the health care provider that the client is ready to have the chest tube removed: Bubbling in the water seal chamber does not necessarily indicate that the client is ready to have the chest tube removed. The decision to remove a chest tube is based on various factors, including the client's clinical status and resolution of the underlying condition requiring chest drainage.

D. Document that the chest drainage system is functioning as intended: Bubbling in the water seal chamber during client breathing indicates that the chest drainage system is functioning as intended. It is an expected finding and does not typically require intervention.