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Fluid intake or retention is greater than the body's needs
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Kidney failure (late phase)
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Heart failure
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Cirrhosis
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Interstitial to plasma fluid shifts (hypertonic fluids, burns)
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Excessive water intake
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Long term corticosteroid therapy
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Cough, dyspnea, crackles
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Increased BP
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Tachypnea
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Tachycardia
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Bounding pulse
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Weight gain (1 L water = 1 kg weight)
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Jugular vein distention
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Increased central venous pressure
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Pitting edema
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Serum: Electrolytes, BUN, creatinine, Hct
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Urine: specific gravity and osmolarity
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Chest x-ray if respiratory complications present
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Monitor respiratory rate, symmetry, & effort
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Monitor breath sounds for signs of pulmonary edema
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Monitor for edema
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Measure pitting edema on scale of 1+ (minimal) to 4+ (severe)
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Monitor dependent edema by measuring circumference of extremities
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Monitor for ascites
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Measure abdominal girth
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Weight pt daily
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Maintain strict I&O
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Monitor vital signs
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Administer diuretics (osmotic, loop) as prescribed
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Limit fluid intake
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Maintain skin integrity
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Use semi-Fowler's position
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Reposition every 2 hr
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Restrict sodium intake
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Cheatography n. The art of mapping complex subjects into clear, instantly navigable reference guides.
