A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit. (Select all that apply.)
A.
Full bounding pulse
B.
Cool extremities
C.
Moist crackles in the lungs
D.
Orthostatic hypotension
E.
Flat neck veins
The correct answer and Explanation is :
The correct answers are:
B. Cool extremities
D. Orthostatic hypotension
E. Flat neck veins
Explanation:
Fluid volume deficit, also known as hypovolemia, occurs when there is a significant reduction in the amount of body fluids, particularly plasma volume. This can happen due to losses such as vomiting, which is common in postoperative patients. Understanding the signs of fluid volume deficit is crucial for early detection and prompt management. Let’s break down the options:
B. Cool extremities
Cool extremities are a sign of poor peripheral perfusion. When the body experiences fluid volume deficit, it compensates by diverting blood from less vital areas (like the skin and extremities) to maintain perfusion of the core organs, such as the brain, heart, and kidneys. This vasoconstriction in the extremities leads to cool, pale, or even mottled skin.
D. Orthostatic hypotension
Orthostatic hypotension is a significant indicator of fluid volume deficit. It is characterized by a drop in blood pressure when a person moves from a lying to a standing position, usually accompanied by dizziness or fainting. This happens because the reduced blood volume makes it harder for the body to maintain adequate blood pressure, particularly when changing positions.
E. Flat neck veins
Flat neck veins, especially when the patient is lying down, indicate a low central venous pressure, which correlates with reduced circulating blood volume. Normally, when a person is lying flat, the jugular veins should be distended. In cases of fluid volume deficit, the veins may appear flat due to the reduced volume.
Incorrect Options:
A. Full bounding pulse
A bounding pulse is typically associated with fluid volume excess, not deficit. It occurs when there is an increase in blood volume or cardiac output, which is not consistent with hypovolemia.
C. Moist crackles in the lungs
Moist crackles, or rales, are associated with fluid overload or pulmonary edema, where excess fluid accumulates in the lungs. This finding is contrary to fluid volume deficit.
By recognizing signs like cool extremities, orthostatic hypotension, and flat neck veins, the nurse can identify fluid volume deficit and take appropriate steps to manage the client’s condition, such as administering fluids and closely monitoring vital signs.