A 75year old man complains of having headaches, being confused, increased fatigue with shortness of breath, and cramps..

Assessment    -    

Draw a Serum electrolyte sample and see if anything is deviated. (sample comes back showing sodium level at  129)     Ask pt. past history to see if we can find cause for disturbance.  Findings- Pt states” I drink 11-12 glasses of water a day plus sometimes a 12 pack or more of great tasting long lasting miller genuine draft.”  Do head to toe assessment. Findings- Crackles in Lower LL, Bounding pulse,  138/99, Jugular vein distension,  edema found in LE bilaterally (+2), HR-103, Resp-20, A & O X 2 Diagnosis   Fluid volume Excess R/T excessive fluid intake AEB- Shortness of breath, orthopnea, anxiety, headaches, confusion, cramps and sodium level of 129.   Risk for impaired tissue integrity R/T excessive fluid intake AEB edema   Risk for impaired gas exchange R/T pulmonary congestion AEB crackles   Goals:               Interventions:                               Evaluations:                                             Brett thanks you for your help!!!!!!!!!!!!!!!! Because he has been hospitalised for fluid volume overload before.