Maintaining Fluid Balance: A Health Promotion Paper
Victoria Mendiola
Excelsior College
Health Assessment and Promotion in Nursing Practice
NUR442
Dr. Deborah Mandel
December 8, 2012

Maintaining Fluid Balance: A Health Promotion Paper
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INTRODUCTION

Fluid overload is a major clinical issue in patients with end stage renal failure. Oftentimes, unresolved and unaddressed fluid overload leads to congestive heart failure. Congestive heart failure is a progressive and systemic disease process that involves the interaction between the heart and kidneys. (Krishnan, 2007). Over time, worsening heart failure coupled with progressive kidney failure leads to diuretic resistance, consistent fluid volume overload and refractory heart failure. (Francis, 2006). Fluid balance is a goal for ESRD patients and should be one of the priorities for health promotion and prevention education. Fluid Overload and the Peritoneal Dialysis Client It is important to note that the client in this paper was diagnosed in 2007 for ESRD and hemodialysis treatment was initiated for this client right away. Initially, patient was getting three times a week dialysis treatments in-center. However, in the last three years, the client’s dialysis treatments were raised to four times per week to avoid fluid overload. Per client’s report, within the last year he would have 1-2 episodes of shortness of breath every three months ending in hospitalizations for congestive heart failure (CHF). In one of the client’s hospitalizations early this year, he was introduced to another treatment modality for ESRD patients. Client pursued peritoneal dialysis based on his nephrologist’s recommendation of said modality. The client’s perception of illness is greatly tied in to his hospitalizations and symptoms associated with CHF. These symptoms are what patient considers hindrance to his ability to enjoy his life and feel good about himself. Although, the client did note that his CHF symptoms had been less upon initiating peritoneal dialysis is it imperative that health promotion and prevention focused on CHF should be the main issue addressed in this paper. Although it is widely assumed that ESRD patients with CHF do better with peritoneal dialysis, studies remain inconclusive. In general, peritoneal dialysis is better in regulating fluid volume preventing further structural cardiac impairment. This is mainly due to the continuous ultra filtration or fluid removal and improved hemodynamic stability (Stack, 2003). Inadequate fluid removal often results in PD failure, necessitating patient’s transfer to hemodialysis (Maaz, 2004) Fluid overload is common in the PD population, and becomes more prominent after a long time on PD. Oftentimes, unresolved and unaddressed fluid overload results in CHF. Prevention of fluid overload is key to health promotion for the client. It is imperative that the client understand that achieving fluid balance with peritoneal dialysis is critical for his health and prevention of illness. The client’s longstanding history of CAD, left ventricular hypertrophy, CHF, and myocardial infarct make fluid balance a priority in his care and health promotion. Maintaining fluid balance is an important educational piece for this client. Patient education is important to individuals with ESRD to enable them to participate in their own care and understand their disease process, including the co-morbidities that increase hospitalizations and death (Curtin, Mapes, Schatell, & Burrows, 2005).The risk factors associated with this patient population such as dietary and fluid compliance, medication, and treatment adherence are easily addressed with education and follow-up.

The health promotion and prevention teaching will start by reviewing with patient his understanding of ESRD and how ESRD relates to fluid balance. The client needs to understand that with ESRD, the kidneys can no longer keep body fluid balanced. Fluid balance is achieved by peritoneal dialysis through ultra filtration or removal of fluids, residual kidney function or urinary output, use of diuretics, adequate nutrition, and fluid intake restriction. Based on the patient’s understanding of ESRD and fluid balance, nursing care plans would be implemented.

Plan of Care for Peritoneal Dialysis Client Nursing care plan for this client will be centered on both increasing patient’s knowledge on his disease process to prevent fluid overload and addressing actual fluid volume overload issue. The first wellness nursing diagnosis that is pertinent for this client is readiness for enhanced self-health management. This nursing diagnosis is defined as “improved management of disease, prevention of complications and exacerbations” (Carpentino-Moyet, 2010, p 548). The NOC nursing diagnosis is knowledge: treatment regimen and the NIC nursing diagnosis is decision-making support, teaching: individual. Goals for this nursing diagnosis is for the client to verbalize understanding of his disease process, verbalize desire to manage ESRD and fluid balance, identify health goals and areas of improvement, identify risk factors and reduce if not prevent incidence of fluid overload and assume responsibility for managing treatment regimen. The goals are focused on supporting the client in managing his health-related situations and at the same time empowering the client to accomplish an improved level of disease-related knowledge, autonomy in making health-care management for improve decisions and better outcomes, self-efficacy and better control of life and health situations. This will result in improved patient involvement with self-health management and care. According to an article in Nephrology Nursing Journal, involvement results in self-care that optimizes the client’s daily life with the disease and improved knowledge, competence and participation in activities related to health (Pagels, Wang, & Wenstrom, 2008). There are numerous interventions for successful outcome with this plan of care. The nurse needs to assess client's individual perceptions of health problems and help client identify health goals and areas for improvement. This step will aid client perceive susceptibility, seriousness and threat of disease thus encourage client to health-seeking behaviors. The nurse also need to review with the client risk factors that may aggravate fluid overload and come up with steps to address risk factors. Discussing barriers also allows the client to plan to improve health practices and behavior. Systematically reviewing areas for potential change can assist the client in making informed choices (Nursingguide.com) The RN need to discuss with client the importance of medical follow-up care, adherence to medication and treatment regimen. Focus will be on educating patient strict adherence to fluid restriction and renal diet with less sodium intake. The more concrete intervention include having patient evaluate fluid balance daily by monitoring fluid intake, monitoring and documenting ultra filtration on dialysis and urine output, documenting weight daily before and after peritoneal dialysis treatment, and documenting blood pressure daily. Reviewing signs and symptoms of fluid overload such as rapid and significant weight gain, edema, shortness of breath, increased fatigue and cough with client encourages self-monitoring and increases the client’s accountability and responsibility in self-health management. Another wellness nursing diagnosis for this particular client is readiness for enhance fluid balance. This nursing diagnosis is defined as “a pattern of equilibrium between fluid volume and chemical composition of body fluids that is sufficient for meeting physical needs and can be strengthened” (Carpentino-Moyet, 2010, p 545). NOC nursing diagnosis is fluid balance and NIC nursing diagnosis is fluid management. One goal for this nursing diagnosis is for client to maintain fluid volume balance as evidenced by weight within 1 kilogram of estimated dry weight, blood pressure within normal range of patient, no complaints of shortness of breath and absence of edema. Other goals are for client to identify strategies to improve fluid balance and to express willingness to enhance fluid balance. The interventions for this nursing diagnosis are focused on the client’s compliance with fluid restriction, treatment, dietary, and medication regimen. One such intervention is to provide education to client about sodium restriction and recommend ways for client to decrease salt intake such as reading food labels for salt content. Providing client with knowledge about sodium control empowers client to make informed choices about his diet. The RN should also help client identify ways to meet fluid restriction such as measuring client’s fluid intake for a 24 hour period. This will help client to manage fluid intake over time and reinforce adherence to fluid restriction. The use of daily home records to document weight, blood pressure, ultra filtration and dialysate solution use should be enforced. This document allows RN to monitor client’s adherence to treatment regimen, and when reviewed every client clinic visit, RN can address any outliers with client. Another intervention is to discuss with client the importance of compliance with medication regimen. Review with patient blood pressure medications and diuretics, and indication of each medication. Adherence to medication regimen increases if patients have been informed about their medication and patients understand how the medications work and that said medications are really needed to cure or manage their illness (Kemmerer, 2007). Discussion and review of using the correct dialysate solution with the client is also an integral part of fluid balance. It is crucial for peritoneal dialysis patients to ascertain how much fluid needs to be removed by the dialysis therapy to maintain fluid balance. This is key in the client’s choice of appropriate dialysate solution used for dialysis therapy. There are three types of dialysate solution. The higher the concentration of the dialysate solution the more fluid is removed from the body during dialysis. Choosing the correct dialysate solution requires the client to assess his fluid volume status by evaluating his weight, blood pressure, any shortness of breath, fatigue, and presence or absence of edema (Sarian, Brault, & Perreault, 2012).

Self-management Articles

An article in the Canadian Association of Nephrology Nurses and Technologists Journal written by Sarian, Brault, & Perrault (2012) discussed evidence based practice that suggests the patients on peritoneal dialysis obtain improved health outcomes and status by adopting self-management strategies. The article addressed the fluid management issues with peritoneal dialysis. According to the study, when patient is unsure on fluid status and the type of solution to use, the current practice is for patient to call nursing staff for guidance (p 19). However, this practice does not promote self-management. In contrast, it encourages patients to rely heavily on the nursing staff to decipher a problem patients have already been taught how to solve. The article further stressed the need for interventions intended to enhance patients’ fluid self- management skill (p 19). In this study, an algorithm was developed that aim to improve patients’ aptitude to solve problems that are fluid balance and maintenance in nature. Patients were also given educational training on how to use the algorithm. Lastly, strategy in partnership with the peritoneal dialysis nurse was implemented (p 19). The algorithm designed would be an asset for the client for self-management of fluid balance and an opportunity for client to be more involved with self-care. The client’s ability to successfully utilize the algorithm will translate in client meeting the goals set in the plan of care and client improved quality of self-health care and management Another article that is related to the client’s health promotion and prevention strategies is an article published by the Nephrology Nursing Journal. In their article “Patient-Nurse Partnerships”, Doss, DePascal, & Hadley (2011) tackled patient-centered model in healthcare. In this model, the patient is viewed as a partner in the development of plan of care and health care decision making ( p 115).According to the study, there is strong evidence that empowering patients to make decisions for their own care results in increased practice of effective self-management (p 116). Case scenarios were presented in which patient-nurse partnership was utilized with improved clinical outcome for patients. The plan of care developed for the client place a high importance on empowering the client. This is synonymous to the article’s take that “empowered patients will be more likely to know their disease, symptoms and treatment.” (p 116). Both articles addressed self-management and patient empowerment by involving patient in the decision making process and consistent education about the client’s disease and its management. However, the first article’s use of the algorithm for the patient provided a more direct and easy approach to managing fluid balance. The algorithm designed would be an asset for the client for self-management of fluid balance and an opportunity for client to be more involved with self-care. The client’s ability to successfully utilize the algorithm will translate in client meeting the goals set in the plan of care and client improved quality of self-health care and management. There is little information about managing fluid balance in peritoneal dialysis patients. Much of the articles and publications available are focused on fluid balance for hemodialysis patients. This is not surprising as majority of ESRD patients remains on hemodialysis. According to the US Department of Health and Human Services website, there are 10 times more patients on hemodialysis than those peritoneal dialysis and home hemodialysis patients combined. Although, hemodialysis and peritoneal dialysis are different modalities, the bulk of fluid balance management is still on fluid restriction, sodium control, medication and treatment compliance. Conclusion The collaborative effort of the nurse and client will achieve the preferred health outcomes of the health promotion-prevention plan, (Pender, Murdaugh, & Parsons, 2011). Focusing on care plans that encourage and promote the client’s autonomy in self-health management and foster independence and empowerment are essential to the client’s improved disease management and prevention. The greatest motivation for the client to change behavior and manage health is allowing him to be active and informed in his health care process, guiding him to take charge of his self- care, and encouraging him to be an active participant of self-health management.
References
Carpetino-Moyet, L. J. (2010). Section 2: HealthPromotion/Wellness Diagnosis. In L. J. Carpetino-Moyet (Ed.), Handbook of Nursing Diagnoses (13th ed., p. 527-564). Philadelphia: Lippincott Williams and Wilkins.
Maaz, D. (2004). Troubleshooting non-infectious peritoneal dialysis issues. Nephrology Nursing Journal, 31, 521-545. Retrieved from http://ebscohost.com.vlib.excelsior.edu[pic][pic][pic]