The intensive care nurse is reviewing a patient's chart to find the most accurate indicator of fluid volume status, which is:
1. Intake and output
2. Daily weights
3. Hematocrit level
4. Systolic blood pressure
2
Rationale 1: Although intake and output are carefully measured in most critically ill patients, they have been shown to be inaccurate. Still, the nurse attempts to maintain as accurate a record as possible.
Rationale 2: Weight is a more accurate indicator of fluid volume status than many of the other assessment parameters. The patient should be weighed daily at the same time on the same properly calibrated scale with the same amount of clothing or bed linens.
Rationale 3: Laboratory values can be used to identify hemodilution from fluid volume excess. It may be evident as a decrease in hemoglobin, hematocrit, and serum sodium values.
Rationale 4: Multiple factors can affect systolic blood pressure readings in addition to fluid excess.
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