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Fluid and Electrolytes (ch 6 pg 345-353)
Terms in this set (49)
Diarrhea causes fluid and electrolyte loss
How is elimination related to F and E balance?
Evaluate for signs of dehydration and sodium and chloride loss. keep in mind children dehydrate faster than adults.
What nursing implication is related to elimination and F & E balance?
Blood loss is fluid loss
How is cellular regulation related to F & E balance?
Observe for signs of blood loss, ID in textbook.
What nursing implications are related to cellular regulation and the F & E balance?
Fluid and electrolyte loss causes changes in cognition
How is cognition related to F & E balance?
Assess mental status frequently
R?O brain trauma before other causes
what nursing implications are related to cognition and the F & E balance?
The body loses the ability to regulate heat loss due to fluid loss thats why they give you a blanket when you are in shock
how is thermoregulation related to F & E balance?
replace fluid IV of sodium bicarb or blood and adjust environment
what nursing implications are related to thermoregulation and the F & E balance?
no fluid = no perfusion
How is perfusion related to F & E balance?
Assess perfusion, administer oxygen if needed, anticipate the meds needed to increase cardiac output
what nursing implications are related to perfusion and F & E balance?
used to ID underlying causes of imbalance. for example diarrhea, fluid retention, trauma and blood loss.
How is the assessment process related to F & E balance?
Assess VS, I/O, daily weights, skin turgor, and mental status.
what nursing implications are related to the assessment process and the F & E balance? look at page 349
administer fluids oral or parenterally, treat underlying cause for example diarrhea
When a patient has fluid volume deficit what do you do to fix it? look at page 347
administer meds like diuretics and reduce fluid intake
when a patient has fluid volume excess what do you do to fix it? look at page 347
limit intake of given electrolyte, admin diuretics, and may need to administer glucose and insulin
What do you do to fix and elevated electrolyte level? look at page 347
administer supplements to replace insuficent levels of electrolyte, and monitor for signs of imbalance
what do you do when your patient has low electrolyte levels?
Administer diuretics early in the disease
Administer dialysis late in the disease
what do you do when your patient has chronic kidney disease?
Monitor fluid and electrolyte balance
Treat underlying cause
what do you do when your patient has acute renal failure?
Identify risk factors such as disease, medications and environmental situations
Obtain data on food and fluid intake, elimination patterns and signs of suggesting fluid and electrolyte imbalances
What are you looking for when doing history assessment on your client? page 350
Moisture status of skin and mucus membranes
Assess mental status
Check extremities for edema
what are you looking for when doing a physical assessment on your patient relating to F & E balance? page 349
helps provide an accurate assessment of client's fluid status. also a rapid gain or loss over a short period indicate fluid changes (over 5 lbs less than a week) 1 kilogram of weight change = 1 liter of fluid change
why would you want to perform a daily weight on your client?
blood pressure is a sensitive indicator of fluid status and a narrowing pulse pressure happens before low blood pressure
why are VS important?
the most commonly assessed are sodium, potassium, chloride, magnesium, and bicarb
what are you looking for in a diagnostic test of serum electrolytes?
hematocrit can reflect fluid status
In a complete blood count what are we looking at?
osmolarity measures the amount of particles in fluid both urine and serum. normal 280-300 mOsm/kg
how does osmolarity indicate fluid balance status? and what is the normal level?
it indicates urine concentration, the normal level is 1.005-1.030
what does a urine specific gravity test tell you? and what is the normal level?
Monitor I & O
Weigh client daily
Engage client in plan of care
Provide client education
what are some independent interventions related to TX F & E imbalances?
Initiate IV therapy
Monitoring fluid balance
Initiate blood transfusion as ordered by healthcare provider
what are some collaborative interventions used to TX F & E imbalances?
Replaces missing electrolytes
Monitor laboratory testing, I&O and vital signs
why do we use electrolyte supplements to TX F & E imbalances?
They Expand fluid volume and replaces proteins and starches
but you need to Monitor closely because they can cause fluid overload
Why would we use colloids to treat the imbalances?
these are our IV Fluids and these mimic the body's extracellular fluid therefore replacing it.
what are crystalloids and why do we use them to treat the fluid imbalance?
diuretics Block sodium and water reabsorption thus promoting urine output this requires you to
Monitor fluid status
why would we use diuretics to treat fluid imbalances?
0.9% sodium chloride
has the same osmolality
as body fluids
which IV solution is isotonic and what is its relation to body fluids?
3% sodium chloride
has a Higher osmolality
than body fluids
Which IV solution is hypertonic and what is its relation to body fluids?
0.45% sodium chloride
has a lower osmolality
than body fluids
Which IV solution is hypotonic and what is its relation to body fluids?
it is hypovolemia caused by dehydration. in other words caused by an increased output or the failure to have adequate input. And for the most part the very young and the very old are at risk for fluid volume deficit.
Describe what is fluid volume deficit, causes, and who is at risk for it? look at page 356
thirst, decreased urine output, tachycardia, tachypnea, hypotension, and decreased cardiac output?
what are clinical manifestations of fluid volume deficit?
thirst is often ignored in older clients, and children present fluid volume deficit differently from adults.
what are some considerations to keep in mind regarding clinical manifestations of fluid volume deficit? look at page 357 and table 6-6
it corrects mild fluid deficits some water alone is sufficent. when rehydrating children give them 1-3 tsp every 10-15 min to start then gradually build
how is oral rehydration a clinical therapy TX FVD and what consideration should you keep in mind regarding children?
Type of dehydration determines solution used
Fluid challenge (Bolus) is a rapid administration of fluids
Because children under 2-years-old have immature renal systems fluid challenges need to be closely monitored
how is IV therapy a clinical therapy to TX FVD?
Fluid volume deficit
Ineffective peripheral tissue perfusion r/t hypovolemia
Risk for injury r/t postural hypotension
what are five nursing diagnosis related to FVD?
The client will drink 500 ml in 3 hours
The client's urine output will be 300 ml in 2 hours
what are some physiological expected outcomes for our clients?
The client will state 3 fluids appropriate for rehydration after teaching session
The parent will identify 3 signs of mild dehydration in their infant at the end of the teaching session
what are some educational expected outcomes for our clients?
Evaluations may be every few minutes in critically dehydrated client
Evaluations should reflect client's intake and output, physical assessment and any revisions needed.
what are some aspects of the evaluation process for patients with FVD?
Too much extracellular fluid either in vascular system (hypervolemia) or the tissue (edema). Etiology- conditions that cause retention of sodium and water or excessive intake of sodium and water and some Risk Factors: Cardiac disease, Renal disease, Pregnancy Diabetes
Describe what fluid volume excess is, its causes, etiology, and the risk factors related to it?
see box 6-2
Rapid increase in body weight
Distended veins that may be difficult to see in infants
Cough and difficulty breathing due to fluid seeping into lungs
Crackles on auscultation
Decrease HCT and BUN
Mental status changes due to cerebral edema
what are some clinical manifestations of FVE?
Focus assessment- Edema check- press on skin of lower extremities for 5 seconds. If present grade on scale page 368
Weigh diapers in children not potty trained
Assess risk factors- IV infusions of isotonic solutions. Children at high risk for fluid volume overload from rapid infusion either intentional or unintentional
what are we looking for in the assessment of FVE?
Excess fluid volume
Risk for impaired skin integrity
Risk for impaired gas exchange
what are four diagnosis related to FVE?
Similar to implementations for fluid volume deficit but need to include measures for skin protection, fluid restrictions, and assessment for dyspnea. Client teaching on sodium restriction, Primary medications are diuretics
What are some nursing implementations for TX FVE?
This set is often in folders with...
Digestion Ch 4 pg 210-226
Grief and Loss Ch 27 pg 1741-1750
Stress and Coping Ch 31 pg. 1900-1916
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