Upgrade to remove ads
N320 Fluid and Electrolyte Balance
Terms in this set (75)
The constant movement of fluids and electrolytes to maintain a balance in the body
Causes of Fluid and Electrolyte Imbalance
-Fluid and electrolyte output is greater than intake and absorption
-Fluid and electrolyte output is less than intake and absorption
-Altered fluid and electrolyte distribution
Common Risk Factors for Fluid and Electrolyte Imbalance
-Conditions: Diabetes, dementia, flu, anorexia, cancer, burns, very old, very young, excessive exercise
-Medications: Diuretics, laxative, potassium, IV fluid, blood transfusion, antacids, multivitamins, and TPNs
-Acute medical condition, injury, and trauma: Hemorrhage, cushing, burns
-Chronic medical conditions: heart failure, diabetes, liver disease, renal failure, crohns, alcoholism
Multi System Effects of Fluid Volume Deficit
Mucous Membranes: Dry (may be sticky), Decreased tongue size, longitudinal furrows increased
Urinary: Decreased urine output, Oliguria, Increased urine specific gravity
Neurologic: Altered mental status, Anxiety, Restlessness, Diminished alterness/cognition, Possible coma
Integumentary: Diminished skin tugor, Dry skin, Pale/cool extremities
Cardiovascular: Tachycardia, orthostatic hypotension, falling systolic/diastolic pressure, flat neck veins, decreased venous filling, decreased pulse volume, decreased capillary refill, increased hematocrit
Potential Complication: Hypovolemic shock
Metabolic Processes: Decreased body temperature, increased body temperature, thirst, weight loss
Multi system Effects of Fluid Volume Deficit
Neurologic: Changes in LOC, confusion, headache, seizures
Respiratory: pulmonary congestion
Cardiovascular: Bounding pulse, increased BP, increased JVD, Presence of S3, Tachycardia
GI: Anorexia and Nausea
Edema: Dependent pitting edema
Most commonly includes sodium, potassium, magnesium, chloride, and bicarbonate
Percentage of whole blood that is composed of RBCs
Determines extracellular fluid volume status
Measure of the solute concentration of the blood
Urine specific gravity
An indicatory of urine concentration
Normal Range: 1.01-1.03
Blood Urea Nitrogen
Measures kidney function and elimination
Elevated BUN indicates dehydration, kidney or liver injury
Normal Range: 8-21mg/dl
Produced when protein or muscles break down
Filtered by kidney and excreted in urine
Good indicated of kidney function
Symptoms of Third Spacing
Decreased blood pressure
Increased heart rate
Decreased urine production
What is third spacing?
Fluid in the wrong areas of the body
ex. face, chest, arms, legs, abdomen
What is the treatment for third spacing?
Get fluids back into vessels
TREAT LIKE DEHYDRATION
When assessing a client with fluid volume deficit, the nurse would expect to find
Orthostatic hypotension and flat neck veins
The nurse is caring for an elderly client who has been receiving IV fluid at 175 mL/hr. The client has crackles, shortness of breath, and distended neck veins. These findings indicate which complication of IV fluid therapy?
Fluid volume excess
The nurse is conducting a teaching session on preventing heat-related illnesses for children who exercise. Which statement indicates understanding or preventive techniques taught?
During activity, stop for fluids every 15-20 minutes
A nurse is taking care of four pediatric clients. Which child does the nurse determine is at greatest risk for dehydration?
An 18-month-old child with tachypnea
What is the major risk of dehydration?
The patient has recent bilateral above the knee amputations and has developed C.Diff diarrhea. What assessments should the nurse use to detect fluid volume deficit in this patient?
Test for skin tenting
Measure rate and character of pulse
Measure postural blood pressure and heart rate
Observe for flatness of neck veins when supine
A patient is admitted to the hospital for an exacerbation of congestive heart failure. IN the care plan in the EMR, the priority nursing diagnosis is fluid volume deficit. What patient goal statement has the tightest priority?
The patient's urine output will remain at least 30 ml/hr
Oral fluids: 1200-1500 ml/day
Water in foods: 1000 ml/day
Water as by-product of food metabolism: 200 ml/day
Total: 2400-2700 ml/day
Urine: 1400-1500 ml/day
-Perspiration: 350-400 ml/day
-Lungs: 350-400 ml/day
Feces: 100-200 ml/day
Total: 2300-2600 ml/day
Electrolyte Imbalances Risk Assessment
Electrolyte intake and absorption: increased or decreased
Electrolyte shifts: to the plasma or out of the plasma
Electrolyte excretion: increased or decreased
Electrolyte loss by abnormal route: GI losses, wounds/injuries, sweating
What is an example of a hypotonic solution?
What is an example of a isotonic solution?
What is an example of a hypertonic solution?
-Stored in bones
-Serum levels interrelated
Hyper/Hypo: result in changed to deep tendon reflexes and cardiac contractility
-Changes in levels reported with GI losses or Gi intake
-Changes in levels result in altered reflexes, muscle weakness, and/or neuromuscular irritability
Hyper: occur for client with renal failure
Closely aligned with sodium levels
-Vital for the conduction of nerve impulses
NORMAL VALUES: 135-145
Losses: GU, GI, Skin
Regulated by: Renal and Endocrine systems
ex. Aldosterone and ADH
NORMAL RANGE: 3.5-5.0
Maintains all muscular activity (especially cardiac muscles)
Vital to cellular functions: protein and glycogen synthesis
80-90% excreted via kindeys, remainder via feces
Regulated by: Adreocorticol hormones and insulin
Which client would be most likely to develop hyperkalemia?
A client who has renal failure
Hypokalemia Sinus Rhythm
-Slightly prolonged PR interval
-Slightly peaked P wave
-ST depressed and prolonged
-Depressed T wave
-Prominent U wave
Hyperkalemia Sinus Rhythm
-Wide flat P wave
-Prolonged PR interval
-Decreased R wave amplitude
-Depressed St segment
-Narrow, peaked T wave
-PO or IV
-Give with foods to decreased Gi irritation
-Must always be diluted
-Never give IV push
-Often given IV bag as maintenance fluid
-Assess IV site frequently for pain/redness (irritating to the vein)
-May be given IV piggyback
IV Potassium Sliding Scale
5.4 or greater: Inform HCP (remove all KCL from IV fluids and hold any oral KCL)
4.0 or greater None
3.5 to 3.9 KCl 20 mEq or 10mEq/hrX2
3.3 to 3.4: KVL 40 mEq or 10mEq/hrX4
3.1 to 3.2: KCl 60mEq or 10mEq/hrX6
Under 3.0: Start KCL or 10mEq/hr and call HCP for further orders
Oral Potassium Sliding Scale
5.4 or greater: Inform HCP (remove all KCL from IV fluids and hold oral KCL)
4.0 or greater None
3.5 to 3.9: KCL 20mEq PO
3.3 to 3.4: KCL 20mEq now and repeat in 4 hours
3.1 to 3.2: KCl 40 mEq now and repeat 20 mEq in 4 hours
Under 3.0: KCL 40 mEq now and call physical for further orders
A client in renal failure has hyperkalemia. The nurse instructs the client to avoid which foods?
Apricots, cantaloupe, orange juice
A client is experiencing a fluid volume deficit. The nurse's assessment indicates: tachycardia, pale cool skin, and decreased urine output. What are the symptoms a result of?
The body's natural compensatory mechanisms
Which intervention is NOT warranted in planning care for a client with hypernatremia?
Restricting fluids to 1200 ml per day
A client has just finished 1 hour of exercise. What lab results should the nurse expect?
The patient has daily weights ordered for the purpose of evaluating fluid loss/gain. When should the patient be weighed?
At the same time each day
Which potassium level would be of greatest concern in a client who is taking furosemide?
Outside the cell
Inside the cell
Colloid IV Soultions
Osmotic pressure pulling water Out of interstitial spaces Into the intravascular space
ex. Albumin and Dextran
Crystalloid IV Solutions
Have smaller practices and cross impermeable membranes much more easily
ex. Isotonic, hypotonic, and hypertonic IV fluids
-Similar to concentration of blood
ex. 9% NS, Lactated Ringers, and Ringers Solution
-Give to patient with dehydration, decreased urine output, hypovolemia, hyponatermia, shock, blood loss, vomiting, diarrhea, respiratory issues, burns, surgery, and diabetic ketoacidosis
CAUTION: Heart failure (prone to fluid overload) and renal failure
Isotonic solutions Nursing Considerations
Assess and document before, during and after infusion:
-Baseline vital signs
-Intake and output
-Hematrocit and Hemoglobin
-Small number Normal Saline
DON'T GIVE: Heart failure and renal failure
-3-5% Salines and higher concentrations of sugar
USE: Severe hyopnatremia, increased cranial pressure, severe hemorrhage loss shock
USE OVER SHORT PERIOD OF TIME
GIVE CENTRALLY SINCE IT IRRITATES VESSELS
Hypertonic Solutions Nursing Considerations
-Assess for signs and symptoms of hypervolemia
-Monitor serum electrolytes
-Monitor administration site
-Not for patients with cardiac or renal conditions that are dehydrated (Can cause hypervolemia)
-Contraindicated for patients with cellular dehydration (diabetic ketoacidosis)
Diabetic Ketoscidosis causes cellular dehydration. Which IV solution would not be recommended for this type of patient?
10% Dextrose in water
The nurse would anticipate the use of hypertonic IV solutions for which of the following clients?
Client who has hypotension
What is the main reason for using IV therapy in a hospitalized patient?
Maintain or restore fluid and electrolyte balance
Which assessment finding would indicate to the nurse that IV fluid replacement therapy was adequate?
Urine oouput of 60 ml/hour for 8 consecutive hours
The nurse would anticipate the use of 5% dextrose-containing IV solution for which client?
The client who will be NPO for 12-24 hours
IV Medication Administration
Complications of IV therapy
-Bruising: First Sign
-Infiltration: vein no longer working; fluid goes out
-Evisceration: Death of tissue
STOP IV AND START A NEW ONE IF: Redness, tender, painful, not flushing, blanching, or red streak
The nurse is caring for a patient who has an IV infusing and complains of the arm feeling cold and dressing feeling tight. What actions should the nurse take first?
Stop the infusion and remove the catheter
The nurse is caring for a patient who required an IV medication to be infused every 6 hours. Which infusion device should the nurse use?
Secondary administration set
The nurse is caring for a patient who needs to continue antibiotic therapy at home for an additional 3 weeks. What type of access device would be indicated?
A PICC line
The nurse is caring for a patient who requires venous access. What factors will be considered when deciding between central access and peripheral access?
Type of fluid needed and anticipated length of therapy
Blood Transfusions Uses
-Surgery with increased blood loss
Blood Transfusion Reaction
Mild: Hives, pruritus, facial flushing
Severe: Severe SOB, bronchospasm, anxiety
Hemolytic Transfusion Reaction:
Low back pain
Fever and Chills
May have immediate Onset
Blood Transfusion Reaction Nursing Considerations
-Stop transfusion and notify HCP
-Change IV tubing
-Treat present symptoms --> oxygen, fluids, epi as ordered
-Recheck crossmatch record with unit
-Obtain 2 blood samples distal to infusion site
-Obtain fist UA-test for hemoglobinuria
-Monitor fluid/electrolyte balance
-Evaluate serum calcium levels
Under what circumstances may a blood transfusion be indicated?
Surgical procedures, hematologic diseases, and trauma resulting in massive blood loss
The nurse is caring for a patient who has an IV of D5W infusing at 125 ml/hr. The patient has a Hgb of 8.2g/dl. The HCP prescribes 2 units of packed red blood cells. What IV fluid should the nurse infuse with the blood?
Change the IV fluid to NS
Following identification of the patient and baseline vital signs, the nurse starts infusion of the blood component. The procedure states the nurse must remain with the patient for the first 15 minutes or 50 ml of blood. What is the priority reason for this action?
A transfusion reaction is most likely to occur during this time period
The nurse is administering a unit of packed red blood cells. The unit has been infusing nearly 4 hours. Why should the nurse be concerned?
There is an increased risk of bacterial growth in the blood product after hanging 4 hours
The nurse is caring for a patient who is receiving a unit of packed red blood cells. The patient complain of blow pack pain and SOB. What action should the nurse take first?
Stop the transfusion
Necessary information for IV fluid calculations
Volume to be infused
Length of time to be infused
Drip factor of IV tubing (if calculating drops per minute)
YOU MIGHT ALSO LIKE...
NURS (FUNDAMENTAL): Ch 39 NCLEX Fluid, Electrolyte…
NUR FUND + PREP U Chapter 39 Fluid, Electrolyte, a…
Chapter 39 Review
Class 17 Objectives
OTHER SETS BY THIS CREATOR
N383 Class 5
N383 Breasts and Regional Lymphatics
N383 Thorax and Lungs