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35 terms

NCLEX, Fluids

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Is thirst a sign of fluid deficit or fluid overload?
fluid deficit
Is a rapid and weak pulse a sign of fluid deficit or fluid overload?
fluid deficit
Are respiratory increases a sign of fluid deficit or fluid overload?
fluid deficit or fluid volume overload
Is poor skin turgor and skin that is cool and moise a sign of fluid deficit or fluid overload?
fluid deficit
Is hypotension a sign of fluid deficit or fluid overload?
fluid deficit
Is emaciation a sign of fluid deficit or fluid overload?
fluid deficit
Are dry eye sockets, mouth, and mucuse membranes a sign of fluid deficit or fluid overload?
fluid deficit
Are anxiety and exhaustion a sign of fluid deficit or fluid overload?
fluid deficit
Is a urine specific gravity a sign of fluid deficit or fluid overload?
fluid deficit
Is decreased urine output a sign of fluid deficit or fluid overload?
fluid deficit
What are lab value changes in fluid deficit?
- increased hemoglobin and hemocrit
- increased Na serum osmulality
- increased BUN
Are headache, lethargy, confusion, and disorientation a sign of fluid deficit or fluid overload?
fluid deficit
How is temperature affected by fluid volume?
No change in overload, increase in deficit
Is a slightly increased, bounding pulse a sign of fluid volume deficit or overload?
fluid overload
Are shortness of breath, dyspnea, and rales a sign of fluid volume deficit or overload?
fluid overload
Is peripheral edema a sign of fluid volume deficit or overload?
fluid overload
Is hypertension a sign of fluid volume deficit or overload?
fluid overload
Are muffled heart sounds a sign of fluid volume deficit or overload?
fluid overload
Is a urine specific gravity of <1.010 a sign of fluid volume deficit or overload?
fluid overload
Is jugular vein distension a sign of fluid volume deficit or overload?
fluid overload
Is apprehension a sign of fluid volume deficit or overload?
fluid overload or fluid deficit
Is increased venous pressure a sign of fluid volume deficit or overload?
fluid overload
What are lab value changes in fluid volume overload?
- decreased hematrocrit and HGB
- decreased BUN, Na+
- decreased serum osmolity
What are potential causes of fluid volume deficit?
- isotonic loss
- vomiting
- diarrhea
- GI suction
- sweating
- decreased intake
- hemorrhage
- third spacing
What are potential causes of fluid volume overload?
- isotonic gain, increased in interstitial compartment, intravascular compartment or both
- CHF
- renal failure
- cirrhosis of the liver
- excessive ingestion of sodium
- excessive or too rapid intravenous infusion
What are nursing interventions for fluid volume deficit?
- force fluids
- provide isotonic IV fluids (LR, .9%)
- I and O, hourly outputs
- daily weights (1 L = 1 kg)
- check skin turgor
- assess urine specific gravity
What are isotonic fluids?
- lactated Ringer's
- .9% NaCl
- Ringer's Solution
- 5% dextrose in water*
What are nursing interventions for fluid volume excess?
- administer diuretics
- restrict fluids
- sodium-restricted diet (6-15 g Na)
- daily weights
- assess breath sounds
- check feet/ankle/sacral region for edema
- Semi-Fowler's position if dyspneic
What is a normal central venous pressure reading?
3-12 cm
What does a elevated CVP measurement indicate?
hypervolemia or poor cardiac contractility
What does a lowered CVP measurment indicate?
hypovolemia
What are potential complications of CVP measuring?
- pneumothorax
- air embolism
- infection at insertion site
What is nursing managment for a CVP measurment?
- dry, sterile dressing
- change dressing, IV fluid bag, manometer, and tubing every 24 hours
- instruct pt to hold breath when tubing changed to prevent air embolism
- check and secure all connections
What are examples of hypotonic IV fluids?
.45% NaCL
What are examples of hypertonic IV fluids?
- 10-15% dextrose in water
- 3% NaCL
- Sodium Bicarb 5%
- 5% dextrose in .9% saline