Upgrade to remove ads
Only $35.99/year

Fluid & Electrolytes Study Guide

Terms in this set (33)

What are the symptoms of hypervolemia/fluid volume excess?
Weight gain
Edema in dependent areas
Bounding peripheral pulses
Hypertension
Jugular vein distention (JVD)
Dyspnea, cough
Abnormal lung soundsNeurologic changes that indicate cerebral edema including decreased level of consciousness, coma, and seizures (hypotonic)
How does hypervolemia/fluid volume excess affect the labs?
Urine specific gravity <1.005
Decreased hematocrit
Adult males <42
Adult females <37
Bun <7Serum sodium <135 (hypotonic)
What are some interventions with hypervolemia/fluid volume excess including dietary considerations?
Monitor vital signs
Monitor intake and output
Assess for edema and JVD (isotonic)
Auscultate lung fields (isotonic)Assess for neurologic changes (hypotonic)
Monitor laboratory results, especially hematocrit, bun, and urine specific gravity
What re the symptoms of hypovolemia/fluid volume deficit?
Confusion
Thirst
Dry mucous membranes
Orthostatic hypotension
Tachycardia
Weak and thread pulse
Decreased skin turgor
Prolonged capillary refill
Decreased urine output Dry sticky mucous membranes
Flushed dry skin
Increased body temperature
Irritability
Seizures
coma
How does hypovolemia/fluid volume deficit affect the labs?
Urine specific gravity >1.030
Increased hematocrit
Adult males >52
Adult females >48
Bun >20Serum sodium >145
List some interventions with hypovolemia/fluid volume deficit including dietary considerations.
Administer fluids
Monitor vital signs
Monitor intake and output
Assess for neurologic changes
Monitor laboratory results especially hematocrit, bun, and urine specific gravity
What direction does fluid shift in the isotonic solutions?
An administered solution that has the same osmolarity as blood plasma
What direction does fluid shift in the hypertonic solutions?
Solution which pulls water from the cell to the extracellular fluid compartment causing cells to shrink.
What direction does fluid shift in the hypotonic solutions?
Where excess water moves into the cells causing them to swell.
What are isotonic IV solutions used for?
have a tonicity essentially the same as blood plasma. These types of fluids increase intravascular volume but do not cause fluid shifts in or out of the cell.
What are hypotonic IV solutions used for?
fluids lower the osmolarity of blood plasma and cause fluid to shift into the cell. These fluids are used to treat hypernatremia or severe dehydration.
What are hypertonic IV solutions used for?
fluids have a tonicity that is markedly higher than 290 mOsm/L. These solutions increase the osmotic pressure of plasma and force fluids to move out of the cell and into the bloodstream.
What are major risks to consider of isotonic solutions?
Can lead to circulatory overload when not monitored closely.
What are major risks to consider of hypotonic solutions?
Continued use can lead to intracellular swelling or water intoxication. Swelling of brain cells causes increased intracranial pressure.
What are major risks to consider of hypertonic solutions?
Hypertonic fluids have a tonicity that is markedly higher than 290 mOsm/L. These solutions increase the osmotic pressure of plasma and force fluids to move out of the cell and into the bloodstream.
How should IV potassium be administered?
Must be given via a calibrated infusion pump so the rate can be regulated. not by gravity infusion. It should also always be thoroughly mixed in 100 to 1000 mL of IV solution and must be infused slowly (generally no faster than 10 mEq/hr).
What should the nurse not do with IV potassium and why?
It should never be given intramuscularly or as an IV bolus or push. Giving IV it directly into the vein causes cardiac dysrhythmias, cardiac arrest, and death. (It is one of the agents used in lethal injection because rapid infusion results in immediate cardiac arrest.)
What are some nursing considerations when administering oral potassium supplements?
Give it with a sufficient amount of water or juice (at least 8 oz) and with meals. It is extremely irritating to the gastric mucosa. Check the amount of urine output. Accumulation occurs if a patient is receiving it and urine output is below 25 mL/h or below 600 mL/d. Remember that 80% to 90% of it is excreted in the urine. Report results to the health care provider.
What are some nursing considerations when administering oral calcium supplements?
Instruct the patient to consume high-calcium foods such as milk and dairy products.
Remind the patient that foods rich in protein and vitamin D enhance calcium absorption.
What are symptoms of and nursing interventions for hyperkalemia?
Anxiety
Irritability
Confusion
Dysrhythmias, including bradycardia and heart block
Muscle weakness, flaccid
Paralysis
Paresthesia
Abnormal crampingTreatment: Monitor vital signs, especially heart rate and rhythm.
Monitor cardiac rhythm with ECG.
Monitor laboratory results for serum potassium levels.
Limit potassium-rich foods.
Administer cation-exchange resins (Kayexalate) as ordered
Administer glucose and insulin as ordered (potassium moves back into cell)
What are symptoms of and nursing interventions for hypokalemia?
Weak, irregular pulse
Fatigue, lethargy
Anorexia, nausea, vomiting
Muscle weakness and cramping
Decreased peristalsis, hypoactive bowel sounds
Paresthesia
Cardiac dysrhythmias
Increased risk for digitalis toxicityTreatment: Monitor vital signs, especially heart rate and rhythm.
Monitor cardiac rhythm with ECG.
Monitor laboratory results for serum potassium levels.
Assess for signs of digitalis toxicity.
Encourage foods high in potassium.
Administer potassium supplements as ordered; IV potassium is diluted properly and administered slowly, usually by infusion. Never administer potassium as an IV bolus or IV push.
Administer potassium supplements with food.
Potassium-wasting diuretics are a major cause of hypokalemia. Diuretics are divided into two categories: potassium-wasting and potassium-sparing drugs. Potassium-wasting diuretics cause excretion of potassium and other electrolytes, such as sodium and chloride, in the urine. Potassium-sparing diuretics cause retention of potassium, but sodium and chloride are excreted in the urine.
Laxatives, corticosteroids, antibiotics, and potassium-wasting diuretics are the major drug classifications that can cause hypokalemia. Other drug classifications that may cause hyperkalemia include oral and IV potassium salts, central nervous system (CNS) agents, and potassium-sparing diuretics.
What are symptoms of and nursing interventions for hypernatremia?
Thirst
Dry and sticky mucous membranes
Weakness
Elevated temperature
Severe hypernatremia causing
Confusion and irritability
Decreased levels of consciousness
Hallucinations
Seizures
>300 mOsm/kgTreatment: Monitor vital signs.
Monitor level of consciousness.
Monitor intake and output.
Monitor laboratory results, especially serum sodium and serum osmolarity.
Limit salt intake and foods high in sodium.
Increase water intake.
Administer hypotonic IV solutions as ordered.
What are symptoms of and nursing interventions for hyponatremia?
Lethargy
Confusion
Weakness
Muscle cramping
Seizures
Anorexia
Nausea
Vomiting
Serum osmolarity <280 mOsm/kgTreatment: Monitor vital signs.
Monitor intake and output.
Monitor laboratory results, especially serum sodium and serum osmolality.
Encourage foods high in sodium.
Restrict water intake.
Administer hypertonic IV saline solutions as ordered.
What are symptoms of and nursing interventions for hypercalcemia?
Lethargy, stupor, coma
Decreased muscle strength and tone
Anorexia, nausea, and vomiting
Constipation
Pathologic fractures
Dysrhythmias
Renal calculiTreatment: Monitor heart rate and rhythm.
Monitor cardiac rhythm with ECG.
Encourage increased fluid intake.
Increase patient activity, including active ROM.
What are symptoms of and nursing interventions for hypocalcemia?
Confusion, anxiety
Numbness and tingling of extremities
Muscle cramps that progress to tetany and seizures
Hyperactive reflexes
Cardiac dysrhythmias
Positive Chvostek and Trousseau signsTreatment: Monitor heart rate and rhythm.
Monitor cardiac rhythm with ECG.
Institute fall and seizure precautions.
Administer oral and/or IV calcium supplements as ordered.
Encourage calcium-rich foods.
What are symptoms of and nursing interventions for hypermagnesemia?
Warm, flushed appearance
Nausea, vomiting
Drowsiness, lethargy
Decreased muscle strength
Generalized weakness
Decreased deep tendon reflexes
Hypotension
Dysrhythmias, especially bradycardia and heart block
Slow, shallow respirations; respiratory arrestTreatment: Assess vital signs, especially heart rate and rhythm.
Monitor cardiac rhythm with ECG.
Assess mental status, changes in level of consciousness.
Assess neuromuscular strength and activity.
Encourage increased oral intake, increased IV fluids.
Administer loop diuretics as ordered.
Provide respiratory support (supplemental oxygen or mechanical ventilation) as needed.
What are symptoms of and nursing interventions for hypomagnesemia?
Irritable nerves and muscles
Hyperactive deep tendon reflexes
Seizures
Dysrhythmias, especially tachyarrhythmias
ECG changes
Altered level of consciousness
Mood swings
Delusions,
hallucinations
Dysphagia
Nausea/vomitingTreatment: Assess vital signs, especially heart rate and rhythm.
Monitor cardiac rhythm with ECG.
Assess mental status, changes in level of consciousness.
Monitor laboratory results, including potassium and calcium levels.
Assess swallowing before administering medications, food, or fluid.
Institute seizure precautions.
Administer oral or IV supplements as ordered.
How is the best way to assess a patient's hydration status? What are some other assessment findings?
Health history
Recent changes in fluid intake, diet, and other lifestyle habits
Vital signs
Pay particular attention to prolonged fever, tachycardia, changes in respirations, and alterations in blood pressure. Intake and output
Oral intake
All fluids and foods that become liquid at room temperature
Output
Body fluids and drainage that can be measured
24 balances
Document intake and output each shift
Daily the shift totals are added to obtain the 24 hour balances
Note trends over subsequent days Weight
A change of 1 kg (2.2 lb) is equivalent to 1 L (1000 mL) of fluid.
Edema
Pitting edema
Graded on a 4+ scale
1+ Slight indentation (2 mm); returns to normal fairly quickly
2+ Deeper indentation (4 mm); indentation lasts longer
3+ Obvious indentation (6 mm); lasts several seconds
4+ Deep indentation (8 mm); remains several minutes
How much urine should a patient produce hourly?
1-2 ml/kg/hr. (0.5 to 1.5 cc/kg/hour.)
What are the normal characteristics of urine?
Volume (1-2L)
Color (yellow/amber)
Turbidity (initially transparent but becomes cloudier with time)
Odor (mild but ammonia smell increases with time)
pH (4.6-8; average is 6)
Specific Gravity (1.005-1.030; more solues= higher SG)
What does specific gravity indicate?
It determines how well the kidneys are functioning and how well kidneys concentrate urine. The higher the number, the more concentrated the urine.
Dehydration, anemia.
What does hematocrit indicate?
Measures the percentage of red blood cells in the total blood volume.
Blood disorders or inadequate mineral production
What does BUN indicate?
Measures amount of nitrogen in blood that comes from urea. Indicates how well kidneys and liver are functioning.
renal function and hydration status
Students also viewed