Fluid and Electrolytes

Term
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Fluid Volume deficit
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Terms in this set (25)
Fluid Volume deficit
fluid shifts from plasma to interstitial fluid
fluid volume excess
fluid shifts from interstitial to plasma
FVD manifestations
dry, thirsty
decrease skin turgor
decrease cap refill
Increased weak thready pulse
increase respiratory rate
decrease urine output and concentrated
weight loss
seizures, coma
lethargic and confused
weak and dizzy
restless
drowsy
postural hypotension
cold clammy skin
FVE manifestations
lethargic and confused
peripheral edema
jugular venous distention
S3 heart sound
muscle spasms
increased BP
normal pulse or full and bounding
polyuria
dyspnea, crackles, pulmonary edema
weight gain
seizures, coma
Nursing Management of FVD
mild loss: oral fluids
Severe: IV solutions and blood products
complications: hypovolemic shock
Nursing Management of FVE
diuretics
fluid restriction
sodium restriction
Complications: ascites and pleural effusion
Nursing Implementation with fluid imbalances
Daily weight
Intake and output
Monitor Labs
FVD: increased BUN, Na+, HCT, plasma, urine osmolality
FVE: decreased BUN, Na+, HCT, plasma, urine osmolality
COACH
color
odor
amount
consistency
how patient is tolerating it
Nursing Implementation for fluid imbalances 2
cardio care
- monitor VS
- thorough assess PRN
Resp. care
- monitor pulse ox
- auscultate lung sounds PRN
Patient Safety: Fall risk
- orthostatic hypotension
- muscle weakness
- changes in LOC
Skin care
- turgor
- mobility
Fluid therapy
- IVF's as ordered
monitor rate of infusion
Nursing Management
Assess
- fluid imbalance
Administer
- IVFs and Rx as needed
- O2 as ordered
Implement
-fall precautions
Monitor
-therapy effectiveness
Oversee UAP
- obtain dws and VS
- frequent oral care
- record I/O
- skin care and repositioning
-elevate edematous extremities
- encourage oral fluids as appropriate
Oversee UAPobtain dws and vsOsmolalitythe concentration of solutes in body fluids Normal plasma 280-295 mOsm/kgWater deficit plasma>295Water excess plasma<275water ingestion equals water loss in the person who hasfree access to water intact thirst mechanism adh mechanismwhat stimulates ADH releasedecreased BP nausea pain hypoglycemia hypoxemiaKidneys produce how much urine each day1.5 LRenal impairment complicationsedema potassium and phosphate retention acidosisGlucocorticoidscortisol anti-inflammatory increase serum glucoseMineralcorticoids (aldosterone)enhances sodium retention and potassium excretionStimulation of the RAAS1.) increased serum potassium 2.) decreased serum sodium 3.) decreased adrenocorticotropic hormoneStimulation of ANP and BNPincreased atrial pressure volumes - heart failure - high serum sodium levels promote water and sodium excretion decreasing blood volume and BPwhat puts periop patients at risk for fluid imbalancesstress of surgery blood loss fluid lossECF volume deficit causesincreased insensible water loss perspiration diabetes insipidus osmotic diuresis hemorrhage GI Losses overuse of diuretics inadequate fluid intake 3rd space fluid shifts: burns, pancreatitisECF volume excess causesExcessive isotonic or hypotonic IV fluids Heart failure Renal failure Primary polydipsia SIADH Cushing syndrome Long-term use of corticosteroids