33. Why should you care? ↑ sodium concentration in ECF Causes H2O to shift from ICF -> ECF compartment Treatment: 0.45% NS (hypotonic) facilitates H2O back into intracellular space
46. Fluid & Electrolyte disorders Excess fluids result from excessive intake or decreased output, from any cause Fluid deficits result from poor intake or excessive output, from any cause Both occur from shifts that occur with various health disorders
80. Fluid Management: FVD Isotonic Electrolyte solutions 0.9% NaCL/Ringer’s solution Expand plasma volume (↓ BP pt’s) Replace abnormal losses Total body water deficits D5W Dextrose is metabolized to carbon dioxide & water ->availability of free water for tissue needs
91. Ms. Hicks Which type of dehydration do you suspect that this Ms. Hicks has? Explain your answer.
92. Ms. Hicks In evaluating the client’s laboratory values, would you expect the following values to be normal, elevated, or decreased? Urine specific gravity Urine volume Serum sodium Serum hct & hgb BUN Serum osmolality
93. Ms Hicks When assessing a patient with FVD, the nurse would expect to find: Increased pulse rate and BP Dyspnea and respiratory crackles Headache and muscle cramps Orthostatic hypotension and flat neck veins
94. Ms Hicks What compensatory mechanism responsible for the client’s rapid pulse?
95. Ms Hicks What immediate interventions are necessary to correct this client’s fluid volume imbalance?
96. Ms Hicks Admitted with hypovolemia. Which IV solution would the nurse anticipate administering? Ringer’s solution 10% dextrose in water 3% sodium chloride 0.24% sodium chloride
97. Ms Hicks What would be most important to monitor to determine the client’s response to corrective interventions?
98. Mr Hicks What assessment data would indicate that the client is having a negative response to fluid resuscitation?
112. Diuretics: Pt & Family Teaching Take in morning and afternoon Change position slowly Weigh daily Avoid salt shaker & processed foods Read food labels ↑ potassium foods (banana/orange juice) Potassium sparing diuretics do not use salt substitute
129. Pitting Edema Extravasation & accumulation of interstitial fluid in tissues Dependent areas of the body Leaves indentation when skin surface is pressed by a finger Reflects high right atrial pressure, for example, in heart failure More severe than non-pitting edema
130. Nursing Diagnosis: FVE Excess fluid volume Risk for Impaired Skin Integrity Risk for Impaired Gas exchange
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132.
133. Mrs Hsu In further assessing the client, what assessment data would indicate that the client has fluid volume excess? Distended hand & neck veins Decreased urine output Decreased capillary refill Increased rate and depth of respirations
134. Mrs. Hsu Increased, bounding pulse JVD Diminished peripheral pulses Presence of crackles Thirst Elevated blood pressure Orthostatic hypotension Skin pale & cool to touch Which of the following assessments would indicate that Mrs. Jones has fluid volume excess?
135. Mrs Hsu After determining the client is not dehydrated, which of the following interventions would be appropriate to correct this hypotonic overhydration? Administration of 0.9% NS Restriction of free water Administration of antihypertensives Restriction of potassium
136. Mrs. Hsu A patient is exhibiting sudden onset of crackles in the lungs, moist respirations, & rapid respiratory rate. Which intervention should be performed first? Weigh the patient Assess capillary refill Measure edema Reduce IV rate
137. Mrs Hsu What would you assess for evidence of a worsening hypotonic condition? Mental status Urine output Skin changes Bowel sounds
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139.
140. Potassium (K+) 3.5 to 5.5 mEq/L Major cation in the ICF Affects cardiac muscle concentration, electrical conductivity, & cell excitability Aids neuromuscular transmission of nerve impulses. Alteration in K+ balance will result in acid-base imbalance Regulation of protein synthesis Regulation of glucose use & storage
147. Assessment: Hypokalemia Health history Anorexia, nausea, vomiting, abdominal discomfort Muscle weakness or cramping Diuretic use Prolonged vomiting or diarrhea Diabetes, Addison or Cushing disease Current medications
182. Mr. Williams C/O abdominal cramping and several very loose diarrhea stools since yesterday. What is the etiology of the client’s symptoms?
183. Mr. Williams Physician orders Kayexalate retention enema to be given stat. Should you clarify the physician’s orders before administering the enema?
184. Mr. Williams Will the physician continue the order for Spironolactone? Explain. What would be some teaching and learning priorities for d/c.
185. Sodium (Na+) 135-145 mEq/liter Normal physiologic function Maintains ECF volume Maintenance of ECF osmolality. Initiation of skeletal muscle contraction Initiation of cardiac contractility Transmission of neuronal impulses Maintenance of renal urine-concentration system
186. Sodium Imbalance Affect osmolality of ECF Affect water distribution between fluid compartments Low Na+ H2O is drawn into cells (swell) High Na+ H20 drawn out of cells
187. Signs & Symptoms Hyponatremia Muscle cramps, Weakness, fatigue Dulled sensorium, irritability, personality changes Hypernatremia Most serious effects are seen in the brain Lethargy, weakness, irritability can progress to seizures, coma, death
188. Point to Remember Pt’s with low Na+ will present with acute onset of confusion Risk for falls in the elderly
191. A patient presents with a serum sodium level of 115 mEq/L. A priority nursing intervention is Seizure precautions Vital signs every two hours Frequent mouth care Cardiac rhythm monitoring
198. Mrs. Hudson 77-year-old female Found confused, unable to get up to the bathroom Weak, anxious, confused to time & place P 110; B 108/58 Skin dry Urine Specific gravity 1.028 Deep tendon reflexes slightly reduced
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200.
201. Calcium (Ca++)8.5 – 10.5 mEq/dl (4-5.5 mEq/L) Functions Enhances activity of enzymes or reactions Skeletal muscle contraction Cardiac contractility Helps activate steps in blood coagulation. Bone strength & density Regulation of neural impulse transmission
205. The most important assessment in a patient with hypercalcemia is Heart rhythm Urine output Trousseau’s sign Weight
206. The nurse evaluates teaching about calcium supplement therapy as effective when the patient states that she will take her calcium tablets All at one time in the morning With meals As needed for tremulousness With a full glass of water
207. Phosphorus 2.5 – 4.5 mEq/dl Vital for intracellular activities Activation of B complex vitamins Plays major role in acid-base balance through its action as a urinary buffer Cell division Plays essential role in muscle, RBC, neurological function Aids in carbohydrate, protein and fat metabolism
210. Magnesium (Mg++) 1.5-2.5 mEq/l Muscle contractility Carbohydrate and protein metabolism. Affects neuromuscular irritability & contractility of cardiac and skeletal muscle. Facilitates transport of Na+ and K+ across cell membranes. DNA & Protein synthesis
218. A male patient’s hematocrit is 56% Serum sodium 150 mEq/L and Potassium of 5.8 mEq/L Which of the following would be indicated for this patient?
219. Prepare to administer a hypertonic IV soultion Prepare to administer a hypotonic IV solution Prepare to administer an isotonic IV solution Implement a fluid and sodium restriction for the patient
220. The nurse is caring for a patient and has just received the laboratory data report. Which of the following results would cause the most concern to the nurse?
222. The nurse is caring for a patient with severe vomiting and diarrhea Nasogastric tube to low wall suction. The nurse realizes that this patient is at risk for which of the following electrolyte imbalances?
224. A patient is admitted to the hospital with a fluid volume excess. Which of the following will the nurse most likely assess for this patient?
225. Dependent edema Blood pressure: 92/55 mm Hg Respiratory rate 14 breaths/minute and unlabored Heart rate 86 beats per minute without ectopy
226. The nurse is caring for a patient in renal failure with a serum potassium level of 7.1mEq/L. Which of the following should the nurse do first to assist this patient?
227. Assess level of consciousness. Measure urine output hourly. Have arterial blood gases drawn. Obtain an electrocardiogram.
228. The nurse is providing discharge instructions to a patient with hypokalemia. Which of the following should the nurse include in these instructions?
229. Take oral Kaexylate as prescribed. Limit the intake of spinach and carrots. Eat a balanced diet, including tomato juice and potatoes. Expect muscle cramps and weakness for at least six weeks.
Notas do Editor
Fluid & Electrolytes/Acid Base BalanceGoal: Reestablish & maintain normal balance -assess clients likely to develop imbalances -monitor clients for early manifestations -implement collaborative interventions
Necessary for cells to be able to carry out their work. Body fluids are in constant motionBody fluids maintain healthy living conditions for body cells
nutrients in foodnormal digestive processesnormal volume, composition, distribution, & pH of body fluids
Homeostasis involvesDelivery of essential elements such as oxygen and glucose to the cellsRemoval of wastes such as carbon dioxide from the cells
Intracellular fluid 40% total body weightEssential for normal cell functionProvides medium for metabolic processes
Extracellular fluid 20% total body weightInterstitial fluid: spaces between cellsIntravascular fluid (plasma-arteries, veins, capillaries)Transcellular fluidUrine, digestive secretions, perspirationCerebrospinal, pleural, synovial fluidsIntraocular, gonadal, pericardial fluids
82 year old women
Isotonic dehydration, the most common type of fluid deficit, is caused by loss of plasma volume. In this case, the client lost volume by excessive vomiting and diarrhea
Urine specific gravity >1.010 Urine volume decreased Serum sodium normal Serum hct & hgb increasedBUN normal or increased Serum osmolality normal
Orthostatic hypotension and flat neck veins
Increased sympathetic discharge
Rapid hydration of IVF
D5W
Urinary output
crackles
weight
Distended hand and neck veins
All except diminished peripheral pulses, thirst, orthostatic hypotension
Restrict free water
Stop IV
Urine output
ElectrolytesMaintain fluid balanceRegulate & maintain acid-base balanceContribute to enzyme reactionsEssential for neuromuscular activityMeasured in mEq/L of watermEq-measure of chemical binding power of the ion
Heart rhythm
Cardiac monitoring
Bacon, fresh fruit salad if it contains bananas, cantalope, kiwi, orange) potato, spinach, & dried fruit; salt subsitute
Deficit knowledge related to dietary intake of potassium as evidenced by dietary intake of potassium rich foods such as potatoes, bacon, and salt subsitute. Deficit knowledge related to lack of familiarity with information resources as evidenced by inaccurate follow through on instructions for medication and dietary intake of potassium rich foods
Loose diarrhea stools. Symptoms are a result of the excess potassium moving from ICF to ECF creating an stimulation of the bowel and resulting in diarrhea.
There is no need to clarify the order. GI s/s of hyperkalemia are increased motility, hyperactive bowel sounds and diarrhea. The kayxalate will reduce the potassium levels consequently the intestinal motility decreases if the enema is successful
Spironolactone is a potassium sparing diuretic and should be d/c.Teach diet, medications, and recognition of s/s of hyperkalemia. Importance of follow up care
Seizure precautions
Because of her symptoms and history knowing that dehydration can be characteristic of hypernatremia the sodium level is expected to be elevated. Assessment: CNS, neurovascular, and CV manifestations Treatment fluid replacement with isotonic solution (NaCl) Teaching sodium content in foods and beverages, safety measures (physiologic changes in the elderly, s/s of dehydration to report, prevention of dehydration and hypernatremia by drinking adequate water
High Ca can cause constipation, polyuria which causes increased thirst; cardiac arrestLow Ca Lethargy, coma
Heart rhythm-dysrhythmias, ECG changes possible HTN, cardiac arrest
