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56 Cards in this Set
- Front
- Back
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Examples of Isotonic dehydration:
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Symptoms may include vomiting and diarrhea.
Fluid loss is not balanced by fluid intake. Because losses of sodium and water are proportionally equal, sodium levels are normal. Most fluid loss is extracellular. |
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Hypotonic dehydration:
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Proportionately more sodium is lost than water. Fluid shifts from extracellular to intracellular components to compensate.
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Hypertonic dehydration:
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Proportionately less sodium is lost than water. Fluid shifts from intracellular to extracellular components to compensate. Onset of signs and symptoms of dehydration may be delayed.Select a category of fluid volume deficit to learn more about the causes:
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. Gastrointestinal losses that cause dehydration include:
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Vomiting
Diarrhea GI suctioning Intestinal fistulas Intestinal drainage. |
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Other fluid losses include:
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Diuretics
Renal disorders Endocrine disorders Excessive exercise Hot environment Hemorrhage Burns to the skin Chronic use of laxatives or enemas. |
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Inadequate fluid intake includes:
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Lack of access to fluids.
Inability to request or swallow fluids Oral trauma Altered thirst mechanism. |
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Retention of sodium and water
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Congestive heart failure
Liver cirrhosis Renal failure Adrenal gland disorders Corticosteroid administration Stress conditions causing ADH and aldosterone release |
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Other causes
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Excessive intake of sodium-containing foods
Drugs that cause sodium retention Administration of excessive amounts of sodium-containing intravenous fluids such as 0.9% normal saline or Lactated Ringer solution |
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Explain where third spacing fluid is. Is it usabale? Does it count towards water volume in the body? |
Fluid may shift to the abdomen, subcutaneous tissues, peritoneal space, pleura, or soft tissues affected by trauma or burns. This fluid is trapped and cannot be used for normal physiological functions; thus it is considered a volume loss to the body
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The shift of fluid and increased capillary permeability in third spacing may be due to:
(this is long and in depth, just read through it.) |
Increased blood hydrostatic pressure, as in intravascular fluid volume excess
Decreased blood colloid osmotic pressure (also called Oncotic pressure) resulting from conditions that reduce plasma proteins, such as nephrotic syndrome Increased interstitial fluid osmotic pressure resulting from conditions that allow excess plasma proteins to leak into the interstitial spaces, such as burns Blocked lymphatic drainage resulting from obstructions, such as tumors Release of histamine and prostaglandins resulting from trauma or irritation of tissues.It is difficult to assess the extent of fluid volume deficit resulting from third spacing. It might not be reflected in weight or intake and output records. Sometimes it is not discovered until organ dysfunction occurs. Delays in recognizing and treating third spacing can lead to irreversible shock and multiorgan system failure. |
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edema can be a sign of __________ spacing |
third |
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Manifestations of acute fluid volume deficit occur _______
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rapidly |
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Manifestations of acute fluid volume deficit occur rapidly and include Mild Weight loss of________% represents mild fluid volume deficit
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2–5%:
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Manifestations of acute fluid volume deficit occur rapidly and include moderate Weight loss of________% represents moderatefluid volume deficit
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6-9% |
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Weight loss of__________ : represents severe fluid volume deficit
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≥10%
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Other manifestations of acute fluid volume deficit (acute dehydration is how i am thinking of it) |
Diminished skin turgor
Postural or orthostatic hypotension with a drop of more than 15 mmHg systolic, representing a loss in intravascular volume Flat neck veins when the client is recumbent Tachycardia Pale, cool skin Decreased urine output. |
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When the loss of fluid occurs more gradually, the client’s fluid volume may be very low before manifestations develop.
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... |
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Fluid volume excess can lead to hypervolemia and _________ __________.
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circulatory overload
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Manifestations of this fluid imbalance include:
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Peripheral edema
Anasarca (severe, generalized edema) Cardiovascular: Full, bounding pulse Distended neck and peripheral veins Increased central venous pressure Tachycardia Hypertension Respiratory: Cough Dyspnea (labored or difficult breathing) Orthopnea (difficulty breathing when supine) Dyspnea at rest Reduced oxygen saturation Moist crackles Pulmonary edema Urinary Polyuria (greatly increased urine output) Hematologic Decreased hematocrit Decreased blood urea nitrogen level NeurologicAltered mental status Anxiety |
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Third spacing manifestations |
CoughAdventitious lung sounds Pulmonary edema Dyspnea Orthopnea Decreased oxygen saturation Peripheral edema Anasarca Ascites (excess fluid in the peritoneal cavity) |
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children risks for fluid and electrolyte imbalance |
Children are less sensitive to thirst.
Children are more susceptible to losses from vomiting, diarrhea, and fever. Infants under radiant warmers or receiving phototherapy are at risk for increased fluid loss. |
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Older Adults Fluid and elect imbal |
Changes in cognition, lack of mobility, and lack of access to fluids in long-term care contribute to insufficient intake. Fear of incontinence may cause self- restriction of fluids. |
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Pregnant women fluid and elec im |
Pregnant women are at higher risk for fluid volume deficit due to nausea and vomiting and increased fluid requirements.Pregnant women are at higher risk for third spacing from decreased venous return and preeclampsia.
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Diagnostic Test
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Serum electrolytes
Serum osmolality Hemoglobin and hematocrit Urine specific gravity and osmolality Central venous pressure Serum BUN and creatinine Liver function tests (transaminases) |
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When replenishing fluid which is the safest, most effective route? |
Oral |
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Oral Replacement gradual to prevent rapid rehydration of the cells In mild fluid deficit, water alone used for fluid replacement In severe fluid deficit, carbohydrate/electrolyte solution such as a sports drink, ginger ale, or rehydrating solution recommended
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oral replacement must be done at what speed? |
gradually
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What type of fluid is used for mild deficit? |
In mild fluid deficit, water alone used for fluid replacement |
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In severe fluid deficit, what is recommended to replenish the fluids?
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carbohydrate/electrolyte solution such as a sports drink, ginger ale, or rehydrating solution is recommended
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Intravenous
Isotonic electrolyte solutions: What do they do to help? |
expand plasma volume and replace abnormal losses
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IV Hypotonic solutions: What is the point of giving them? |
provide water to treat total body water deficits
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Loop diuretics To inhibit ___________________ in the ascending loop of Henle
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sodium and chloride reabsorption
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Thiazide diureticsTo promote the excretion of (four things)______________ by decreasing absorption in the distal tubule
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sodium, chloride, potassium, and water
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Potassium-sparing diureticsTo promote excretion of ___________ by inhibiting sodium-potassium exchange in the distal tubule
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sodium and water
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Nursing care of clients affected by third spacing should be focused on:
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Assessing, Facilitating, and Protecting skin integrity
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Third Spacing: Assesing |
Assessing and promoting respiratory function by monitoring lung sounds and oxygen saturation, placing the client in Fowler’s position, encouraging incentive spirometer use, coughing, and deep breathing
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Third Spacing: Facilitating |
Facilitating the clearance of fluid from the third space by elevating affected areas and encouraging client activity as tolerated
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Protecting skin integrity,
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as edematous tissue is often easily damaged. Nurses should be vigilant about repositioning clients frequently, using friction- and shear-reducing techniques and padding bony prominences to avoid pressure.
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Treatment for Hypernatremia |
Hypernatremia Fluid replacement at rates less than 0.5–1 mEq/hr to prevent intracranial fluid shifts and cerebral edema
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Hyponatremia
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Increased dietary sodium
Sodium containing IV fluids |
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Hyperkalemia
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Calcium gluconate
Insulin and glucose administration Sodium polystyrene sulfonate Diuretics |
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Hypokalemia
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Hypokalemia Potassium salts replacement
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Hypercalcemia
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(excess serum calcium)
Discontinuation of thiazide diuretics Discontinuation of supplements Low-calcium diet Partial parathyroidectomy |
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Hypocalcemia
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(insufficient serum calcium)Calcium replacementIV replacement in severe cases, not to exceed 60 mg/min
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Hyperchloremia
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(excess serum sodium)DiureticsIV fluidsTreatment of underlying causeDialysis
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Hypochloremia
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(insufficient serum sodium)
Increasing dietary salt Adding chloride to IV fluid Treating underlying causes |
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Health history
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Shortness of breath or dyspnea
Persistent cough Recent weight loss or gain Medications History of cardiac, renal, liver, or endocrine disease Perception of thirst Perception of urine output Recent strenuous exercise or unusual activity Recent fever or GI illness Diet and fluid intake recall Anorexia (loss of appetite) Difficulty sleeping while lying down |
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Physical examination
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Auscultation of heart and lungs
Vital signs, oxygen saturation Quality of pulses Distention or flattening of vessels Mucous membranes Skin turgor Presence of edema, ether local, dependent, or generalized Laboratory values |
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Things to consider when diagnosing Just read over |
Potential for impaired gas exchange Impaired tissue perfusion related to fluid deficit Impaired skin integrity related to edema Alterations in fluid volume Alterations in cardiac output Increased risk for injury related to hypotension Increased risk for injury related to the neurologic and neuromuscular effects of electrolyte imbalance Potential for enhanced wellness through identifying strategies for maintaining fluid balance Potential for enhanced knowledge regarding diet and nutrition. |
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Nursing Process: Planning
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The client will achieve electrolyte and fluid balance.
The client will maintain regular cardiac output and rhythm. The client will replace fluids lost during exercise. The client will return to normal hydration status. The parents of pediatric clients will practice strategies for preventing the child from becoming dehydrated. The client will have clear lung fields and oxygen saturation within normal limits. The client will maintain skin integrity. The client will tolerate increased levels of activity. The client will make appropriate food choices with regard to sodium and fluids. |
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Nursing Process: Implementation
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Obtaining daily weight
Recording intake and output Providing oral rehydration Administering IV fluids as ordered Monitoring laboratory values Initiating safety precautions to prevent falls Teaching strategies for minimizing postural hypotension Repositioning the client every 2 hours. |
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Examples of interventions that may be appropriate for inclusion in the plan of care for the client with fluid volume excess include: NEED TO KNOW
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Obtaining daily weight
Recording intake and output Restricting fluids as ordered Administering diuretics and other medications as ordered Monitoring laboratory values Repositioning the client every 2 hours Placing the client in Fowler’s position if the client experiences respiratory difficulty Monitoring oxygen saturation. |
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Examples of interventions that may be appropriate for inclusion in the plan of care for the client with electrolyte imbalance include:
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Monitoring electrolyte levels
Recording intake and output Administering electrolyte replacement as ordered Observing for signs and symptoms of dehydration of electrolyte imbalance. |
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For clients with fluid or electrolyte imbalances:
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Teach the importance of maintaining adequate fluid intake (at least 1,500 mL/day).
Teach how to prevent fluid deficit: o Avoid exercising during extreme heat. o Increase fluid intake during hot weather. o If vomiting, take frequent small amounts of ice chips or clear liquids, such as flat cola or ginger ale. o Reduce intake of coffee, tea, and alcohol, which increase urine output and can cause fluid loss. (Recent studies have called into question the diuretic effects of caffeine.) |
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Nursing Process: Evaluation
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During the evaluation phase, the nurse evaluates:The client’s response to all nursing interventionsThe degree to which the client goals and outcomes were achievedThe need for revising the client’s plan of care, including modifying, adding, or discontinuing nursing diagnoses and interventions.
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For the client with fluid and electrolyte imbalances who successfully achieves the identified client goals and outcomes, examples of nursing observations during the evaluation phase may include the following:
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The client achieved electrolyte and fluid balance
The client maintained regular cardiac output and rhythm The client replaced fluids lost during exercise The client returned to normal hydration status The parents of pediatric clients practiced strategies for preventing the child from becoming dehydrated The client had clear lung fields and oxygen saturation within normal limits The client maintained skin integrity The client tolerated increased levels of activity The client made appropriate food choices with regard to sodium and fluids. |
