Chapter 6-fluids & Imbalance Flashcards
Diffusion
Substance moves from high to low
Filtration
Movement of both water and sm molecules move through a semipermeable membrane.
Hydrostatic
Force of water
Isotonic
Same osmolarity as the blood
Importance of water
Cellular metabolism, blood volume, body temp, solute transport.
Average adult water loss
2500 mL daily
Hypovolemia
Decrease in blood volume
Most common form of dehydration
Hemorrhage
Hypovolemia can occur 2 ways
Hemorrhage
Fluid from the intravasvular space moves into the interstitial space
Dehydration symptoms
Thirst Tenting turgor Rapid weak pulse Low bp Elevated temp Decreased urine (less 30 mL) Dark urine Constipation Weight loss
Complications of dehydration
Organ function failure
Diagnostic test for dehydration
BUN
Blood urea nitrogen
Specific gravity increases
Elevated hematocrit
Nursing diagnosis for dehydration
Risk for deficient fluid volume
Nursing diagnosis expected outcome for dehydration
Pt will be adequately hydrated as evidence of stable weight, moist mucous membranes, and elastic skin turgor.
As a person ages, water decreases from 60% to 50% of total body weight
Secondary to increase in body fat
Secondary to increase in body fat
Fluid excess
Too much fluid in the body
Hypervolemia
Excess fluid in the intravasvular shape
Conditions that cause hypervolemia
Poorly controlled IV therapy
Excessive arrogant ion of wounds
Excessive ingestion of water
Conditions that can result in hypervolemia
Renal failure
Heart failure
Inappropriate antidiuretic hormone
Prevention of hypervolemia
Monitor IV therapy
Use of an electronic fusion pump
Monitor the amt of fluid used for arrigation
Symptoms of hypervolemia
Elevated bp
Bounding pulse
Increased and shallow respiration
Diagnostic test for hypervolemia
BUN and hematocrit decrease
Plasma increased
Decrease in specific gravity
Therapies for hypervolemia
Diuretic and diet
Positioning
Keep head elevated to avoid aspiration
Fowler’s position–allows for greater lung expansion
Oxygen if ordered–provides oxygen to organs
Drugs used for hypervolemia
Lasix
Furosemide
Excretes sodium and water and potassium
Diet therapy for hypervolemia
Mild fluid intake
Sodium restricted diet
Data collection for hypervolemia
Edema in back and lower limbs
I&O
Pitting edema over a honey area
Assess lung sounds
Crackles if there is an accumulation of fluid
Weight gain or lossNursing diagnosis foe hypervolemia
Excess fluid volume related to excessive fluid intake
Expected outcome for hypervolemia
Patient return to normal status as evidenced by return to weight that is normal for pt, absence of edema, and clear lung sounds
Hypo atresia
Sodium deficit
Normal level of serum sodium
135-145
Hypokalemia
Calcium deficit
Signs and symptoms of hypokalemia
Muscle cramps Shallow respiration Weak, irregular pulse Orthostatic hypotension (postural) Dysrythmia Changes in mental status Lethargy GI motility decreases
Alkalosis
Acid-base imbalance
Therapeutic measures foe hypokalemia
IV potassium supplements after pt has voided (kidneys eliminate excess potassium).
Potentially dangerous
Too high causes cardiac arrest
Administered slowly and NEVER by push
RN administers only
