Fluid and Electrolyte Imbalance Flashcards
Exam 1 Med-Surg Review
What are the two types of fluid imbalances?
Fluid volume deficit (FVD) and fluid volume excess (FVE)
FVD is characterized by dehydration and volume depletion, while FVE can be caused by various disease states.
What is fluid volume deficit (FVD)?
Negative fluid balance, dehydration, volume depletion
FVD can occur due to physiologic fluid loss, such as GI losses, burns, or excessive sweating.
What conditions can lead to fluid volume excess (FVE)?
- Heart failure
- Liver cirrhosis
- Kidney disease/injury
- Excessive IV fluid administration
FVE can also be influenced by cardiac, liver, renal, and endocrine disorders.
What are the risk factors for fluid volume deficit (FVD)?
- Physiologic fluid loss
- Disease, illness, injury
- Incidence and prevalence
Examples include GI losses, burns, excessive sweating, and third-spacing.
What are the risk factors for fluid volume excess (FVE)?
- Cardiac disorders
- Liver disorders
- Renal disorders
- Endocrine disorders
- Pregnancy
- Age over 65 with impaired renal or cardiac function
Excessive IV fluid administration also contributes to FVE.
List the clinical presentations associated with fluid imbalance.
- Cardiovascular
- Neurologic
- Pulmonary
- Urologic
- Integument
- Musculoskeletal
- Laboratory/diagnostics
These presentations help distinguish between FVD and FVE.
What is the first step in applying the nursing process for fluid imbalance?
Assessment: Recognize cues of fluid volume deficit/excess
This involves gathering history, conducting physical assessments, and reviewing laboratory results.
What role does aldosterone play in fluid balance?
Regulation of fluid balance
Aldosterone helps to retain sodium and water, influencing overall fluid volume.
What is considered hyponatremia?
Sodium level < 136 mEq/L
It can lead to symptoms such as confusion, seizures, and hypotension.
What are the symptoms of hypernatremia?
- Lethargy
- Agitation
- Thirst
- Hypertension
- Seizures
These symptoms reflect an excess of sodium in the body.
What dietary recommendations are made for a patient with hyperkalemia?
Limit dietary intake of potassium
Continuous cardiac monitoring is also important in managing hyperkalemia.
What are the symptoms of hypokalemia?
- Bilateral muscle weakness
- Abdominal distention
- Decreased bowel sounds
- Dysrhythmias – inverted T wave
These symptoms indicate low potassium levels.
What is the normal range for serum potassium levels?
3.5-5.2 mmol/L
Levels outside this range indicate hypo- or hyperkalemia.
What is the role of the nurse in managing hypocalcemia?
- Encourage supplementation with calcium and Vitamin D
- Use fall precautions
- Monitor for symptoms after thyroid or parathyroid surgery
Education regarding calcium replacement is also crucial.
What are the signs of hypercalcemia?
- Anorexia
- Fatigue
- Hypoactive reflexes
- Lethargy
- Decreased LOC
These symptoms indicate elevated calcium levels.
What is the normal range for serum magnesium levels?
1.8-2.6 mg/dL
Levels outside this range can lead to symptoms of hypo- or hypermagnesemia.
What nursing action should be taken for a patient with hypermagnesemia?
- Restrict sources of excessive magnesium intake
- Monitor urinary output during IV magnesium infusions
Fall prevention measures should also be employed if weakness or confusion are present.
What are the symptoms of hypophosphatemia?
- Confusion
- Lethargy
- Seizures
- Memory loss
- Hypertension
These symptoms indicate low phosphorus levels.
True or False: IV potassium can be given at a rate greater than 20 mEq/hr.
False
This is a safety guideline due to the risk of complications.
What should be assessed hourly for an adult receiving IV solutions containing potassium?
IV site condition
This is essential for monitoring potential complications.
On morning assessment of your patient in room 123 who has severe burns. You notice that fluid is starting to accumulate in his abdominal tissue. You note that his weight has not change and his intake and output is equal. What do you suspect?
A. This is normal and expected after a burn and it is benign
B. Document this finding as non-pitting abdominal edema.
C. Intravascular compartment syndrome
D. Third spacing
D. Third spacing
After obtaining an EKG on a patient you notice that ST depression is present along with an inverted T wave and prominent U wave. What lab value would be the cause of this finding?
a. Magnesium level of 2.2
b. Potassium level of 5.6
c. Potassium level of 2.2
d. Phosphorus level of 2.0
C. Potassium level of 2.2
You are taking a patient’s blood pressure manually. As you pump up the cuff above the systolic pressure for a few minutes you notice that the patient develop a carpal spasm. Which of the following is true?*
A. The patient is having a normal nervous response to an inflating blood pressure cuff that is inflated above the systolic pressure
B. This is known as Trousseau’s Sign and is present in patients with Hypercalcemia
C. This is known as Chvostek’s Sign
D. This is known as Trousseau’s Sign and is present in patients with hypocalcemia
D. This is known as Trousseau’s Sign and is present in patients with hypocalcemia
In report from a transferring facility, you receive information that your patient’s Magnesium level is 1.2. When the patient arrives, you are ordered by the doctor to administer Magnesium Sulfate via IV. Which of the following interventions takes priority?
A. Set-up bedside suction B. Set-up IV Atropine at bedside due to the bradycardia effects of Magnesium Sulfate C. Monitor the patient's for reduced deep tendon reflexes and initiate seizure precautions D. None of the above are correct
C. Monitor the patient’s for reduced deep tendon reflexes and initiate seizure precautions
