Fluid & Electrolyte; Giddens charts

Question 1

TOO LITTLE VOLUME (ECV DEFICIT)

Answer 1

Sudden weight loss, skin tenting, dry mucous membranes, vascular underload: rapid thready pulse, postural BP drop, lightheadedness, flat neck veins when supine, oliguria, syncope, shock if severe

Question 2

TOO MUCH VOLUME (ECV EXCESS)

Answer 2

Sudden weight gain, dependent edema, vascular overload: bounding pulse, distended neck veins when upright, dyspnea, pulmonary edema if severe

Question 3

TOO DILUTE (HYPONATREMIA)

Answer 3

Impaired cerebral function: decreased LOC, nausea, seizures if severe; serum Na+ <130 mEq/L

Question 4

TOO CONCENTRATED (HYPERNATREMIA)

Answer 4

Impaired cerebral function: decreased LOC, thirst (not older adults), seizures if severe; serum Na+ >145 mEq/L

Question 5

HYPOKALEMIA

Answer 5

Bilateral ascending flaccid muscle weakness, abdominal distention, constipation, postural hypotension, polyuria, cardiac dysrhythmias; serum K+ <3.5 mEq/L

Question 6

HYPERKALEMIA

Answer 6

Bilateral ascending flaccid muscle weakness, cardiac dysrhythmias, cardiac arrest if severe; serum K+ >5.0 mEq/L

Question 7

HYPOCALCEMIA

Answer 7

Increased neuromuscular excitability: positive Chvostek’s and Trousseau’s signs, muscle cramps, twitching, hyperactive reflexes, carpal and pedal spasms, tetany, seizures, laryngospasm, cardiac dysrhythmias; serum total Ca++ <9 mg/dL (4.5 mEq/L)

Question 8

HYPERCALCEMIA

Answer 8

Decreased neuromuscular excitability: anorexia, nausea, constipation, muscle weakness, diminished reflexes, decreased LOC, cardiac dysrhythmias; serum total Ca++ >11 mg/dL (5.5 mEq/L)

Question 9

HYPOMAGNESEMIA

Answer 9

Increased neuromuscular excitability: positive Chvostek’s and Trousseau’s signs, insomnia, hyperactive reflexes, muscle cramps and twitching, nystagmus, tetany, seizures, cardiac dysrhythmias; serum Mg++ <1.5 mEq/L

Question 10

HYPERMAGNESEMIA

Answer 10

Decreased neuromuscular excitability: flushing, diaphoresis, diminished reflexes, hypotension, decreased LOC, muscle weakness, respiratory depression, bradycardia, cardiac dysrhythmias; serum Mg++ >2.5 mEq/L

Question 11

FRAMEWORK FOR NURSING INTERVENTIONS FOR PEOPLE WITH DISRUPTED FLUID AND ELECTROLYTE BALANCE

Answer 11

Provide safety and comfort.
Facilitate oral intake if appropriate.
Administer collaborative interventions:
Adjustment of fluid intake or output
Treatment of the underlying cause
Monitor for complications of therapy.
Teach how to prevent imbalances in the future or when to seek help (if chronic).

Question 12

1. A patient has newly diagnosed hyperparathyroidism. What should the nurse expect to find during an assessment at the beginning of the nursing shift?

Answer 12

Parathyroid hormone (PTH) shifts calcium from the bones into the extracellular fluid (ECF). Excessive PTH causes hypercalcemia, which is manifested by lethargy and constipation

Question 13

A patient injured in an earthquake today when a wall fell on his legs received 9 units of blood an hour ago because he was hemorrhaging. Which laboratory value should the nurse check first when the report returns?

Answer 13

The patient has two major risk factors for hyperkalemia: massive sudden cell death from a crushing injury (potassium shift from cells into the extracellular fluid) and massive blood transfusion (rapid potassium intake).

Question 14

A patient has a tumor that secretes excessive antidiuretic hormone (ADH). He is confused and lethagic. His partner wants to know how a change in blood sodium can cause these symptoms. What should the nurse teach the patient’s partner?

Answer 14

The normal action of ADH is renal reabsorption of water, which dilutes the blood. Excessive ADH causes hyponatremia, which is manifested by a decreased level of consciousness because the osmotic shift of water into the brain cells impairs their function.

Question 15

A patient has acute gastroenteritis with watery diarrhea. Which statement by this patient would indicate that the nurse’s teaching has been effective?

Answer 15

Sodium-containing fluids are removed from the body by acute diarrhea and must be replaced to prevent an extracellular fluid volume (ECV) deficit.

Question 16

The home health nurse should assess a patient who has chronic diarrhea for which fluid and electrolyte imbalances? (Select all that apply).

Answer 16

Chronic diarrhea has a high risk of causing ECV deficit, hypokalemia, and hypocalcemia because it increases the fecal output of sodium-containing fluid, potassium, and calcium.