Fluid, Electrolytes, and Acid-Base Balance (Nursing Management) Flashcards
The _________ is particularly important for identifying clients who are at risk for fluid, electrolyte, and acid–base imbalances.
nursing history
Choose the following that might indicate risk for fluid and electrolyte imbalance:
- A client’s current and past medical history reveals conditions such as chronic lung disease or diabetes mellitus that can disrupt normal balances.
- Medications prescribed to treat acute or chronic conditions (e.g., diuretic therapy for hypertension) also may place a client at risk for altered homeostasis.
- ## Older people and very young children, clients who must depend on others to meet their nutrition and hydration needs, and people who cannot afford or do not have the means to cook food for a balanced diet.
All of the above
When obtaining a nursing history, the nurse needs to not only recognize risk factors but also gather data about the client’s
- food and fluid intake
- fluid output
- the presence of signs or symptoms suggestive of altered fluid and electrolyte balance.
Three simple clinical measurements that the nurse can initiate without a primary care provider’s order are:
daily weights, vital signs, and fluid intake and output
_________ provide a relatively accurate assessment of a client’s fluid status. Significant changes in weight over a short time, for example, more than 2.3 kg (5 lb) in a week or more than 1 kg (2.2 lb) in 24 hours, are indicative of acute fluid changes.
Daily weights
Choose the following that is true:
- Each kilogram (2.2 lb) of weight gained or lost corresponds to 1 L of fluid gained or lost.
- Such fluid gains or losses indicate changes in total body fluid volume rather than in any specific compartment, such as the intravascular compartment.
- Rapid losses or gains of 5% to 8% of total body weight indicate moderate to severe fluid volume deficits or excesses.
All of the above
Changes in _________ may indicate, or in some cases precede, fluid, electrolyte, and acid-base imbalances.
Ex: elevated body temperature may be a result of dehydration or a cause of increased body fluid losses.
vital signs
The following shows vital signs changes in response to fluid and electrolyte imbalance, except:
- Tachycardia is an early sign of hypovolemia
- Pulse volume will decrease in FVD and increase in FVE.
- Irregular pulse rhythms may occur with electrolyte imbalances.
- Changes in respiratory rate and depth may cause respiratory acid–base imbalances or indicate a compensatory mechanism in metabolic acidosis or alkalosis.
- RR of 16 bpm
- Blood pressure (BP), a sensitive measure for detecting blood volume changes, may fall significantly with FVD and hypovolemia or increase with FVE.
- Postural, or orthostatic, hypotension may also occur with FVD and hypovolemia.
RR of 16 bpm
Measurement and recording of all fluid intake and output (I&O) during a _________ provides important data about a client’s fluid and electrolyte balance.
24-hour period
T/F: Generally, I&O are measured for hospitalized clients, particularly those at increased risk for fluid and electrolyte imbalance.
T
What is the unit used to measure I&O?
milliliter (mL)
Consist of water, milk, juice, soft drinks, coffee, tea, cream, soup, and any other beverages. Include water taken with medications.
Oral fluids
T/F: To measure the amount of water consumed from a water pitcher, measure how much water remains in the pitcher and subtract this amount from the volume of the full pitcher.
T
Record the fluid volume as approximately one half the volume of the _______ . For example, if the ice chips fill a cup holding 200 mL and the client consumed all of it, the volume consumed would be recorded as 100 mL.
ice chips
These include ice cream, sherbert, custard, and gelatin. Do not measure foods that are pureed, because purees are simply solid foods pre- pared in a different form.
Foods that are or become liquid at room temperature
This include the volume of water used for flushes before and after medication administration, intermittent feedings, residual checks, or any other water given via a feeding tube.
Tube feeding
The includes exact amount of IV fluid administered and must be recorded, since some fluid containers may be overfilled. Blood transfusions are included in the total.
Parenteral fluids
These are administered as an intermittent or continuous infusion must also be included (e.g., ceftazidime 1 g in 50 mL of sterile water). Most of it are mixed in 50 to 100 mL of solution.
IV Medications
Fluid used to irrigate urinary catheters, nasogastric tubes, and intestinal tubes must be recorded if not immediately withdrawn as part of the irrigation.
Catheter or tube irrigants
Following each voiding, pour the urine into a measuring container, note the amount, and record the amount and time on the I&O form. This process is a means to get the?
urine output
For clients with _________, empty the drainage bag into a measuring container at the end of the shift (or at prescribed times if the output is to be measured more often). Note and record the amount of urine output.
retention catheters
In intensive care areas, urine output often is measured ________.
hourly
If a client is ________ of urine, estimate and record these outputs. For example, for an incontinent client the nurse might record “Incontinent × 3” or “Drawsheet soaked in 12-in. diameter.”
incontinent
T/F: A more accurate estimate of the urine output of infants and incontinent clients may be obtained by first weighing diapers or incontinence pads that are dry, and then subtracting this weight from the weight of the soiled items.
T
Each gram of weight left after subtracting is equal to ________.
1 mL of urine
If urine is frequently soiled with feces, the number of ________ may be recorded rather than the volume of urine.
voidings
The amount and type of fluid and the time need to be specified.
Vomitus and liquid feces
