Fluid volume or fluid loss

Question 1

ICF made up of

Answer 1

water & electrolytes

Question 2

ECF made up of

Answer 2

Plasma, interstitial fluid, transcellular fluid

Question 3

Fluid shifts result in:

Answer 3

Edema

Question 4

Abnormal loss of bodily fluids (diarrhea, vomiting, excess urine output)

Answer 4

Hypovolemia

Question 5

Most common manifestation with hypovolemia

Answer 5

Weight loss

Question 6

Clinical Manifestations of hypovolemia;

Answer 6

i. Drowsiness, lethargy, confusion, weakness
1. Decrease inhibition to the brain
ii. Thirst, dry mucus membranes, decreased skin turgor
iii. Hypotension, tachycardia, tachypnea
iv. Decreased urine output

Question 7

Nursing interventions: Hypovolemia

Answer 7

i. Monitor patient’s I & O, vital signs, mental status
ii. Daily weights, assess skin turgor & mucus membranes
iii. Encourage fluid intake (if possible) OR administer IV fluid replacement per physician’s order

Question 8

Clinical Manifestations of Hypervolemia

Answer 8

a. Headache, confusion
b. Peripheral edema, JVD, bounding pulse
c. Dyspnea, crackles, weight gain
d. Muscle spasms
e. Pleural parasitosis (removing fluid in lung)
f. Removing fluid from abdomen

Question 9

fluid volume deficit: priority problems

Answer 9

i. Fluid imbalance
ii. Impaired cardiac output
iii. Acute confusion
iv. Potential complication: Hypovolemic shock

Question 10

Excessive Fluid Volume priority problems

Answer 10

i. Fluid imbalance
ii. Impaired gas exchange
iii. Impaired tissue integrity
iv. Activity intolerance
v. Disturbed body image
vi. Potential complications: Pulmonary edema, ascites

Question 11

a. Abnormal retention of fluids

b. Excessive fluid intake

Answer 11

Hypervolemia