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Clinical Concepts > Hydration > Flashcards

Hydration Flashcards

1
Q

fluid refers to what?

A
  • water and electrolytes
  • approximately 60% of body weight in adults
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2
Q

water serves as

A
  • MEDIUM FOR METABOLIC REACTIONS
  • TRANSPORT VEHICLE
  • LUBRICANT
  • INSULATOR & SHOCK ABSORBER
  • TEMPERATURE REGULATOR –> why we sweat
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3
Q

most of the water in our body is what?

A
  • intracellular fluid
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4
Q

overview: intracellular

A
  • 2/3 TO 3⁄4 OF BODY’S TOTAL FLUID
    • SKELETAL MUSCLES
    • 40% OF BODY WEIGHT IN ADULT
    • PRINCIPLE CATION K+
    • PRINCIPLE ANIONS—PO4- & SO4-
  • ppl w/ a lot of muscles has higher water content
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5
Q

overview: extracellular

A
  • PRINCIPLE CATION NA+/ ANION CL-
  • INTERSTITIAL
    • FILLS SPACES BETWEEN CELLS
    • 15% OF BODY WEIGHT IN ADULT
  • INTRAVASCULAR
    • BLOOD & LYMPH
    • 5 % OF BODY WEIGHT
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6
Q

24 hr I&O is what?

A
  • approximately equal
  • impossible to measure everything
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7
Q

routes of gains

A
  • ORAL—ADULT NEEDS 2500 ML/ DAY –> most get 1500 ML/day
  • ENTERAL –> thru the gut –> what you’re taking orally
  • PARENTERAL –> beside the gut –> IV fluids, total parental nutrition
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8
Q

Routes of Losses

A
  • KIDNEYS—1-2 L/DAY FOR ADULT, 30 ML/HOUR
    MINIMUM (how to know if they have adequate intake and output)
  • LUNGS—300-400 ML/ DAY (droplets when you’re talking, when you can see ur breath)
  • SKIN (sensible (seeing someone sweat) and insensible (losing moisture on skin when its cold))
  • GI TRACT—100-200 ML/DAY (more if you have diarrhea)
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9
Q

aldosterone

A
  • major influence
  • adrenal cortex
  • kidneys excrete K+
  • secretes potassium and reabsorbs sodium
  • regulates sodium and potassium in kidney tubules
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10
Q

kidneys

A
  • REGULATE ECF VOLUME & OSMOLALITY
  • REGULATE ELECTROLYTE LEVELS IN ECF
  • REGULATE PH OF ECF
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11
Q

lungs

A
  • regulate H+ concentration
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12
Q

Factors that Affect Fluid & Electrolyte Balance: age

A
  1. Infants– proportion of total body water (70-80%) greater than adults, more vulnerable to loss
  2. Adults—women less fluid volume than men due to differences in muscle mass
    • Pregnancy–48% plasma volume increase; even greater w/ multiples
  3. Older adult
    • approx 6% reduction in TBW–due to loss of muscle mass; decrease ratio of ICF to ECF
    • decrease renal function and inability to concentrate urine
    • decreased aldosterone
    • decreased sensation of thirst; decreased volume of saliva
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13
Q

Factors that Affect Fluid & Electrolyte Balance: climate

A

High heat and low humidity increase loss through perspiration

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14
Q

Factors that Affect Fluid & Electrolyte Balance: diet

A
  1. Adequate intake of fluid, salt, K+, Ca++, Mg++, carbohydrates, fats & proteins maintains balance
  2. Protein depletion–> hypoalbuminemia –> edema
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15
Q

Factors that Affect Fluid & Electrolyte Balance: stress

A
  • increase aldosterone & glucocorticoid production –> water retention
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16
Q

Factors that Affect Fluid & Electrolyte Balance: exercise

A
  • increase sensible water loss & electrolyte loss
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17
Q

Factors that Affect Fluid & Electrolyte Balance: illness

A
  1. Surgery–> stress response, increase fluid retention
  2. Burns–loss of skin leads to increase fluid loss
  3. CV disorders– decrease CO leads to decrease kidney perfusion–> circulatory overload
  4. Respiratory disorders–increase risk of respiratory acidosis
  5. Renal disease
  6. Cancer–> increase risk of Ca++ disturbances with bone destruction
  7. Head injury–> alteration in ADH secretion
  8. GI disturbances–loss of fluid, K+, H+, Cl-
  9. Diabetes–poorly controlled leads to increase fluid loss in order to clear glucose through kidney
  10. Fever leads to insensible water loss
18
Q

Factors that Affect Fluid & Electrolyte Balance: medications

A
  1. Diuretics–Loss of water & Δ K+
  2. Laxatives–fluid loss
  3. Corticosteroids–Na+ & fluid retention
19
Q

Factors that Affect Fluid & Electrolyte Balance: medical treatments

A
  • GI suctioning increase H+ and K+ losses
20
Q

Factors that Affect Fluid & Electrolyte Balance: body composition

A
  • differs
  • more water = more muscles
21
Q

nursing history

A
  • FOOD & FLUID INTAKE
  • FLUID OUTPUT
  • SIGNS OF FLUID IMBALANCES
  • DECREASE
    • THIRST, DRY SKIN & MM, decrease URINE
      OUTPUT
  • INCREASE
    • SWOLLEN ANKLES, WEIGHT GAIN, SOB
  • DISEASE PROCESSES—KIDNEY, HEART, LIVER
  • MEDICATIONS
22
Q

physical examination

A
  • SKIN TURGOR
    • FONTANELS: soft spot on babies head. sunken if dehydrated
    • TONGUE TURGOR: should have one line running down the middle. dehydrated = have cracks and furoughs
  • MOISTURE IN ORAL CAVITY
  • FACIAL APPEARANCE
  • EDEMA: too much fluid. press finger and there would be an indentation
  • HAND & NECK VEINS: will stand out if they have too much fluid
  • NEUROMUSCULAR IRRITABILITY
  • MENTAL STATUS: confusion is a sign of fluid volume excess and dehydration
  • LUNG SOUNDS: crackles in lungs. too much fluid. going into places it shouldn’t be
23
Q

5 signs of dehydration

A
  1. dry, chapped lips
  2. headaches
  3. dry skin
  4. achy joints
  5. fatigue
24
Q

daily weights

A
  • best measurement for fluid volume excess
  • 1 liter of fluid = 1KG = 2.2 lbs
  • weigh them everyday at the same time in the same clothing
25
Q

vital signs

A
  • FLUID DEFICIT (not enough fluid moving around)-TACHYCARDIA, WEAK PULSE, decrease BP
  • FLUID EXCESS (too much fluid)—FULL BOUNDING PULSE, increase BP
26
Q

intake & output

A
  • MEASURE ANYTHING THAT IS LIQUID
  • 1 CUP = 8 OUNCES
  • 1 OUNCE = 30 ML
27
Q

Lab Studies

A
  • H&H –> increase hematocrit indicates dehydration
  • SERUM ELECTROLYTES –> normal potassium levels (3.5-5). sodium: 135-145
  • PROTEIN LEVELS
  • ABG
  • increased albumin levels = not enough fluid –> dehydration
28
Q

HYPOVOLEMIA (DEFICIENT FLUID VOLUME NANDA)

A
  • DECREASED INTRAVASCULAR, INTERSTITIAL AND/ OR INTRACELLULAR FLUID. THIS REFERS TO DEHYDRATION, WATER LOSS ALONE WITHOUT CHANGE IN SODIUM
  • PATIENT MUST NOT BE NPO FOR THIS TO BE A NURSING DIAGNOSIS
29
Q

HYPERVOLEMIA (EXCESS FLUID VOLUME NANDA)

A
  • INCREASED ISOTONIC FLUID RETENTION
  • FLUID & NA RETAINED IN ISOTONIC PROPORTIONS
    (WHEN NA ↑ AND FLUID ↓= DFV)
30
Q

IMPAIRED ORAL MUCOUS MEMBRANES

A
  • DISRUPTIONS OF THE LIPS AND/ OR SOFT TISSUE OF THE ORAL CAVITY
  • ELECTROLYTE DISTURBANCES
  • if it’s dry it’s not impaired, it’s at risk for impairment
31
Q

projected outcomes

A
  • INTAKE AT LEAST ______ML
  • NA+ 135-145
  • MOIST MM
  • GOOD (too vague) SKIN TURGOR –> need to be specific –> will return to normal w/in 3 seconds
  • WEIGHT WITHIN NORMAL LIMITS FOR THE INDIVIDUAL –> what have they previously weighed
32
Q

NOC: fluid balance

A
  • 24 HOUR INTAKE AND OUTPUT STABLE
  • ADVENTITIOUS BREATH SOUNDS NOT PRESENT
  • BODY WEIGHT STABLE
  • NECK VEIN DISTENTION NOT PRESENT
33
Q

interventions

A
  • MONITOR I&O –> do not need an order from a doctor to do this
  • DAILY WEIGHTS— BEST MEASUREMENT
  • MANAGE ORAL FLUIDS
    • FF= FORCE FLUIDS (find out what they like to drink)
    • RESTRICT FLUIDS
      • ICE CHIPS ONE-HALF OF FROZEN VOLUME
  • DIET MODIFICATION—K+, NA+
  • PATIENT TEACHING
34
Q

interventions: types of IV fluids

A
  • ISOTONIC—EXPAND VASCULAR VOLUME
    • NS, D5W, LR
  • HYPOTONIC—SHIFT FLUID INTO CELLS
    • 1⁄2 NS, 2.5% DEXTROSE
  • HYPERTONIC—DRAW FLUID FROM CELLS
    • D5/.45NS, D5/NS, D5/LR
  • BLOOD PRODUCTS–ALBUMIN
35
Q

interventions: maintaining IV infusions

A
  • STERILE PROCEDURE
  • CHANGING TUBING
  • FLUID RATE—ORDERED BY MD
    • FOR ADULT TYPICALLY 75-100 ML/ HOUR
    • KVO—SLOW RATE DEFINED BY INSTITUTIONAL POLICY—
      AROUND 30 ML/ HOUR
    • BOLUS RATE—LARGE AMOUNT INFUSED OVER 15-30 MINUTES. OFTEN 250 ML IN ADULT PATIENT
36
Q

NIC

A
  • FLUID MANAGEMENT
  • FLUID MONITORING
  • HYPOVOLEMIA MANAGEMENT
37
Q

evaluation

A
  • I= O=
  • NA+=
  • SKIN TURGOR_______
  • MUCUS MEMBRANES MOIST______
  • WEIGHT=
38
Q

WHEN WEIGHING THE CLIENT WITH A NURSING DIAGNOSIS OF FLUID VOLUME EXCESS, THE NURSE SHOULD WEIGH THE CLIENT

A

A. TWO HOURS AFTER A MEAL
B. AT BEDTIME
(A and B are influenced by what pt eats)
C. ON THE SAME SCALE EACH DAY (correct)
D. WITHOUT CLOTHING

39
Q

WHICH OF FOLLOWING IS A CORRECTLY STATED NURSING DIAGNOSIS FOR THE CLIENT WITH AN ALTERATION IN FLUID & ELECTROLYTE STATUS?

A

A. DEFICIENT FLUID VOLUME R/T NPO STATUS (nothing I can do to improve this bc they are NPO)
B. EXCESS FLUID VOLUME R/T HEART FAILURE (can’t unfail a heart)
C. DEFICIENT FLUID VOLUME R/T DIFFICULTY SWALLOWING (correct)
D. EXCESS FLUID VOLUME R/T PHYSICIAN ORDERING TOO MANY IV FLUIDS.

40
Q

AN ELDERLY NURSING HOME RESIDENT HAS REFUSED TO EAT OR DRINK FOR SEVERAL DAYS AND IS ADMITTED TO THE HOSPITAL. THE NURSE SHOULD EXPECT TO FIND WHICH OF THE FOLLOWING (fluid deficit)

A

A. INCREASED BLOOD PRESSURE (would decrease)
B. WEAK, RAPID PULSE (correct)
C. MOIST MUCOUS MEMBRANES (would be dry)
D. JUGULAR VEIN DISTENTION

41
Q

A MAN BRINGS HIS ELDERLY WIFE TO THE EMERGENCY DEPARTMENT. HE STATES
THAT SHE HAS BEEN VOMITING AND HAS HAD DIARRHEA FOR THE PAST 2 DAYS. SHE APPEARS LETHARGIC AND IS COMPLAINING OF LEG CRAMPS. WHAT SHOULD THE NURSE PLAN TO DO FIRST?

A

A. START AN IV OF NORMAL SALINE
B. OBTAIN BLOOD FOR SERUM ELECTROLYTES (correct)
C. OFFER THE WOMAN FOODS HIGH IN SODIUM & POTASSIUM
D. ADMINISTER A MEDICATION TO STOP VOMITING

42
Q
  • YOU ARE RECORDING I&O FOR CLIENT AT 3 PM. THEY WERE NPO FOR BREAKFAST. AT LUNCH THEY HAD 1⁄2 CUP OF JELLO, A BOWL OF SOUP (6 OUNCES) & A CAN OF SODA (12 OUNCES). THEY DRANK 1 CUP OF WATER AFTER LUNCH. THEY HAD 800 ML OF IV FLUIDS. WHAT WAS HIS INTAKE ON YOUR SHIFT?
A
  • 4 oz jello + 6 oz soup + 12 oz soda + 8 oz water = 30 oz
  • 30 oz times 30 ml/oz = 900 ml
  • 900 ml + 800 ml = 1700 ML

Clinical Concepts (18 decks)

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