Unit 3 - Fluids & Electrolytes Part 2 Flashcards
T/F: As an adult ages, the thirst mechanism declines
T
*In a client with an altered level of consciousness, this can increase the risk of dehydration and high serum osmolality
A poor intake of water (i.e only 2 glasses) could indicate a loss of the thirst response, which occurs as a normal age-related change.
_____ is a poor indicator of fluid balance in an older adult client.
Skin turgor (due to normal skin aging elasticity changes)
A body mass index within normal limits (Would/Would Not) contribute to dehydration. A body mass index associated with overweight or obesity could be associated with dehydration, as fat cells contain little or no water.
would not
_____ _____ _____ may occur if clients, especially the very young or old, are receiving IV fluid rapidly
Fluid volume excess
Older adult clients are (less/more) able to concentrate their urine, making them susceptible to dehydration. In addition, there is a deficit of the thirst response. However, fever, nausea, and vomiting resulting from these changes are not considered normal but can contribute to the problem of dehydration
less
For children with mild to moderate dehydration, _____ _____ _____ is the first intervention, given in frequent, small amounts
oral rehydration therapy
Individuals with a higher percentage of body fat have _____ body fluid
less
Women had proportionally _____ body fat, _____ body fluid than men
more, less
Water accounts for _____ of an adult man’s body weight
60%
Water accounts for _____ of an adult woman’s body weight
52%
Water accounts for only _____-_____ of an obese individual’s body weight
30%-40%
A body mass index associated with overweight or obesity could be associated with _____, as fat cells contain little or no water.
dehydration
The elderly usually have _____ body mass muscle putting them even more at risk
less
Suggested sodium intake is = _____-_____
1500-2300 mg/day
_____ _____ have a greater sensitivity to sodium
African Americans
_____ _____ occurs when fluid loss is characterized by a proportionately greater loss of sodium than water, causing serum sodium to fall below normal levels.
Hypotonic dehydration
_____ ______ occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion.
Isotonic dehydration
T/F: the body continually attempts to compensate for a fluid and electrolyte imbalance by shifting fluids and electrolytes from one component to another
T
Is it rare for only one type of imbalance to occur?
Yes
stress can _____ cellular metabolism, blood glucose concentration, and catecholamine levels
increase
stress can _____ production of ADH
increase
_____ _____ _____ and _____ levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to _____ _____ _____ _____.
Antidiuretic hormone (ADH) aldosterone sodium and water retention
_____ _____ comes first for fluid volume deficit
GI Assessment
The most common cause of fluid volume deficit is excessive loss of _____ _____, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage.
gastrointestinal fluids
Low potassium: Hypokalemia
What to do?
encourage to consume potassium-rich foods. Which would include: bananas.
Nursing Assessment for Infant
sunken Fontanel for fluid deficit
Nursing Assessment:
The nurse is concerned that a client with a fluid imbalance is at risk for an _____ _____ _____.
alteration in perfusion
Nursing Assessment:
Data indicates that the client is experiencing an alteration in perfusion may include:
- Peripheral pulses present and are they full
- Capillary refill of nail beds 3 seconds
- Are they Oriented to person, place, and time
- Low BP
- possibly an elevated pulse as a compensatory measure
Nursing Assessment:
Fluid Volume Deficit:
What happens?
The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited (tachycardia; pale, cool skin; and a decreased urine output.) The body naturally attempts to conserve fluid internally specifically for the brain and heart.
*Avoid diuretics, they would cause further fluid loss, and is contraindicated.
T/F: Edema increases the client’s risk for impaired skin integrity, especially feet, coccyx areas.
T
First place you’ll notice a change when body is low on fluid
in the vessels
*hypovolemia)
Vital Signs with someone with Hypovolemia: Pulse: Temperature: BP: Respirations: Central Veinous Pressure: Cap refill: Cognitive: GI: Renal: Skin:
Pulse: racing Temperature: elevated BP: low = weaker pulse Respirations: faster Central Veinous Pressure: decreased Cap refill: sluggish Cognitive: dizziness/weakness GI: thirsty, acute wt. loss Renal: decreased urine volume Skin: cool/clammy/pale
….initial orthostatic hypotension…lead to a hypotensive state
Vital Signs with someone with Hypervolemia: Heart Rate: BP: Central Veinous Pressures: Cognitive: GI: Respiratory:
Opposite of Hypovolemia
Heart Rate: fast, because there’s so much fluid = easy to feel pulse
BP: increase
Central Veinous Pressures: increase
Cognitive: Confusion, Weakness, edema
GI: weight gain
Respiratory: pulmonary edema (as it leads to Heart Failure)
An elevated blood pressure could indicate _____ _____ _____ or _____ ______.
fluid volume overload
sodium sensitivity
The _____ measures the volume of whole blood that is composed of RBCs
hematocrit
normal hematocrit value for a female is _____ to _____
37% to 47%
The hematocrit level will _____ in overhydration
decrease
_____ _____ is a measure of the solute concentration of the blood and are used to evaluate fluid balance
Serum osmolality
Normal of serum osmolality values are __________
280-300 mOsm/kg
An increase in serum osmolality indicates a _____ _____ _____; a decrease reflects _____ _____ _____
fluid volume deficit
fluid volume excess.
Serum potassium is _____ an electrolyte used to determine an alteration in fluid balance. _____ _____ values would be more appropriate
not
Serum sodium
_____: can occur from immobility. Ambulation of the client helps to prevent leaching of calcium from the bones into the serum.
Hypercalcemia
_____: The client will need additional dietary phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus..
Hypophosphatemia
Client Education for _____ _____ _____: the electrolyte will need to be restricted, in the form of a low-sodium diet, and diuretics provided. Diuretics will remove excess fluid being held in the body because of the extra sodium.
elevated sodium level
_____ _____: Monitoring of heart rate and rhythm would be more appropriate with a potassium imbalance.
Potassium imbalances
_____ _____ _____: Elevating the head of the bed would be appropriate if the client were demonstrating signs of fluid volume overload..
Fluid Volume Overload
Client Education: Low-sodium salt substitutes are not really _____. They may contain half as much sodium as regular salt. The client should be instructed to use salt substitutes sparingly because larger amounts often taste bitter instead of salty. Clients should be instructed to read food labels for the amount of sodium in the food item. Baking soda and baking powder contain sodium and should be restricted on a sodium-restricted diet. In place of salt or salt substitutes, the client should be instructed to use herbs, spices, lemon juice, vinegar, and wine as flavoring when cooking.
sodium-free
For fluid and electrolyte imbalance. Initiate _____ _____
intravenous therapy
_____: fluid administered subcutaneously, may be employed as a fluid delivery method, especially among older adults.
Hypodermoclysis
_____ _____ _____: symptoms may include crackles, shortness of breath, and jugular vein distention.
Fluid Volume Excess
_____ _____ _____ : you may be administering diuretics
Fluid Volume Excess
The client on hemodialysis is expected to have a reduction of _____ _____
extracellular fluid
_____ is vital in regulating muscle contraction and relaxation.
Calcium
_____ controls and regulates water balance in the body.
Sodium
_____ is used in the body to synthesize ingested protein.
Magnesium
_____: water soluble (i.e. glucose, NACL)
Crystalloid
