Fluid Imbalance
Electrolyte Imbalance
Acid-Base Imbalance
Lab Tests
Nursing Intervention
100

Too much fluid is the body from excessive intake of ineffective removal from the body

What is Overhydration. (278)

Examples: Fluid overload-excess fluid or water. Includes hemodilution making amount of blood components seem lower.

Hypervolemia (FVE) - excess of water and electrolytes so that the 2 are still in the right proportion

100

Water deprivation (NPO)

Diabetes Insipidus

Heat stroke

Burns

Excessive sweating


What are conditions that cause relative sodium excess?

100

Inadequate chest expansion secondary to muscle weakness, respiratory depression due to opioids, poison, anesthetics. inadequate ventilation

What are risk factors for respiratory acidosis?

100

Elevated Hct, BUN, Urine specific gravity, Sodium and blood osmolality

What are lab results for dehydrated clients?

100
  • I &O, daily wts
  • Breath sounds
  • Sodium restriction diets
  • Fluid restriction
  • Monitor clients receiving diuretics
  • Semi or high fowler’s
  • Monitor sodium and potassium levels
  • Pressure reducing mattress, assess bony prominences

What are nursing interventions for Fluid volume excess?

200

A shift of water from the plasma to the interstitial space.

What is relative dehydration. (277)

Actual dehydration- lack of fluid in the body

Isotonic dehydration (hypovolemia/FVD)- lack of both water and electrolytes causing a decrease in circulating blood volume.

200

Excessive sweating

diuretics use

kidney disease

 low sodium diet routines

NG tube suction of isotonic gastric contents 

What are risk factors for Hyponatremia

200

Tachypneic

inability to concentrate, numbness, tingling, tinnitus

tachycardia, atrial dysrhythmias

rapid, deep respirations

What are manifestations of Respiratory alkalosis?

200

Decreased Hgb/Hct, blood osmolarity, Sodium, urine specific gravity, BUN

What are lab results for fluid volume excess clients?

200

Daily weights

Encourage foods and fluids such as beef broth, tomato juice

Administer LR or normal saline

What are interventions for hyponatremia?

300

Thready, fast pulse

hypotension

tachypnea

decreased CVP

dizziness

thirst

oliguria

cool, clammy skin

poor skin turgor

flattened neck veins

What are manifestations of hypovolemia?

300

Results from and increased loss from the body such as vomiting, diarrhea, prolonged nasogastric suctioning, and excessive laxative use.

What is hypokalemia?
300

Results in decreased HCO3 and decreased pH

What is metabolic acidosis?

300

Blood level less than 3.5 mEq

What is hypokalemia?

300
  • Oral or IV rehydration therapy
  • Monitor I &O, VS
  • Monitor for changes in mentation
  • Monitor weight every 8 hrs while fluid replacement is in progress
  • Safety Precautions
  • Encourage slow position changes, stand up slowly.

What are nursing interventions for fluid volume deficit (dehydration)

400

Weigh yourself daily. Notify provider if 1-2lb gain in 24 hrs, and 3lb gain in 1 week

Encourage low sodium diet

Adhere to fluid restrictions

What is Hypervolemic client education?

400

Peaked T waves, wide QRS, and PR, ST depression

What are ECG changes of hyperkalemia.

400

Results from base excess such as antacids, venous administration of bases (blood transfusion, TPN, or sodium bicarb)

What is metabolic alkalosis?

400

Blood level less than 9 mg/dL

What is calcium level for hypocalcemia?

400

Loop diuretics

Cation exchange resin

Beta-2 agonists

What are medications that increase potassium excretion?

500

Administer O2, Monitor VS, Administration of Colloids or crystalloids, administration of vasoconstrictors and agents that increase myocardial contractibility and perfusion.

What are nursing interventions for hypovolemic shock?

500

Inadequate Vitamin D intake, ESKD, lactulose intolerance, malabsorption issues

What are risk factors of hypocalcemia?

500

The pH, CO3, and PaCO2 are outside of the expected reference range,

What is Partial Compensation?

500

Blood level greater than 5.0 mEq, Hgb /Hct increased with dehydration and decreased with kidney failure, BUN and creatinine increased with kidney failure, metabolic acidosis with kidney failure.

What are lab results for hyperkalemia?

500

Treat the underlying cause

Education can vary in relation to client's condition

What is nursing care for acid-base imbalances?

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