Anatomy
An organ that maintains fluid balance through filtration?
What are the kidneys
Physical manifestations of fluid volume overload.
What is edema, SOB/Dsypnea, weight gain?
This fluid is most commonly used in replacement related to isotonic loss and dehydration.
What is 0.9% NaCL?
The nurse is caring for an older adult with an elevated sodium level, which of the following interventions would be most effective?
a.Restrict fluid intake
b.Administer a diuretic
c.Monitor serum osmolarity
d.Encourage fluid intake
d. Encourage fluid intake
Rationale:
Encouraging fluid intake is important in preventing and treating dehydration that results in elevated sodium levels.
Restricting sodium does not replace necessary fluids
A diuretic will worsen the condition
Monitoring osmolality does not change the condition
A nurse could discover these assessment findings in a patient with an exacerbation of congestive heart failure?
What is crackles at the bases upon auscultation, LE edema, dyspnea at rest, increased heart rate, bounding pulse, confusion?
These are visual indicators of dehydration
What are skin turgor, dry mucous membranes, dark urine, sunken eyes?
Client symptoms related to fluid volume deficit
What is weakness, fatigue, dizziness, headache?
You would expect to see this fluid type administered in an ICU, as a result of this possible development of this condition..
What is increased intercranial pressure?
The RN is caring for a client who is severely dehydrated. Which action can be delegated to a UAP?
a.Consulting with a healthcare provider regarding lab results
b.Infusing 500 mL of normal saline over 60 minutes
c.Monitor IV fluid to maintain a drip rate of 75 mL/hr
d.Provide oral care Q2H
d. Provide oral care Q2H
Rationale:
Providing oral care would be within the scope of practice for a UAP. Frequent oral care is important for a severely dehydrated patient.
Consulting with a care provider is the responsibility of the RN.
Infusing fluids and monitoring IV infusion rates require the intervention of the licensed personnel
The nurse is assessing fluid balance in a client with heart failure. Which assessment is best in determining fluid balance?
a. Ask the client to record fluid intake
b. Place an indwelling catheter to measure urine output
c. Auscultate lungs for adventitious sounds
d. Weigh the client daily at the same time
d. Weigh the client daily at the same time
Rationale:
The best assessment for fluid balance in the client with heart failure would be daily weights at the same time, daily.
Asking the client to record intake is not an accurate measure of fluid volume overload
Placing an indwelling catheter for a client that does not have an obstruction is not the best indicator of fluid balance
Auscultating adventitious lung sounds could indicate fluid volume overloard, however this could take longer to develop
Antidiuretic hormone is produced here.
What is the hypothalamus?
Clinical manifestations of fluid loss/ deficit:
What is dry mucous membranes, tachycardia, hypotension, thready pulse, decreased skin turgor, prolonged cap refill, decreased urine output
This fluid is administered for conditions such as Diabetic ketoacidosis (DKA)
What is hypotonic solution?
The nurse is caring for a client receiving lactated ringers at 100 ml/hr. Which assessment finding indicates a need for intervention?
a.Blood pressure of 115/66
b.Pulse rate of 98
c.Auscultating crackles
d.O2 saturation of 95%
c.Auscultating crackles
Rationale:
Ausucltating crackles is a sign of fluid volume overload.
Blood pressure of 115/66 is within defined limits
Pulse of 98 is still within defined limits
O2 of 95% is an expected finding
It will take greater than 20 seconds for this indentation in the skin to return to normal.
What is 4+ pitting edema?
These hormones regulate fluid balance
What are ADH, Aldosterone and Renin
A patient presenting with anasarca could be suffering from which conditions?
What is heart failure, liver failure, kidney failure?
Which fluid imbalance would require blood be administered?
What is isotonic fluid loss?
A client develops fluid volume overload in the ICU. Which intervention would the nurse perform?
a.Draw blood for lab tests
b.Elevate the head of the bed
c.Place extremities in dependent position
d.Place the patient in a Trendelenburg position
b.Elevate the head of the bed
Rationale:
Elevating the head of the bed will make it easier for chest expansion and breathing (ABC’s).
Blood draws for lab values will not have an immediate impact on the patient.
Placing extremities in a dependent position will increase peripheral edema.
Placing a patient in a Trendelenburg position will make breathing more difficult.
These individuals are at greatest risk for fluid imbalances.
What are the elderly, sick, extremely young?
The best indicator for fluid balance
What is weight?
Common cause of hypovolemic shock.
What is blood loss?
A new nurse graduate can expect to administer which fluid on a typical med-surg unit.
What is 0.9% NaCl, D5W, Ringers lactate, lactated ringers? (isotonic fluids)
An older adult is admitted to the medical surgical unit with dehydration. Which assessment indicates the client is safe for ambulation?
a.Assess for dry mucous membranes
b.Check for orthostatic blood pressures
c.Notes the pulse rate is 78 beats/min and bounding
d.Client is oriented to self
b.Check for orthostatic blood pressures
Rationale:
Orthostatic blood pressures done while lying in bed, sitting at the bed side and lastly when standing indicate postural changes. Low blood volumes when standing indicate decreased perfusion to the brain resulting in dizziness, light-headedness and increase the risk for falls.
Dry mucous membranes and pulse can indicate dehydration
Orientation to self, alone is not a good indicator for ambulation
These mechanisms contribute to fluid volume deficit.
What are kidneys inability to concentrate urine to conserve water, decreased thirst mechanism, polypharmacy, certain medications (diuretics), dysphagia, frailty, dementia, inability to hold a cup?