Fluid Balance
What interventions would you implement for a patient with fluid volume excess?
Monitor daily weight (weight loss indicates successful intervention)
Administer diuretics and O2 as ordered
Fluid and sodium (Na) restrictions
Monitor I & O and put in Fowler's position
What could happen to a patient's blood pressure when receiving a hypertonic solution?
What is it could become elevated?
What is the normal range for sodium (Na)?
135 to 145 mEq/L
What is the normal range for potassium?
3.5 to 5.0 mEq/L
What are the normal values for pH??
Normal pH = 7.35 to 7.45
What interventions would you implement for a patient with deficient fluid volume?
Monitor daily weight (most accurate way to evaluate fluid balance)
Monitor I & O
Increase fluid intake (PO and IV if severe)
Treat underlying cause
How many hours does blood need to be administered into a patient and why?
What is 2-4 hours to reduce the risk of infection?
Who is at risk for developing hypocalcemia?
Patients with NPO status, use of diuretics, GI suctioning (especially continuous), decreased aldosterone, excess ingestion of hypotonic fluids
What is the priority nursing intervention for potassium imbalance?
What is applying a cardiac monitor?
What health problems put a patient at risk for respiratory acidosis?
Chronic lung diseases such as COPD
What signs/symptoms would you expect to see in a patient with fluid volume excess?
Bounding pulse, increased BP, weight gain, increased and dilute urine output , increased and shallow respirations. May see neck vein distention, pitting edema of lower extremities, crackles in the lungs.
What could happen to a patient's blood pressure when receiving a hypotonic solution?
What is decrease causing hypotension because it is puling out of the intravascular space?
What are the symptoms of hyponatremia?
Can be vague and depends on if has a fluid imbalance as well. Severe hyponatremia presents with weakness, N/V/D and mental status changes such as confusion, disorientation and personality changes due to low sodium and osmolarity which causes more water to collect in and around the brain.
What are the sign/symptoms of hypokalemia?
Muscle fatigue and cramping, mental status changes, shallow ineffective respirations due to diminished skeletal muscle activity, irregular and weak/thready pulse, dysrhythmias
What are the normal levels of PaCO2 and HCO3?
Normal PCO2 = 35 to 45
Normal HCO3- = 22-26
What is included in a hydration assessment of a patient?
Monitor daily weights.
Assess for skin tenting (forehead or sternum)
Assess mucous membranes and tongue for moisture and furrows
Assess for thirst and urine output
What are signs of infiltration?
What are edema, and pale and cool skin?
What are the signs/symptoms of hypernatremia?
Thirst, mental status changes due to too little water in and around the brain, tremors, seizures, muscle weakness
What can treat hyperkalemia?
What are calcium gluconate, insulin and dextrose, and kayexalate?
What happens to potassium levels during acidosis?
What is they are elevated because the body is trying to compensate by pushing H+ into the cell exchanging it for K+?
What labs and signs/symptoms would you expect to see in a patient with dehydration?
Increased Hct and BUN, increased urine specific gravity, low BP, rapid pulse, increased temperature, decreased urine output, skin tenting, dry skin and mucous membranes.
What patient's is LR contraindicated in?
What are patient's with liver and renal problems and those with severe hypovolemia?
What are the interventions for hypernatremia?
Monitor weight, monitor I & O, administer diuretics, restrict dietary sodium
What are food sources of potassium?
Potatoes, sweet potatoes, soybeans, banannas, tomato juice, dried apricots, kidney beans, orange juice, spinach
A patient is experiencing metabolic acidosis. How does the body compensate to correct the acidosis?
Patient develops Kussmaul respirations, which is a deep, labored breathing pattern. This allows the lungs to expel more acidic CO2 which is causing the acidosis. Seen in diabetic ketoacidosis (DKA).