Final Exam SG Fluid and Electrolytes <10 questions: Review assessment findings: over hydration vs. dehydration

- Fluid Volume Deficit (Hypovolemia) can occur with abnormal loss of body fluids (i.e. diarrhea, fistula, drainage, hemorrhage, polyuria), inadequate intake, or a shift of fluid from plasma into interstitial fluid o NOT dehydration (dehydration refers to loss of pure water alone without corresponding loss of sodium) o Causes:  ↑ Insensible water loss or perspiration (high fever, heatstroke)  Diabetes insipidus  Osmotic diuresis  Hemorrhage  GI losses—vomiting, NG suction, diarrhea, fistula drainage  Overuse of diuretics  Inadequate fluid intake  Third-space fluid shifts—burns, intestinal obstruction o Manifestations:  Restlessness, drowsiness, lethargy, confusion  Thirst, dry mucous membranes  Decreased skin turgor, ↓ capillary refill  Postural hypotension, ↑ pulse, ↓ CVP  ↓ Urine output, concentrated urine  ↑ Respiratory rate  Weakness, dizziness  Weight loss  Seizures, coma - Fluid Volume Excess (Hypervolemia) may result from excessive intake of fluids, abnormal retention of fluids (e.g., heart failure, renal failure), or a shift of fluid from interstitial fluid into plasma fluid o Causes:  Excessive isotonic or hypotonic fluids  Heart Failure  Renal failure  Primary polydipsia  SIADH  Cushing syndrome  Long-term use of corticosteroids o Manifestations:  Headache  Confusion  Lethargy  Peripheral edema  Distended neck veins  Bounding pulse  Increased BP  Increased CVP  Polyuria (w/ normal renal function)  Dyspnea  Crackles (rales)  Pulmonary edema  Muscle spasms  Weight gain  Seizures  Coma - Nursing Implementation o Monitor I & O  Intake should include: oral, IV, and tube feedings and retained irrigants  Output includes: urine, excess perspiration, wound or tube drainage, vomitus, and diarrhea  Estimate fluid loss from wounds and perspiration  Measure the urine specific gravity, >1.025 = concentrated and <1.010 = dilute urine  FVE S/S = pulse is full and bounding, pulse is not easily obliterated, distended neck veins (jugular venous distention), increased blood pressure  FVD S/S = mild to moderate fluid volume deficit: compensatory mechanisms include sympathetic nervous system stimulation of the heart and peripheral vasoconstriction  Stimulation of the heart increases the heart rate and, combined with vasoconstriction, maintains the blood pressure within normal limits; change in position from lying to sitting or standing = increase in the heart rate or a decrease in the blood pressure (orthostatic hypotension); if vasoconstriction and tachycardia provide inadequate compensation, hypotension occurs when the patient is recumbent  Severe fluid volume deficit: weak, thready pulse that is easily obliterate, flattened neck veins  Severe, untreated fluid deficit = shock o Respiratory Changes  ECF excess = pulmonary congestion and pulmonary edema as increased hydrostatic pressure in the pulmonary vessels forces fluid into the alveoli  S/S: shortness of breath, irritative cough, and moist crackles on auscultation  ECF deficit = an increased respiratory rate due to decreased tissue perfusion and resultant hypoxia o Neurological Changes  ECF excess = cerebral edema as a result of increased hydrostatic pressure in cerebral vessels  ECF deficit = alteration in sensorium secondary to reduced cerebral tissue perfusion  Assessment of neurologic function includes evaluation of o (1) the level of consciousness, which includes responses to verbal and painful stimuli and the determination of a person's orientation to time, place, and person o (2) pupillary response to light and equality of pupil size o (3) voluntary movement of the extremities, degree of muscle strength, and reflexes o Daily Weights  Increase of 1 kg (2.2 lb) is equal to 1000 mL (1 L) of fluid retention (provided the person has maintained usual dietary intake or has not been on nothing-by-mouth [NPO] status)  Pt. weighed at the same time every day, wearing the same garments, and on the same carefully calibrated scale o Remove excess bedding and empty all drainage bags o If bulky dressings or tubes are present, which may not necessarily be used every day, record a notation regarding these variables on the flowsheet or nursing notes o Skin Assessment  Skin areas over the sternum, abdomen, and anterior forearm- pinch for turgor (less predictive of fluid deficit in older persons because of the loss of tissue elasticity)  ECF volume deficit  Skin turgor is diminished; there is a lag in the pinched skinfold's return to its original state (tenting)  Cause the skin to appear dry and wrinkled (older adult= normally dry, wrinkly, and unelastic)  Oral mucous membranes will be dry, the tongue may be furrowed, and complaints of thirst  Skin may be cool and moist if there is vasoconstriction to compensate for the decreased fluid volume  Mild hypovolemia usually does not stimulate this compensatory response  The skin will be warm and dry  ECF volume excess  Skin that is edematous may feel cool because of fluid accumulation and a decrease in blood flow secondary to the pressure of the fluid  Fluid can also stretch the skin, causing it to feel taut and hard; assess for edema over tibia or fibia o Protect edematous tissues from extremes of heat and cold, prolonged pressure, and trauma o Frequent skin care and changes in position will protect the patient from skin breakdown o Elevation of edematous extremities helps promote venous return and fluid reabsorption o Dehydrated skin needs frequent care without the use of soap