MS Exam 2 notes

Fluid + Electrolytes-Acid Base Dehydration= FVD; Hypovolemia Fluid intake/retention does not meet body’s fluidneeds; results in fluid volume deficito Lack of fluid intake or excess fluid loss o Alteration in the fluid balance regulators: Thirst  Hormones  Lymphatic system  Kidneys o Common causes of dehydration: Vomiting  Diarrhea o Clinical manifestations:  Peripheral pulses cold and clammy extremities Weak and tready  Dry mucous membrane Abnormal lab valuesInterventions Push fluids without IVDaily morning weightsMonitoring input and output every 24 hoursMonitor for fallsBraden scale (skin problems)Fluid Overload: FVE- Hypervolemia (ThirdSpacing) Can develop from administration of too much or a failure to excrete fluids and usually results in an elevated sodium level o Failure to excrete fluids  Renal failure  Edema as with heart failure  Excess of body fluid=” everything is watered down” “Over hydration” Hypervolemia- excess fluids in vascular system  Third-spacing- excess fluids in interstitialspaces, water intoxication  Water intoxication-excess fluids in the cells o Peripheral vascular resistance increases too, which can lead to pulmonary edema and heart failure. o Nursing interventions: assess lungs sounds at least every two hours LabsBUN will be low (diluted)Hematocrit will be low (diluted)Sodium will be low (diluted) Respiratory + cardiovascular  Crackles, pallor  Elevated blood pressure Moist mucous membrane Shallow, rapid respirations  Peripheral edema (pitting)  Weight gain  JVDInterventions for Excess Fluids Volume /FVE  Reduce sodium + fluid intake  Mobilize fluids Turning, positioning  Prevent complications Elevate head of bed (HOB) 30 degrees Monitor lab values  Provide skin care  Modification for older adult patients Teach  Low-sodium diet  Use of alternative seasonings  Avoid mixing, ACE inhibitors - K+ salt substitutes  Fluid restrictions  Daily weights Electrolyte Imbalances Sodium- 135-145 mmol/L Responsible for where salt goes water followsHyponatremia: Most common electrolyte disorder; it is directly related to changes in the fluid volume status as sodium moves into cells + potassium moves intoECF, which results in INTRACEULLAR EDEMA. o Sodium <135 (less than) o Causes:  abnormal loss or excretion of sodium  Water imbalance Hormonal imbalance (such as excess ADH) Hypothyroidism Renal failure  Diuretics; excessive use is a common cause of hyponatremia as well as GI wound drainage.  Diarrhea  Vomiting  Wound drainage  Burns  Excess perspiration o Risk: Seizures + death if electrolytes not corrected o S/S:  Headache + apprehension  Confusion; Hypotension (especially orthostatic) Hallucinations, seizures, coma, + even death may occur. o The decrease in vascular volume presents as hypotension, tachycardia, + weak thready pulse. o Treatment: Water restriction, administer saline solution IV slowly if FVD, furosemide if fluid overload, TX underlying cause o Nursing DX: FVD, FVE, Risk for disturbed thought process, decreased cardiac output o Fall precautions Hypernatremia: Sodium/ Na+: >145 (greater than) Associated with high mortality rate. It occurs in about 1% of hospitalized patients + usually associated with water loss (watery diarrhea) or sodium gain. o Causes: insufficient water intake, insufficient sodium excretion due to hormone imbalance, renal failure, corticosteroids, increased sodiumintake or increased water loss because of fever, hyperventilation, increased metabolism, + dehydration owing to sweating, vomiting, or diarrhea o Risk: Hypervolemia associated with hypernatremia in some patients may cause HF + or pulmonary edema S/S: o Confusion o Weight gain due to fluid retention o Restlessnesso Irritability o Agitation owing to increase neural activity with normal or low fluid volume