Fluid Imbalance- 5 questions DONE Flashcards
Identifying risk factors for fluid volume excess
Heart failure
Renal failure
Cirrhosis
Long-term corticosteroid use
Cushing syndrome
Increased sodium intake
Polydipsia
SIADH
Identifying manifestations of fluid volume excess
HYPERVOLEMIA
Bounding pulse, Increased BP
Dyspnea, crackles, pulmonary edema
Confusion, headache, lethargy
Edema
Ascites
Increased urine output
JVD
Muscle spasms
S3 heart sound
Weight gain
(notify provider if over 1 kg overnight)
Seizures, coma
Identifying cues of dehydration
Decreased capillary refill
Confusion, restlessness, drowsiness, lethargy
Cold clammy skin
Postural hypotension, increased pulse
Increased RR
Weight loss
Decreased skin turgor
Oliguria; Concentrated urine output
Weakness, dizziness
Thirst, dry mucous membranes
Seizures, coma
Proper IV fluid for hypotonic
0.45% sodium chloride
avoid using in patients with liver disease or burns
do not administer with blood products
Proper IV fluid for isotonic
0.9% Normal saline
D5W
D5LR
Ringers solution
monitor for cues of fluid overload or continued hypovolemia
Proper IV fluid for hypertonic
3% sodium chloride
Dextroses
Evaluating interventions for intravenous fluid therapy
Hypovolemia
Identify and treat cause; monitor for effectiveness
Encourage oral intake; provide fluid patient enjoys
Administer isotonic IVF as ordered
Physical assessment
CV, respiratory [give supplemental O2 as necessary/ordered]
VS
mucous membranes
skin turgor
urinary output
Safety risk for falls! (due to postural hypotension; muscle weakness, dizziness)
Evaluating interventions for intravenous fluid therapy
Hypervolemia
Identify and treat cause
Fluid restriction
Physical assessment
CV [bounding pulse, JVD, S3, elevated BP]
Respiratory [ dyspnea crackles, elevated RR, give supplemental O2 as ordered]
VS
Urine characteristics and amount
Discontinue IVF
Diuretics
Dialysis (may be required)
