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Introduction To Nursing > USCR Fluids > Flashcards

Flashcards in USCR Fluids Deck (60):
1

What is physiological homeostasis?

balance of fluids, electrolytes, acids&bases regulated by multiple processes.

These processes regulate fluid intake&output, movement of water and substances dissolved in in.

2

Function of fluid in the body?

transport of nutrients/waste, electrolytes, oxygen
lubricant
insulator& shock absorber
assist in regulating/maintaining body temperature
all metabolic reactions in the body occur in a fluid environment

3

Fluid compartments in the body?

extracellular: plasma, interstitial, intravascular
Intracellular
Transcellular fluid: cerebrospinal, pleural, synovial fluids and fluids in GI tract; separated from other fluids by epithelium.

Intracellular fluid (ICF) is all the fluid within body cells, approx. 40% of body weight.
Extracellular fluid (ECF) is all the fluid outside cells; 20% of body weight, divided into:
-interstitial fluid, including lymph: fluid between cells and outside blood vessels: 15%
-intravascular fluid: blood plasma: 5%

4

What does ICF & ECF contain?

oxygen from lungs
dissolved nutrients from GI tract
excretory products of metabolism (carbon dioxide)
electrolytes

5

Water body composition of infant, adult, older adult?

infant: 70-80%
Adult 50-60%
Older adult: 45-55%

6

4 methods in which electrolytes and water move throughout the body?

osmosis
diffusion
filtration
carrier-mediated transport

7

What is osmosis?

water movement through a semi-permeable membrane from a low solute concentration to a high solute concentration

8

What is diffusion?

movement of molecules from high concentration to low concentration

9

What is filtration?

movement of water and solutes across a membrane from high pressure to low pressure

10

What is carrier-mediated active transport?

assisted movement of molecules across plasma membrane that would not otherwise be able to move
EX: sodium-potassium pump

11

What are electrolytes?

chemical compounds found in all body fluids, dissolved into ions

carry an electrical charge as ions and exchange for other ions with the same charge

vital for many body functions and carefully regulated

ingested and used for basic physiological processes

stored for future use or excretes

solute [solid] dissolved into solvent [liquid] (expressed as mmol/L, mmol of electrolyte per L of solvent)

12

What electrolytes are in ECF?

sodium
chloride
bicarbonate

13

What electrolytes are in ICF?

potassium
magnesium
phosphate

14

Function of sodium?

maintenance of fluid balance
maintenance of PH balance
transmission pf nerve impulses
important for muscle contraction

15

Normal serum sodium?

135-145mmol/L

16

What is hyponatremia?

decrease sodium level

17

Causes of hyponatremia?

net loss of sodium or net gain of water
vomiting
diarrhea
excessive sweating
extensive burns
use of diuretics
excessive water intake (polydipsia)

18

What is hypernatremia?

increase sodium level

19

Causes of hypernatremia?

net loss of fluids or excess salt intake
fever
diarrhea
excessive intake of table salt or IV saline solution
inadequate fluid intake

20

Signs & symptoms of hyponatremia?

Serum Na < 135mmol/L
anorexia/Nausea & vomiting/abdominal pain
Lethargy/confusion/apprehension
seizure/coma
postural hypertension
tachycardia
dry mm

21

Action demands for hyponatremia?

diet high in sodium
weighing daily
limit water intake
put safety measures in place (seizures)

22

Signs & symptoms of hypernatremia?

Serum Na > 145 mmol/L
dry, red swollen tongue
dry/sticky mm
thirst
oliguria
postural hypertension
disorientation
seizures

23

Action demands for hypernatremia?

diet low in sodium
increase fluid intake (PO or IV)
safety measures to prevent falls
oral care

24

Potassium function?

maintenance of regular heart rhythm
conduction of neuromuscular impulses
muscle contraction
PH maintenance

normal potassium range: 3.5-5.0 mmol/L

25

What is hypokalemia?

decrease potassium level

26

Causes of hypokalemia?


Due to : loss or poor intake of potassium

diarrhea/overuse of laxatives
potassium wasting diuretics
porr intake of potassium rich foods
vomiting/gastric suction
excessive perspiration

27

Causes of hyperkalemia?

Hyperkalemia
NOTE! It is less common than hypokalemia (mostly with renal failure)

renal failure
oliguria
high potassium intake
extensive burns
IV solutions containing potassium

28

Signs & symptoms of hypokalemia?

serum potassium less than 3.5 mmol/L
muscle weakness
leg cramps
depressed deep tendon reflexes
fatigue
confusion/disorientation
cardiac dysrhythmia
anorexia/N & V

29

Action demands for hypokalemia?

diet high in potassium
take KCl supplements (PO or IV)
rest periods
safety measures
taking antiemetics (prevent N & V)

30

S & Symptoms of Hyperkalemia?

Potassium level > 5.0 mmol/L
neuromuscular weakness/absence of reflexes
cardiac dysrhythmia
low BP
numbness in extremities
diarrhea

31

Action demands for hyperkalemia?

avoid foods high in potassium
use safety measures to prevent falls
avoiding K-containing salt substitutes

32

Regulation of body fluids by intake?

liquids
solid foods
metabolism or carbohydrates, proteins & fats

33

Regulation of body fluids by output?

urine
feces
insensible losses
skin: perspiration
lungs: exhalation

34

Regulation of body fluids by hormones?

ADH (antiduretic hormone): regulates water excretion from kidneys

Aldosterone: regulates Na & K balance & wate reabsorption

35

Factors affecting fluid & electrolyte balance?

age
gender
body size
temperature
exercise
diet

36

Chronic diseases for fluid & electrolyte balance?

CHF
COPD
renal disease
diabetes
cancer
malnutrition

37

Chronic diseases for fluid & electrolyte balance?

CHF
COPD
renal disease
diabetes
cancer
malnutrition

38

Acute conditions for fluid & electrolyte balance?

gastroenteritis
trauma
surgery
fever
bowel obstruction

39

Medications for fluid & electrolyte balance?

diuretics
corticosteriods
NSAIDs
antibiotics
laxatives
potassium

40

Medical treatment for fluid & electrolyte balance?

chemotherapy
IV
NG suction
NG feeding
respirators

41

What happens when homeostasis is not maintained?

Fluid volume excess (hypervolemia)
Fluid volume deficit (hypovolemia)

42

Clinical manifestation of FVE fluid volume excess?

Weigh gain
moist mm
bounding pulse, tachycardia
increase BP
distended neck & peripheral veins
moist crackles in lungs, dyspnea, SOB, cough
peripheral edema

43

Nurisng actions for FVE?

place client in fowler's position (30-90 degrees)
administer diuretics prn
restrict fluid intake
restrict sodium intake
prevent skin breakdown

44

Helping to restrict fluid intake actions?

Give the client rationale; explain how much & what type of fluids can be taken in
Help the client decide amount & time of fluids to be taken with & between meals
Set short term goals
Place fluids in small containers-perception
Offer ice chips-melted are half the frozen volume
Frequent mouth care to ↓ thirst sensation
Avoid chewing salty or sweet foods (candy, gum)
Encourage participation of patient and family in keeping record of fluid intake

45

Clinical manifestation of FVD fluid volume deficit?

Weight loss
Dry mucous membranes
Decreased or absent tearing (eyes)
Flat neck veins
Weak pulse
Low BP
Headache, disorientation

46

Nursing actions for FVD?

↑ PO intake & administer IV fluids prn
Provide mouth care
Provide safety measures
Prevent skin breakdown

47

Facilitating fluid intake?

Give the client rationale & amount of fluid needed (promotes compliance )
Establish 24 hour plan
Identify fluids that client likes
Help client choose foods high in water content (ice cream, jello, fruits, sorbet )
Supply cups, straws; keep fluids within reach
Encourage client participation in recording
Involve family members

48

Assessment of fluids?

Client’s Health History: Interview (BCF data, subjective data).

Physical Examination: (objective data)

Diagnostic and laboratory studies

49

Client health history: BCF data?

Developmental data
Cognitive & physical abilities

Age
Elderly & young children dependent on others

Health state data
History of kidney disease or diabetes mellitus
Recent acute condition-gastroenteritis, trauma
Effects on ADLs

Health care systems factors
Treatment plan- medications affecting fluid balance

Patterns of living
Occupation-demands of work
Resources-economic (ability to buy healthy food)

50

Client health history: subjective data?

Thirst/dry mouth
Headache
Dizziness
Dyspnea (SOB)
Anorexia / Nausea
Change in amount/colour of urine

51

Client health history: self care practices?

Food intake:
amount of sodium intake
Restricted diet

Typical fluid intake in 24 hours:
Amount
Type: ETOH (alcohol) consumption
Caffeine intake (tea, coffee)
Time of day
Likes / dislikes

Exercise

52

Client health history: Physical examination; objective data?

Proceed in an organized manner.
Use techniques of:
Inspection
Palpation
Percussion
Auscultation

53

Inspection?

Skin
Color
Eyes
Sunken / bulging
Conjunctivae

Mouth / Lips
Moisture
Intactness

Neurological system
Level of consciousness
Respiratory system
Rate
Rhythm
Depth
CVS system
Jugular & hand veins

54

Palpation?

Cardiovascular system
Capillary refill
Pulse: rate, rhythm, strength
Peripheral pulses

Skin
Turgor
Edema
Temperature
Moisture

GU (genitourinary) System
Palpation of bladder or use of a bladder scanner to see how much urine is in the bladder if necessary

55

Auscultation?

Respiratory System:
Breath sounds
Wheezes and crackles in FVE

CVS System:
Blood pressure

GI System:
Bowel sounds

56

Objective data?

Fluid balance

Fluid intake:
PO
IV
Tube feeding

Fluid output:
Urine
Feces
Vomitus
Tube drainage

57

Intake and output?

Nursing responsibility to measure and keep record of intake (all PO, NG feeding, IV) and output (tube drainages, urine, feces prn, vomitus)

Record on sheets provided by hospital and/or in patients chart/nursing notes

58

Lab and chart data?

Urine specific gravity (concentration)
Electrolytes ( Na, K )
BUN, creatinine levels
Arterial blood gases (pH of blood)
Hematocrit

59

Nursing diagnoses and prescription?

Fluid Volume balance

Fluid Volume deficit (Hypovolemia)
(loss of both water & electrolytes from ECF)

Fluid volume excess (Hypervolemia)
(retention of water & Na+ in circulation)

60

Standard Action Demand
Fluid & Electrolyte Balance?

Maintain, promote fluid & electrolyte balance by:

1.Consuming 2000-2500 ml of water daily
2.Avoiding foods or fluids high in salt, sugar
caffeine
3.Following a well balanced diet
4.Limiting alcohol intake
5.↑ fluid & electrolyte intake before,
during & after strenuous exercise
6.Maintaining normal body weight
7.Educating oneself about medications affecting
fluid & electrolyte balance
8.Recognizing risk factors such as vomiting, diarrhea, inability to
consume fluids due to illness
9.Recognizing signs of fluid imbalance such as sudden weight change, decreased urine output, swollen ankles, SOB, dizziness, confusion.
10.Seeking professional help for noticeable signs of fluid