USCR Fluids Flashcards

Question

What is hypokalemia?

Answer 1

decrease potassium level

Answer 2

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 ```

Answer 3

Hyperkalemia NOTE! It is less common than hypokalemia (mostly with renal failure) ``` renal failure oliguria high potassium intake extensive burns IV solutions containing potassium ```

Answer 4

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

Answer 5

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

Answer 6

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

Answer 7

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

Answer 8

liquids solid foods metabolism or carbohydrates, proteins & fats

Answer 9

``` urine feces insensible losses skin: perspiration lungs: exhalation ```

Answer 10

ADH (antiduretic hormone): regulates water excretion from kidneys Aldosterone: regulates Na & K balance & wate reabsorption

Answer 11

``` age gender body size temperature exercise diet ```

Answer 12

``` CHF COPD renal disease diabetes cancer malnutrition ```

Answer 13

``` CHF COPD renal disease diabetes cancer malnutrition ```

Answer 14

``` gastroenteritis trauma surgery fever bowel obstruction ```

Answer 15

``` diuretics corticosteriods NSAIDs antibiotics laxatives potassium ```

Answer 16

``` chemotherapy IV NG suction NG feeding respirators ```

Answer 17

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

Answer 18

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

Answer 19

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

Answer 20

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

Answer 21

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

Answer 22

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

Answer 23

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

Answer 24

Client’s Health History: Interview (BCF data, subjective data). Physical Examination: (objective data) Diagnostic and laboratory studies

Answer 25

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)

Answer 26

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

Answer 27

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

Answer 28

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

Answer 29

``` 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 ```

Answer 30

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

Answer 31

Respiratory System: Breath sounds Wheezes and crackles in FVE CVS System: Blood pressure GI System: Bowel sounds

Answer 32

Fluid balance Fluid intake: PO IV Tube feeding ``` Fluid output: Urine Feces Vomitus Tube drainage ```

Answer 33

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

Answer 34

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

Answer 35

Fluid Volume balance Fluid Volume deficit (Hypovolemia) (loss of both water & electrolytes from ECF) Fluid volume excess (Hypervolemia) (retention of water & Na+ in circulation)

Answer 36

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

USCR Fluids Flashcards

(60 cards)