NUR2 Exam 1

Treatment for Hypovolemia

1 Unit Packed Red Blood Cells

What is the focus assessment for hypovolemia? (10)

1. Ask when last time they had fluids or ate 2. Skin turgor (tinting) 3. sweating, moist skin 4. mucous membranes 5. fluid status I &O (IV, urine output, JP output) 6. Anxiety or agitation 7. Cool, clammy skin 8. Confusion 9. Decreased or no urine output 10. Rapid breathing

What are the signs and symptoms for hypovolemia? (8)

1. Dizziness 2. Sweating 3. Shortness of breath 4. BP: 88/35 (low) 5. Pulse: 120 (high) 6. 02 Sat: 88% 7. RR: 16 8. Temp: 98. 6

What are the proper interventions for hypovolemia? (10)

1. Lower head of bed, elevate legs (trendelenburg), treat hypotension 2. Administer 02 NC 3. UAP- retake vitals 4. Check I & O (I=150ml, O= 400ml) 5. Offer ice chips 6. Check JP for drainage 7. Dim lights for dizziness 8. Check chem panel (H&H will be low) 9. Check mouth for oral secretions 10.Check IV patency

Hyponatremia

A low sodium level may be due to loss of sodium ions, or more commonly, from an excess of body water that dilutes the sodium in the bloodstream. The most common electrolyte abnormality in hospitalized patients is hyponatremia.

Hypernatremia

Hypernatremia is defined as having a serum sodium level that is above the normal range (136 to 145 mEq/L). Hypernatremia may occur when excess sodium ions are present in the body, or when water is lost from the body, leaving the sodium ions more concentrated.

Hypokalemia

Hypokalemia is defined as having a potassium level lower than the normal range of between 3.5 and 5.5 mEq/L. Hypokalemia results from anything that causes either an excessive loss of potassium from the body or from a prolonged decrease of ingestion of potassium.

Hypotonic IV solution

Solution administered intravenously will dilute the intravascular space lowering the osmolality. This will cause water to move across the semipermeable membrane into the cell.

Hypertonic IV solution

Solution placed in the intravascular compartment, it exerts a high osmotic pressure. The high osmotic pressure will draw water from inside the cells, across the semipermeable cell wall into the intravascular space to dilute the high concentration of solutes.

Isotonic IV solution

Solution that has the same osmotic pressure as the referent solution (e.g., plasma).

Sodium Level

The normal sodium level in the body ranges from 136 to 145 mEq/L.

What would you indicate to the MD about hypovolemia

What would you indicate to the MD S- Patient complains of dizziness, SOB, weak, and sweaty. BP: 88/35 (low), Pulse: 120 (high), 02 sat: 88%, RR: 16. I &O (including IV rate and JP drainage) NPO from surgery B-Patient post thryoidectomy, history for hypotension A- Elevate legs, 02 NC R- Increase fluids STAT (Bolus 500). Increase IV rate from 15ml/hr

Oncotic pressure

a special type of osmotic pressure that is due to the presence of proteins. Proteins in the bloodstream exert oncotic pressure to pull fluid out of the interstitial space into the intravascular space to maintain fluid balance and osmolality.

Extracellular fluid (ECF)

accounts for approximately one third of the body's fluid, and includes the fluid in the bloodstream,

What is Hypovolemia

an emergency condition in which severe blood and fluid loss make the heart unable to pump enough blood to the body. This type of shock can cause many organs to stop working.

Nursing Assessment of Hypervolemia

daily weight breath sounds and assess for edema.

Diagnostic testing for Hypervolemia

decreased bun creatinine serum osmolality serum sodium level and chest x ray

Manifestations of Hypervolemia

edema, distended neck veins, lung crackles, shorrtness of breath, weesing, tachycardia, increased bp pulse pressure weight and urine output

What is Hypervolemia

fluid volume excess retention of sodium and water.

Etiology of Hypervolemia

heart faluire, renal failure, and cirrhosis of the liver from increased aldosterone secretion. increase in total sodium

Intracellular fluid (ICF)

is that fluid inside each cell in the body and accounts for approximately two- thirds of the body's fluid.

Pathophysiology of Hypervolemia

simple fluid overload, diminished function of homeostatic mechanisms

Osmotic pressure

the ability of a solution to draw water across a semipermeable membrane to affect the concentration

Intravascular fluid

the fluid in the bloodstream (excluding the fluid within the cells inside the bloodstream),