Hypervolemia

2lb, 1L

A ____ wt gain in 24 hours indicates that the client is retaining ____ of fluid

ADH

At risk for Hypervolemia- altered cardiac/kidney function, have an increased ____ productions (sometimes accompanies brain trauma)

Corticosteroid, rapid, colloid

At risk for Hypervolemia- receiving _______ therapy, large _____ volumes of IV fluid, or IV ______ solutions

alcohol, caffeine

Avoid beverages with ______ or _______ because they increase urination and contribute to fluid deficits

Hypovolemia

BP falls, heart rate increases to maintain adequate cardiac output

Hypervolemia

Blood cell count/hct levels low as the result of hemodilution

Fluid deficit

Dry, sticky mucus membranes, sunken eyes, weak, sleepy, reduced cognition

Fluid deficit

Dry/small volume stool, Skin poor/tents/warm/flushed/dry

Fluid excess

Easily fatigued, JVD, Reduced cognition, anxious

Hypovolemia

Elevated hct/blood counts- high urine specific gravity- normal serum electrolyte levels- CVP <2-3mm Hg

Circulatory overload

Hypervolemia can lead to ____________ ________, a fluid volume that exceeds what is normal for the intravascular space and can compromise cardiopulmonary function

Pitting edema

Hypervolemia: _________ _________ usually does not occur until there is a 3-L excess in the intravascular volume

salt, sodium

Hypovolemia, DO NOT restrict ______ or ______ intake

Hemoconcentration, increase

Hypovolemia: __________ a high ratio of blood components in relation to watery plasma, ______ potential for blood clots/urinary stones/reduces kidneys abilities to excrete nitrogen wastes

Older adults

In ______ ______ assess skin turgor using the forehead or sternum

Fluid excess

Moist/Labored respirations, Light yellow urine, Bulky stools,

Fluid deficit

Rapid/weak/thready pulse, rapid/shallow respirations, scant/dark yellow urine

Fluid excess

Skin cool/pale/moist, skin turgor- pitting/dependent edema, Moist mucus membranes

Fluid excess

Swollen eyes, Crackles/gurgles in breath sounds, Dyspnea, orthopnea

Older adults

The most common fluid imbalance in ________ ______ is dehydration. Comes from reduced thirst sensation, use of diuretics, laxatives, enemas

Fluid deficit

Wt. loss over 2lb/24hr, low BP, Evlevated temperature

Early signs

______ ______ of hypervolemia: wt. gain, elevated BP, increased breathing effort

chronic

______ laxative use may promote excess fluid loss

fluids

______ that can be included if allowed: gelatin, popsicles, ice cream, sherbet

Fluid retention

_______ _______ can occur secondary to excessive salt intake, adrenal gland dysfunction, corticosteroids (prednisolone)

Postural hypotension

a drop in systolic pressure of 15mm Hg immediately after client rises from sitting or recumbent position

3000, 4000

a goal of _____ to _____ mL is NOT excessive for dehydrated clients

Hemodilution

a reduced ratio of blood components to watery plasma

Hypervolemia

consequence of heart failure, inadequate elimination, kidney disease

Dependent edema

edema in body areas most affected by gravity (feet, ankles, sacrum, buttocks)

Hypervolemia

high volume of water in the intravascular fluid compartment

falls, severely

in Hypovolemia BP _____ with postural changes, or it becomes ________ lowered when blood is rapidly lost

500mL 50mL

report output that is less then _____ /24hrs or less than _____/hr

excess, BP, force

the _____ volume raises ___ and causes the heart to increase ____ of contraction

Hypervolemia

urine specific gravity is low, CVP is elevated above normal range of 2-6 mmHG

specific gravity

urine that is dark yellow, strong odor, or _____ ______ of 1.020 or more indicates low fluid volume

Fluid excess

wt. gain over 2lb/24hr, High BP, Full/Bounding Pulses,