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,
