Med Surg Chapter 16 FLUID,ELECTROLYTE,ACID-BASE
What is the standard formula for calculation daily fluid intake?
*100 mL/kg for the first 10 kg of weight, plus * 50 mL/kg for the next 10 kg of weight, plus * 15 mL /kg per remaining kilograms of weight
What is the medical management of Third-spacing?
- Albumin infusion -IV diuretic
What is the nursing care plan for hypervolemia?
- Baseline and daily weights ( A weight gain of 2 lbs in 24 hours indicated that the client is retaining 1 L of fluid) -Accurate intake and output -Ausculate lung sounds - Measure BP, heart rate, respiratory rate - Inspect skin for edema, cracks and breakdown
What does the nursing management of hypernatremia consist of?
- Maintain accurate intake and output measurements -Assess vital signs every 1-4 hours -Prescribed dietary restrictions or supplements
What are the priority electrolytes of Electrolyte imbalances?
- Sodium - Potassium - Calcium - Magnesium
What are the causes of hypernatremia?
-Diarrhea -Excessive salt intake without water intake -High Fever -Excessive water loss -Decreased water intake
What are the diagnostic findings of third-spacing?
-Hemoconcentration -CVP is below normal -Blood counts are borderline
Electrolyte deficits sometimes results from?
-Inadequate intake of food that provides their natural source. -Administering IV solutions that contain no or only some needed electrolytes -Vomiting - Diarrhea -diuretics
What is sodium essential for?
-Maintaining normal nerve and muscle activity -Regulating osmotic pressure -Preserving acid-base balance
What are the assessment findings of hyponatremia?
-Mental confusion -Muscular weakness -anorexia -elevated body temperature -tachycardia -restlessness -nausea, vomiting
What does the medical management of hyponatremia include?
-Oral administration of sodium (Foods high in sodium, water to which salt has been added and salt tablets) -Administration of IV solutions containing sodium chloride
What are factors that contribute to excess electrolytes?
-Overabundance or orally consumed or parenterally administered electrolytes -Kidney failure -Endocrine dysfunction -crushing injuires -Burns
What are the causes of hyponatremia?
-Profuse diaphoresis -Profuse Diuresis -Loss of GI secretions (suctioning, drains) -Addison's disease
What are the assessment findings of hypernatremia?
-Thirst -Dry, sticky mucous membranes -Decreased urine output -Fever -A rough, dry tongue -Lethargy
What does the medical management of hypernatremia consist of?
-Water Intake -Hypotonic IV solution (e.g., 0.45% sodium chloride or 5% dextrose)
What are the causes of third-spacing?
-hypoalbuminemia -Burns -Severe elastic reactions
What clients are at risk for hypovolemia?
...
What are 5 processes by which water and dissolved chemicals are relocated in the body?
1. Osmosis 2. Filtration 3. Passive Diffusion 4. Facilitated diffusion 5. Active transport
What are four ways in which the body normally loses fluid?
1. Urination 2. Bowel elimination 3. Perspiration 4. Breathing
Normal concentration ranges for sodium is
135-145 mEq/L
What is the average fluid intake per day for adults?
2500mL/day *However, it can range between 1800 and 3000 mL/day
About _____% of the adult human body is water.
60 E.g., For every 100lbs of body weight, approximately 60lb is water.
a 42-year-old client has chronic hyponatremia, which requires weekly blood labs to keep him from lapsing into convulsions or a coma. What is the level of serum sodium below which convulsions or coma can occur? A) 135 mEq/L B) 140 mEq/L C) 142 mEq/L D) 147 mEq/L
A) 135 mEq/L
At what point do baroreceptors signal the brain to release ADH? Select all that apply A)Blood volume decreases by 10% B) Systolic BP falls below 90 mm Hg C) The right atrium is overfilled D) Blood volume increases by 10%
A) Blood volume decreases by 10% B) Systolic BP falls below 90 mm Hg.
Your client has been hospitalized for several days following a fractured pelvis. You suspect that the client's calcium level is elevated because of which symptoms? Select all that apply A) Excessive thirst B) Constipation C) Abdominal cramps D) Positive Chvostek's sign E) Deep bone pain
A) Excessive thirst B) Constipation E) Deep bone pain
To confirm an acid-base balance , it is necessary to assess which of the following findings from the results of a client's arterial blood gas (ABG) results. Select all that apply A) HCO3 B) PaCO2 C) K+ D) Na+ E) pH F) Glucose
A) HCO3 B) PaCO2 E) pH
The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply A) Maintain intake and output records B) Administer IV bicarbonate C) Document presenting signs and symptoms. D) Compare ABG findings with previous results E) Suction the client's airway
A) Maintain intake and output records C) Document presenting signs and symptoms D) Compare ABG findings with previous results
You are caring for a 62-year-old male client with hypovolemia. You will use which of the following interventions to manage your client's fluid deficiency? Select all that apply A) Provide the bulk of the fluid intake with meals. B) Add thickeners to all fluids besides water. C) Offer a Large volume of water first thing in the morning. D) Ensure fluids are an appropriate temperature. E) Find out what types of fluids the client prefers.
A) Provide the bulk of the fluid intake with meals. D) Ensure fluids are an appropriate temperature. E) Find out what types of fluids the client prefers.
__________ means excessive accumulation of acids or excessive loss of bicarbonate in body fluids.
Acidosis
__________ are substances that release hydrogen into fluid.
Acids
____________ means excessive accumulation of bases or loss of acid in body fluids.
Alkalosis
What are the assessment findings of third-spacing?
Ascites Generalized edema
A 73-year-old male client was admitted to the hospital unit after 2 days of vomiting and diarrhea. His wife became alarmed when he demonstrated confusion and elevated temperature and reported "dry mouth." You suspect the client is experiencing which of the following conditions? A) Hypercalcemia B) Dehydration C) Hyperkalemia D) Hypervolemia
B) Dehydration
Client's diagnosed with hypervolemia should avoid sweet or dry food because: A) It can cause dehydration B) It increases the client's desire to consume fluid. C) It obstructs water elimination D) It can lead to weight gain
B) It increases the client's desire to consume fluid.
A 69-year-old male client with congestive heart failure must measure his weight daily and phone it to your office for his medical record. What is the best time of day for this client to weigh himself? A) After dinner B) Same time each day C) After breakfast D) After lunch
B) Same time each day
_____________ are stretch receptors in the aortic arch and carotid sinus that signal the brain to release ADH when blood volume decreases by 10% systolic BP falls below 90 mm Hg, or the right atrium is underfilled.
Baroreceptors
_________ are substances that bind together with hydrogen.
Bases
The human body is an intricate mechanism that maintains homeostasis through a multitude of chemical reactions. The measurable chemical levels disclose how well the body is (or is not) functioning. Which of these chemical substances release hydrogen into fluid? A) Bases B) Alkalines C) Acids D) Electrolytes
C) Acids
A client is at risk for impaired skin integrity due to compromised circulation related to heart failure. Interventions to maintain intact skin includes: A) Changing the client's position every 4 hours B) Restricting ambulation C) Applying elastic stockings D) Keeping client's legs lower than the heart
C) Applying elastic stockings Rationale: Elastic stockings support valves in the veins and prevent fluid from pooling in dependent areas such as the feet and ankles.
During his annual physical exam, your 72-year-old male client complains of muscle cramps in his calves and that he feels "tired a lot." He is taking ethacryic acid (Edecrin) for his hypotension. Your client will be evaluated for which of the following electrolyte imbalance based on his symptoms? A) Hypocalcemia B) Hyperkalemia C) Hypokalemia D) Hypercalcemia
C) Hypokalemia Rationale: Symptoms of hyperkalemia include diarrhea, nausea, muscle weakness, parasthesias, and cardiac dysrhythmias.
Translocation is a term used to describe the general movement of fluid and chemicals within body fluids. In every client's body, fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area? A) Evaporation B) Filtration C) Osmosis D) Active transport
C) Osmosis
You record that the oral fluid intake of your febrile 150-lb female client has been 2600 mL. You conclude that A) Your client's oral fluid intake exceeds the standard for her weight B) Your client's' oral fluid intake is below the standard for her weight C) Your client's oral fluid intake has been adequate for her weight D) Your client's oral intake must be supplemented with IV fluid.
C) Your client's oral fluid intake has been adequate for her weight Rationale: In healthy adults, oral fluid intake averages about 2500 mL/day
Hypervolemia can lead to ______________.
Circulatory overload
___________ is a fluid volume that exceeds what is normal for the intravascular space and can potentially compromise cardiopulmonary function.
Circulatory overload
The medical priority in Third- spacing is to restore ______________ in clients with hypotension and eliminate the trapped fluid.
Circulatory volume
What is the nursing management for hypovolemia?
Consume 8 to 10 glasses of fluid each day ( more during hot and humid water) Avoid beverages with caffeine and alcohol Reduce sodium intake?? Rise slowly from a sitting or lying position to avoid dizziness and potential injury.
A 77-year-old retired male client visits your general practice office twice monthly to maintain control of his congestive heart failure. He measures his weight daily and phones it to the office for his medical record. In a 24-hour period, how much fluid is the client retaining if his weight increases by 2lb? A) 500 mL B) 1500 mL C) 1250 mL D) 1 L
D) 1 L
As a nurse in a pediatric practice, you know that an average, healthy infant should have what percentage of interstitial body fluid? A) 4% B) 15% C) 10% D) 25%
D) 25%
Which conditions lead to chronic respiratory acidosis in older adults? A) Overuse of sodium bicarbonate B) Erratic meal patterns C) Decreased renal function D) Thoracic skeletal change
D) Thoracic skeletal change
_________ results when the volume of body fluid is significantly reduced in both extracellular and intracellular compartments.
Dehydration
_________ results when the volume of the body fluid is significantly reduced in both extracellular and intracellular compartments.
Dehydration
Edema in body areas most affected by gravity, such as the feet, ankles, sacrum, or buttocks
Dependent edema
What are the early signs of hypervolemia? What are the other assessment findings?
Early Signs: Weight Gain Elevated BP Increased breathing effort Other signs: Pitting or non pitting edema Dependent Edema Moist lung sounds
_______________ occur when there is a deficit or an excess of electrolytes or when electrolytes are translocated to any one or more fluid compartments.
Electrolyte Imbalance
__________ are substances that carry an electrical charge when dissolved in fluid.
Electrolytes
_____________ are in both intracellular and extracellular water.
Electrolytes
What are the three chemical substances that are components of body fluid?
Electrolytes, acids and bases
What are some diagnostic findings that indicate hypovolemia?
Elevated hematocrit (Hct) level and blood cell counts Elevated urine specific gravity
What are some causes of hypervolemia?
Excessive oral intake Rapid IV infusion of fluids Heart Failure Kidney disease Fluid retention can occur secondary to excessive salt intake adrenal gland dysfunction circulatory overload
_____________ is water in the body located outside cells.
Extracellular fluid
_________ is the process in which dissolved substances require the assistance of a carrier molecule to pass through a semipermeable membrane.
Facilitated diffusion
_________ is the process that promotes the movement of fluid and some dissolved substances through a semipermeable membrane using pressure differences.
Filtration
_________ is a general term describing any of several conditions in which the body's water is not in the proper volume or location.
Fluid imbalance
_______ is a high ratio of blood components in relation to watery plasma.
Hemoconcentration
_________ is excess sodium in the blood.
Hypernatremia
__________ means there is a high volume of water in the intravascular fluid management.
Hypervolemia
__________ refers to a low volume of extracellular fluid.
Hypovolemia
low volume of extracellular fluid
Hypovolemia
Losses from sweat and the vapor in exhaled air are referred to as ________________ because they are, for practical purposes, unnoticeable and unmeasurable.
Insensible losses
_______________ is water located between the cells.
Interstitial fluid
________ is water located within the cells.
Intracellular fluid
The potassium cation is the chief electrolyte found in ________________.
Intracellular fluid.
____________ is water located in the plasma (serum) portion of blood.
Intravascular fluid
Positively and negatively charged particles
Ions
How does hemodilution effect the blood cell count and hematocrit level?
It causes both to be low
What are the diagnostic findings of hypervolemia?
Low hematocrit level Low blood cell count Urine specific gravity is low Hemodilution CVP is elevated
What is the function of potassium?
Maintaining normal nerve and muscle activity
___________ is the movement of water through a semipermeable membrane from a lower to higher concentration of solutes.
Osmosis
__________ is the process in which dissolved substances such as electrolytes move from an area of high concentration of solutes to an area of lower concentration of solutes through a semipermeable membrane.
Passive diffusion
_____________ processes govern the movement and relocation of fluids and chemicals at the cellular level.
Physiologic
translocation of fluid and exchange of chemicals (electrolytes, acids, bases) is continuous
Physiologic process
Indentions in the skin after compression
Pitting edema
What is the medical management for hypovolemia?
Restore fluid deficit by increasing the volume of oral intake and administering IV fluids.
What does medical management of hypervolemia consist of?
Restrict oral and parental fluid intake Diuretics are prescribed Limit salt and sodium intake
What is the diagnostic finding of hypernatremia?
Serum sodium level is >145 mEq/L
__________ describes the translocation of fluid from the intravascular or intercellular space to tissue compartments where it becomes trapped and useless.
Third-spacing
One of the earliest signs of hypovolemia is ________?
Thirst
If the ____________ depletes fluid volume in the intravascular area, it can lead to hypotension, shock, and circulatory failure.
Translocation
_____________ (movement back and forth) of fluid and exchange of chemicals- including electrolytes, acids, and bases- is continuous in and among all areas where water is located.
Translocation
What are things that cause hypovolemia?
Vomiting, diarrhea, wounds, profuse urination, hemoconcentration
The _________ is the difference between sodium and potassium cation (positive ion) concentrations and the sum of chloride and bicarbonate ___________ (negative ions) in the extracellular fluid.
anion gap; anions
Positively charged electrolyte
cation
The primary sources of body fluid are ________ and __________.
food; liquids
A reduced ratio of blood components to watery plasma
hemodilution
An excess of potassium in the blood is called?
hyperkalemia
Higher than normal serum sodium level is called?
hypernatremia
A deficit of potassium in the blood is called?
hypokalemia
Lower than normal serum sodium level is called?
hyponatremia
With third-spacing the client manifests signs and symptoms of _________________ with the exception of weight loss.
hypovolemia
As fluid volume _________, the body loses fluid, primarily through urination, in a proportionate volume to maintain or restore equilibrium.
increases
