-
First Priority Interventions
Hyponatremia
- S sodium intake increase, seizure precautions
- O overload- restrict water intake
- D Daily weight
- I Intake and OUtput
- U use isotonic fluids (0.9% NaCl)
- M Monitor vital signs and LOC
-
Hyponatremia
LABS
- decreased serum sodium(NA) <135mEq/L
- decreased serum osmolality <275mOsm/kg
-
Hyponatremia
SIGNS
- decreased BP
- decreased muscle strength
- decreased deep muscle reflexes (DTR)
- increased pulse
- confusion(elderly) & lethargy
-
Hyponatremia
- Sodium deficit Na<135mEq/L
- May effects these systems: Neurological, Cardiac, Endocrine
- Risk Factors: Vomiting, GI suctioning, Renal disease (kidney), skin losses such as burns.
-
What is the expected outcome for the administration of IV furosemide (Lasix) with a client who has fluid volume excess?
a. BP change from 108/78 to 140/90
b. Pulse change from 72/min to 108/min
c. decreased crackles in lower lung fields
d. weight from 142lbs to 150lbs
- answer: c. decreased crackles in lower lung fields, (we have increased crackles with EFV, so lasix decreases fluid, and would decrease the crackles heard)
- (a)- a sign of FVE is increased BP, if we give lasix we decrease fluid so BP would decrease too.
- (b)- a sign of FVE is increased or normal pulse, if we give lasix we decrease fluid so pulse should become more normal range.
- (d)- if we give lasix we decrease fluid excess and weight gain would not be an expected outcome.
-
Which clinical finding indicates that client is experiencing potential fluid volume excess?
a. BP change from 108/78 to 140/90
b. decreased crackles in lower lung fields
c. pulse increased from 72/min to 80/min
d. weight from 150lbs to 151lbs.
- with fluid volume excess our signs increase...
- answer: a. BP change from 108/78 to 140/90
- BP increases with (FVE)
- (b)-increase crackles not decreased
- (c)-pulse does increase or stay normal with bounding, ^from 72 to 80 still within normal range of 60-100bpm.
- (d)-weight isn't an increase of +2lbs.
-
First Priority Interventions for (FVE)
- RISTRICT FOR FVE
- R reduce IV flow rate
- E evaluate breath sounds and ABGs
- S Semi-fowler's position
- T treat with oxygen and diuretics as ordered
- R Reduce fluid and sodium intake
- I I & O and weight
- C ciculation, color, and presence of edema
- T turn, cough & reposition every 2 hrs. (gets fluid out of lungs)
-
Hypervolema (FVE)
LABS
- DECREASED
- Hct <36 women, <40 men
- serum osmolality <275
- serum sodium (NA) <135
- BUN <10
-
Hypervolemia
Signs:
- (all Increased)
- BP, RR, ^dyspnea, orthopnea, crackles, HR (may be increased or normal but bounding), confusion, weight >2lb increase in 24hrs, edema, ascites, distended neck veins.
-
Hypervolemia
- fluid volume excess (FVE) Causes:
- heart or renal failure, cirrhosis
- ^Na (fluid follows sodium)
- excess IV fluids (fluid overload)
- decreased albumin (decreased proteins in blood)
-
What would be the priority nursing intervention for a client with a B/P change from 140/88 to 86/62?
a. put client in supine position with legs elevated
b. notify provider of care.
c. put client in fowler's position
d. evaluate characteristics of mucous membranes
- Answer=a. put client in supine position with legs elevated.
- (if client BP drops drastically they may be in shock)
- (b.)-you would call provider, after you initially put them in supine position to decrease the work load of the heart
- (c.)-you would not put client in flowler's position, increases work load of heart
- (d.)-you may evaluate the mucous membranes to find out the cause of the shock and decreased BP, but putting them in supine is first priority)
-
Which system specific assessment findings would the client present with who has been vomiting for 24hrs?
a. B/P increased from 110/70 to 130/80
b. Urine output decreases from 95cc/hr to 75cc/hr
c. BUN-15
d. weight two days ago was 145, now 142lbs.
- ANSWER= d. weight two days ago was 145, now 142lbs.
- *a weight fluctuation of a loss of 2lbs or a gain of 2lbs is cause for concern.
- - (a.) BP decreases with fluid loss
- -(b.) urine output decrease is correct, but 75cc is still within normal range (>30cc/hr)
- -(c.) BUN 15 is within normal limits, >20 would be cause for concern.
-
First Priority Interventions for (FVD)
- F fluid replacement
- L level of consciousness, (safety) LOC
- U Urine <30 ml/hr, report trends
- I I & O (input and output of fluids)
- D Document daily weight, vital signs
- S Safety-position changes slowly. If in shock legs up! (helps fluid get to heart and brain)
-
Fluid volume deficit (FVD)
Hypovolemia
Lab Results to look for
- All INCREASED!!! (With fluid deficit labs go up)
- ^Hct (more than 3x hgb)
- ^BUN > 20
- ^Specific Gravity > 1.030
- ^Osmolality > 295mOsm/kg water
- ^Serum Na > 145 mEq/L
-
Hypovolemia
- fluid volume deficit (blood and fluid)
- Signs: Dry mucous membrances-^ thirst
- decrease in weight
- decreased urine output
- decrease fluid to pump so PULSE ^
- decrease in blood pressure (late sign)
- decreased skin turgor
-
Weight Loss or Gain
A loss of 2 pounds or a gain of 2 pounds is cause for concern with too much fluid loss or too much fluid retention.
-
Fluid Output
- Kidneys produce a minimum of 30cc/hr (30mL or 1oz)=1oz/hr
- Insensible loss- 600cc/m2/day, by sweating, lungs through breathing, and feces.
-
Osmolality
- concentration of solutions
- (solute & solutes per kg of water)
- Serum Osmolality 275-295 (normal range)
- Fluids within the 275-295 normal range are Isotonic
- fluids with greater that 295 mOsm/kg= hypertonic
- fluids with less than 275 mOsm/kg=hypotonic
|
|
