Fluid and Electrolyte Imbalances in Nursing
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Questions and Answers

What assessment should be performed to monitor potential fluid retention in a patient?

  • Monitor skin turgor at the change of shift
  • Measure blood pressure daily
  • Weigh the patient daily under consistent conditions (correct)
  • Assess urinary output every hour

Which symptom may indicate fluid volume excess in a patient?

  • Dry mucous membranes
  • Elevated blood glucose levels
  • Decreased respiratory rate
  • Increased blood pressure (correct)

Which neurological change should be assessed in patients experiencing fluid volume alterations?

  • Pupil dilation
  • Improved cognitive function
  • Affect changes such as confusion or lethargy (correct)
  • Increased reaction time

How does fluid volume deficit typically impact respiratory status?

<p>Results in increased respiratory rate due to hypoxia (C)</p> Signup and view all the answers

What is the relationship between weight gain and fluid retention?

<p>1 kg weight gain is equal to 1000 mL fluid retention (A)</p> Signup and view all the answers

Which of the following is NOT a clinical manifestation of hypovolemia?

<p>Hyperactivity (B)</p> Signup and view all the answers

What lab finding may indicate dehydration in hypovolemia?

<p>Increased hematocrit (B)</p> Signup and view all the answers

Which treatment is primarily used to replace both water and electrolytes in hypovolemia?

<p>Lactated Ringer's solution (C)</p> Signup and view all the answers

Which of the following could indicate a successful management of hypovolemia?

<p>Stable blood pressure (A)</p> Signup and view all the answers

What is dehydration primarily characterized by?

<p>Loss of pure water without corresponding loss of sodium (B)</p> Signup and view all the answers

Which condition is NOT a possible cause of ECF volume excess?

<p>Dehydration (A)</p> Signup and view all the answers

Which of the following is a cause of hypovolemia?

<p>Chronic laxative abuse (C)</p> Signup and view all the answers

What is the primary result of blood loss in hypovolemia?

<p>Decreased cardiac output (A)</p> Signup and view all the answers

What type of IV solution is typically used to replace both water and needed electrolytes?

<p>Lactated Ringer's solution (D)</p> Signup and view all the answers

Which type of fluid is administered when rapid volume replacement is indicated?

<p>Isotonic (0.9%) sodium chloride (B)</p> Signup and view all the answers

Which of the following symptoms is NOT commonly associated with fluid volume deficit?

<p>Increased skin turgor (A)</p> Signup and view all the answers

What is a key monitoring parameter to assess fluid volume deficit?

<p>Input and output (D)</p> Signup and view all the answers

How is hypervolemia characterized?

<p>Increased intravascular fluid (B)</p> Signup and view all the answers

Which condition can lead to fluid volume deficit due to disease processes?

<p>Diabetes Insipidus (A)</p> Signup and view all the answers

What is a common clinical manifestation of fluid volume deficit?

<p>Postural hypotension (D)</p> Signup and view all the answers

What is the principal cation found in intracellular fluid?

<p>Potassium (A)</p> Signup and view all the answers

What is the primary form of therapy for managing fluid volume excess?

<p>Diuretics and fluid restriction (C)</p> Signup and view all the answers

Which of the following is NOT a clinical manifestation of hypervolemia?

<p>Hypotension (D)</p> Signup and view all the answers

How many kilograms of weight gain correspond to approximately 1000 mL of fluid retention?

<p>1 kg (D)</p> Signup and view all the answers

What indicates a patient is at risk for hypovolemic shock?

<p>Fluid loss without replacement (C)</p> Signup and view all the answers

Which nasal diagnosis is associated with the risk for impaired skin integrity?

<p>Excess fluid volume (D)</p> Signup and view all the answers

Which of the following symptoms may indicate hypervolemia?

<p>Peripheral edema (A)</p> Signup and view all the answers

What may be necessary if fluid excess leads to ascites or pleural effusion?

<p>Abdominal paracentesis or thoracentesis (A)</p> Signup and view all the answers

What measurement indicates concentrated urine?

<p>Greater than 1.025 (A)</p> Signup and view all the answers

What is a potential complication of hypervolemia?

<p>Pulmonary edema (A)</p> Signup and view all the answers

What cardiovascular change might indicate a fluid volume deficit?

<p>Orthostatic hypotension (B)</p> Signup and view all the answers

Which nursing diagnosis is more likely to be associated with hypovolemia?

<p>Decreased cardiac output (B)</p> Signup and view all the answers

What complication can arise from excess fluid in the body?

<p>Pulmonary edema (A)</p> Signup and view all the answers

Which action is essential for accurately assessing fluid retention in patients?

<p>Weigh the patient at the same time daily on a calibrated scale (D)</p> Signup and view all the answers

Which of the following is a nursing implementation for monitoring fluid volume?

<p>Monitoring I &amp; O (C)</p> Signup and view all the answers

What respiratory symptom might be observed in a patient with fluid excess?

<p>Moist crackles on auscultation (B)</p> Signup and view all the answers

How does fluid deficit affect the respiratory rate?

<p>It increases due to decreased tissue perfusion (B)</p> Signup and view all the answers

What are the common classifications of fluid and electrolyte imbalances?

<p>Deficits and excesses (A)</p> Signup and view all the answers

A patient with prolonged nasogastric suction is most likely to experience a deficiency of which electrolytes?

<p>Na+, K+, H+, and Cl– (A)</p> Signup and view all the answers

Which condition is synonymous with ECF volume deficit?

<p>Hypovolemia (B)</p> Signup and view all the answers

Which of the following could cause fluid and electrolyte imbalances directly?

<p>Burns or heart failure (D)</p> Signup and view all the answers

What can lead to metabolic alkalosis in a patient suffering from electrolyte imbalances?

<p>Loss of hydrochloric acid (HCl) (C)</p> Signup and view all the answers

What nursing process principle is important when managing fluid and electrolyte imbalances?

<p>Utilizing the nursing process and collaboration (D)</p> Signup and view all the answers

Which of the following best differentiates fluid volume deficit from dehydration?

<p>Fluid volume deficit involves more considerations than just water loss (A)</p> Signup and view all the answers

Which therapeutic measure can result in fluid and electrolyte imbalances?

<p>IV fluid replacement (A)</p> Signup and view all the answers

Flashcards

ECF Volume Deficit

A condition where the extracellular fluid (ECF) volume in the body is lower than normal, also known as hypovolemia.

Hypovolemia Initial Symptoms

Initial signs of hypovolemia include thirst, dry mouth, reduced urine, weakness, and low blood pressure when standing.

Hypovolemic Shock

A severe form of hypovolemia characterized by low blood pressure, fast heart rate, rapid breathing, and reduced or absent urine production. More severe and potentially dangerous condition.

ECF Volume Deficit Treatment

Replacing lost fluids and electrolytes. Oral fluids, IV fluids (Lactated Ringers or 0.9% saline), and blood transfusions (when applicable), are used to restore fluid balance.

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ECF Volume Excess

A condition where there's too much ECF in the body, called hypervolemia.

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Hypervolemia Causes

Hypervolemia can stem from conditions affecting fluid retention, such as heart failure, liver problems, kidney issues, excessive salt intake, and medications.

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Assessing Treatment Success (Fluid Deficit)

Monitoring urine output and blood pressure are key indicators to measure improvement after treatment of low extracellular fluid.

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ECF Volume Deficit Assessment

Checking fluid intake and output, vital signs (including orthostatic blood pressure and pulse), skin turgor, and moisture of mucous membranes for signs and symptoms of low body fluid.

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Fluid Imbalance Causes

Fluid imbalances happen because of illnesses (like burns or heart failure) or medical treatments (like IV fluids or diuretics).

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Fluid Volume Deficit

A condition where there is too little fluid in the body's extracellular spaces.

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Fluid Volume Excess

A condition where there is too much fluid in the body's extracellular spaces.

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ECF Volume Deficit Symptoms

Symptoms of too little fluid volume can include thirst, dry mouth, and low blood pressure.

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ECF Volume Excess Symptoms

Symptoms of too much fluid volume can include swelling (edema) and high blood pressure.

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Fluid Imbalance Treatment

Treatment focuses on restoring balance through fluids and/or electrolytes, often with IV fluids, oral rehydration, or medications depending on the cause.

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Fluid and Electrolyte Imbalances and Illness

Illnesses and injuries often lead to fluid and electrolyte imbalances.

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Fluid Imbalance and Medication

Certain medications, like diuretics, can cause these imbalances by affecting fluid retention.

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Dehydration

Loss of pure water without losing sodium.

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Hypovolemia

Decreased blood volume (intravascular fluid).

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Hypervolemia

Increased intravascular fluid.

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Edema

Increased interstitial fluid, fluid buildup around cells.

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Intracellular fluid

Fluid inside cells, containing electrolytes like potassium.

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Extracellular fluid

Fluid outside cells, containing electrolytes like sodium.

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Fluid Volume Deficit Causes

Loss of body fluids due to vomiting, diarrhea, hemorrhage, or excessive sweating.

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Fluid Volume Deficit Symptoms

Symptoms include restlessness, hypotension, tachycardia, and decreased urine output.

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Assessing LOC

Evaluating a patient's level of consciousness.

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Pupillary Response

Checking how pupils react to light.

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Fluid Retention (1 kg)

Gain of 1000 mL (1 liter) of fluid in the body.

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Respiratory changes (fluid)

Fluid affects breathing; excess causes pulmonary issues.

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Neurologic changes (fluid)

Fluid imbalances affect brain function, potentially leading to confusion.

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Fluid Volume Excess

A condition where there is too much fluid in the body's extracellular space, also called hypervolemia.

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Hypervolemia Symptoms

Symptoms include weight gain, bounding pulse, jugular vein distention, dyspnea, crackles, and edema.

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Hypervolemia Treatment Goal

Remove excess fluid without changing electrolyte balance or osmolality.

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Fluid Volume Excess Cause

Identify and treat the underlying cause of the fluid retention.

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Hypervolemia Management

Diuretics, fluid restriction, and sodium restriction are common treatments.

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Daily Weights for Fluid Imbalance

Daily weights are crucial to track fluid changes; a 1 kg gain equals about 1 L of retained fluid.

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Nursing Diagnosis: Hypervolemia

The nursing diagnosis for hypervolemia is 'excess fluid volume'.

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Potential Hypervolemia Complications

Potential complications of excess fluid can be pulmonary edema, ascites, or other problems from fluid overload.

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Hypovolemic Shock Risk

Continued fluid loss without replacement puts a patient at risk for a life-threatening condition.

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Hypervolemia Cause

Excess fluid volume occurs due to increased water and/or sodium retention in the body.

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Fluid Intake Monitoring

Monitoring all fluids consumed (oral, IV, enteral) is crucial for assessing hydration status.

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Fluid Output Monitoring

Tracking urine, perspiration, wound drainage, vomit, and diarrhea to assess fluid loss.

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Urine Specific Gravity

A measure of urine concentration; high values (over 1.025) indicate concentrated urine; low values (under 1.010) indicate dilute urine.

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Cardiovascular Changes

Changes in blood pressure, pulse strength, and jugular vein distention reflect fluid balance in the circulatory system.

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Orthostatic Hypotension

A sudden drop in blood pressure when standing up, a symptom of low fluid volume.

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Pulmonary Edema

Fluid buildup in the lungs, a potential complication of excess fluid volume.

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Study Notes

Fluid and Electrolyte Imbalances

  • Outcomes: Describe safe, patient-centered, evidence-based nursing care for adults, guided by the Caritas philosophy. Discuss critical thinking and clinical reasoning to provide quality patient care.

Competency

  • Describe factors creating a culture of safety related to medication administration.
  • Discuss critical thinking and clinical judgment used for accurate, safe medication administration.

Concept

  • Fluid and Electrolyte: Physiological mechanisms maintaining fluid and electrolyte balance promoting bodily functions.

Unit Outcomes

  • Describe the nursing process and collaborative management when caring for patients with fluid and electrolyte imbalances.
  • Fluid imbalances:
    • Extracellular fluid volume deficit
    • Extracellular fluid volume excess

Fluid and Electrolyte Imbalances Overview

  • Directly caused by illness or disease (e.g., burns, heart failure).
  • Result of therapeutic measures (e.g., IV fluids, diuretics).
  • Classified as deficits or excesses.
  • Example: Prolonged nasogastric suction may cause Na+, K+ deficiency; fluid volume deficit, and metabolic alkalosis.
  • Imbalances commonly occur in patients with major illnesses or injuries due to disrupted homeostatic mechanisms. Imbalances can be directly caused by illness or disease, or by therapeutic measures (e.g., IV fluids/medications).

Extracellular Fluid Volume Imbalances

  • Deficit (Hypovolemia): Not the same as dehydration. Dehydration is only water loss, whereas Hypovolemia involves loss of both water and sodium. This results in decreased blood volume (intravascular fluid), and increased interstitial fluid (edema)
    • Intracellular fluid contains: Solutes (oxygen, electrolytes, glucose). Cations (potassium, magnesium). Anions (phosphate, sulfate).
    • Extracellular fluid contains: Principal electrolytes (sodium, chloride, bicarbonate). Interstitial fluid (surrounds cells). Intravascular fluid (plasma). Transcellular and lymph fluids.
  • Excess (Hypervolemia/Edema): Increased intravascular fluid.

Possible Causes of ECF Volume Deficit (Hypovolemia)

  • Abnormal loss of body fluids (e.g., vomiting, diarrhea, GI suctioning, fistulas, chronic laxative/enema use).
  • Renal losses (e.g., diuretics, renal disorders, endocrine disorders).
  • Hemorrhage.
  • Excessive sweating, increased temperature.
  • Inadequate intake.

Fluid Volume Deficit Clinical Manifestations

  • Initial signs: thirst, dry mucus membranes, decreased urine output, weakness, lethargy, postural hypotension.
  • Possible hypovolemic shock: hypotension, tachycardia, tachypnea, decreased/absent urine output, decreased cardiac output. Coma, death.
  • Assessments: intake and output, vital signs (orthostatic blood pressure/pulse), skin turgor, mucous membrane moisture, capillary refill.
  • Labs may show an increased hematocrit due to relative concentration of RBCs with less fluid in the vasculature.

Fluid Volume Deficit Management (Hypovolemia)

  • Treatment: Replace water and electrolytes.
  • PO fluids
  • IV fluids (Lactated Ringers or isotonic 0.9% sodium chloride): used for rapid volume replacement when caused by blood loss/ volume loss and isotonic 0.9% sodium chloride when needed rapid volume replacement.
  • Evaluation: Monitor intake and output, blood pressure.

Possible Causes of ECF Volume Excess (Hypervolemia)

  • Retention of sodium and water (e.g., heart failure, liver cirrhosis, renal failure, increased ADH & aldosterone in stress conditions).
  • Excessive intake of sodium-containing foods, drugs causing sodium retention, sodium-containing IV fluids.

Fluid Volume Excess Clinical Manifestations

  • Excess volume: weight gain ( > 5% body weight)
  • Circulatory overload: bounding pulse, jugular vein distention, increased central venous pressure.
  • Respiratory distress: Dyspnea/orthopnea, crackles, cough (pulmonary edema).
  • Other: Polyuria, ascites, edema.

Nursing Implementation for Fluid Imbalances

  • Daily weights: Weigh patients at the same time each day, wearing the same clothes, using the same calibrated scale. A 1 kg (2.2 lbs) weight gain is equal to about 1000 ml (1 L) of fluid retention.

  • Monitor intake and output (I&O): Oral, IV, tube feedings; urine output, perspiration, wound drainage, vomiting, diarrhea).

  • Monitor fluid volume status: Include checking for changes in vital signs (blood pressure, pulse force, jugular venous distention), ECG changes, and orthostatic hypotension.

  • Assess neurologic function: Level of consciousness, pupillary response, voluntary movement.

  • Assess respiratory changes: Pulmonary congestion, shortness of breath, and crackles.

  • Other Assessments: Skin assessment (turgor), mucous membranes (moisture).

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Description

This quiz explores the critical aspects of nursing care related to fluid and electrolyte imbalances. It covers the physiological mechanisms, patient-centered care, and the nursing process involved in managing these imbalances effectively. Enhance your understanding of medication administration and safety within the healthcare setting.

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