Nursing Care for Hypervolemia

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Questions and Answers

What assessment finding indicates hypervolemia?

Weight loss

Pitting edema (correct)

Low blood pressure

Dehydration

Which of the following interventions is appropriate for managing a client with hypervolemia?

Increase fluid intake

Promote fluid retention

Administer diuretics (correct)

Encourage high sodium diet

What is a primary goal in the nursing care plan for a client with excess fluid volume?

Ensure the client's weight increases gradually

Promote unrestricted dietary sodium intake

Maintain a fluid intake of 2 liters per day

Ensure accurate intake and output monitoring (correct)

Which of the following causes can lead to hypervolemia?

Chronic renal failure Signup and view all the answers

What nursing measure is best to assess fluid retention in a client?

Tracking daily weight Signup and view all the answers

What are the primary components of body fluids?

Water and electrolytes Signup and view all the answers

Which of the following is a characteristic of extracellular fluid?

Fluid containing plasma Signup and view all the answers

What is the average fluid intake for an adult in a day?

2500 mL/day Signup and view all the answers

Which mechanism is responsible for the retention of water in the body by releasing ADH?

Osmoreceptors Signup and view all the answers

What is hypovolemia primarily characterized by?

Low volume of extracellular fluid Signup and view all the answers

How does the sodium-potassium pump function in fluid and electrolyte regulation?

It uses ATP to transport sodium out of and potassium into the cell. Signup and view all the answers

What does dehydration signify regarding fluid levels?

Reduction of both extracellular and intracellular fluids Signup and view all the answers

Which of the following accurately describes osmosis?

Movement of water through a semipermeable membrane Signup and view all the answers

What is the role of natriuretic peptides in fluid regulation?

Increase urine production, reducing blood volume Signup and view all the answers

What is the most appropriate nursing intervention for a client experiencing hypercalcemia?

Encourage increased fluid intake. Signup and view all the answers

Which of the following conditions is characterized by a pH greater than 7.45?

Metabolic Alkalosis Signup and view all the answers

In the management of metabolic acidosis, which of the following interventions is appropriate?

Administer sodium bicarbonate. Signup and view all the answers

Which assessment finding is expected in a patient experiencing respiratory alkalosis?

Numbness and tingling of fingers. Signup and view all the answers

Which of the following is a common cause of respiratory acidosis?

Chronic obstructive pulmonary disease (COPD). Signup and view all the answers

What can be an immediate manifestation of metabolic acidosis?

Increased respiratory rate. Signup and view all the answers

During a narcotic overdose, which acid-base imbalance is most likely to occur?

Respiratory Acidosis Signup and view all the answers

Which measurement would indicate an acidosis disturbance in arterial blood gases (ABGs)?

HCO3 < 22 Signup and view all the answers

What is a common cause of third-spacing?

Hypoalbuminemia Signup and view all the answers

Which assessment finding is associated with hyponatremia?

Mental confusion Signup and view all the answers

What is the primary role of sodium in the body?

Regulating fluid volume Signup and view all the answers

Which condition is directly associated with hypokalemia?

Cardiac dysrhythmias Signup and view all the answers

Which of the following causes hypocalcemia?

Vitamin D deficiency Signup and view all the answers

What would be a significant diagnostic finding in a patient with severe hypernatremia?

Serum sodium > 145 mEq/L Signup and view all the answers

Which electrolyte imbalance can be caused by renal disease and diuretics?

Hypomagnesemia Signup and view all the answers

What is the medical management approach for hypokalemia?

Increasing potassium intake Signup and view all the answers

Which of the following is NOT a cause of hypernatremia?

Addison disease Signup and view all the answers

A patient with hypocalcemia may exhibit which sign?

Positive Chvostek sign Signup and view all the answers

Study Notes

Nursing Care of Patients with Fluid, Electrolyte, and Acid-Base Imbalances

Objectives:
- Identify the purposes of fluids and electrolytes in the body
- List the signs and symptoms of common fluid imbalances
- Predict patients at highest risk for dehydration and fluid excess
- Identify data to collect in patients with fluid and electrolyte imbalances
- Describe therapeutic measures for patients with fluid and electrolyte imbalances
- Identify the education needs of patients with fluid imbalances
- Categorize common causes, signs and symptoms, and treatments for sodium, potassium, calcium, and magnesium imbalances
- Identify foods high in sodium, potassium, and calcium
- Give examples of common causes of acidosis and alkalosis
- Compare how arterial blood gases change for each type of acid-base imbalance

Fluid and Electrolyte Balance

Body Fluids:
- Components: water and chemicals
- Electrolytes: substances carrying electrical charge in fluid
- Acids: release hydrogen into fluid
- Bases: substances binding with hydrogen
- Purpose: regulate fluid volume, buffer blood to maintain neutral pH (body's negative feedback loop; bases bind with hydrogen)

Fluid and Electrolyte Balance - Body Fluid Compartments

60% of body is water
For every 100 lbs of body weight, approximately 60 lbs is water (1 lb = 500 ml)
Accurate daily weight is important to track fluid balance
Intracellular fluid (ICF): fluid inside cells (35%-40% of body weight)
Extracellular fluid (ECF): fluid outside cells
- Interstitial fluid: fluid between cells (10%-15% of body weight)
- Intravascular fluid (plasma): fluid within blood vessels (5% of body weight)

Intake and Output

Average Fluid Intake (adult): 2500 mL/day (range: 1800-3600 mL/day).
Sources: food and liquids
Fluid Elimination:
- Urination
- Bowel elimination
- Perspiration
- Breathing
- Insensible losses (sweat, exhaled air)

Distribution of Fluids and Electrolytes

Physiologic processes: movement of fluid and exchange of chemicals (electrolytes, acids, bases) is continuous.
Five processes:
- Osmosis: movement of water across a semipermeable membrane, influenced by concentration of dissolved substances
- Filtration: promotes fluid movement due to pressure differences, e.g., kidneys.
- Passive and facilitated diffusion: movement of substances, e.g., insulin facilitates glucose distribution.
- Active transport: sodium-potassium pump; requires ATP.

Mechanisms of Fluid and Electrolyte Regulation

Types:
- Osmoreceptors: neurons sensing blood concentration and stimulating ADH release (antidiuretic hormone)
- Baroreceptors
- Renin-angiotensin-aldosterone system (RAAS): chemicals released to increase blood pressure and volume
- Natriuretic peptides (ANP and BNP): increase urine production

Fluid Imbalances

Hypovolemia: low volume of extracellular fluid
- Causes: vomiting, diarrhea, wounds, excessive urination, hemoconcentration
- Assessment findings: thirst
- Diagnostic findings: elevated hematocrit (Hct), elevated urine specific gravity
- Medical management: restoring fluid deficit (oral or IV)
- Nursing Management: 8-10 glasses of water per day, avoid caffeine and alcohol, no sodium restriction
Hypervolemia: high volume of water in intravascular fluid
- Causes: excessive oral intake, IV fluids, heart failure, kidney disease, adrenal gland dysfunction, circulatory overload
- Assessment findings: weight gain, elevated blood pressure, pitting or non-pitting edema
- Diagnostic findings: low hematocrit (Hct), low urine specific gravity
- Medical management: restrict oral or parenteral fluids, diuretics, limit sodium

Nursing Care Plan: Hypervolemia

Nursing Diagnosis: Excess Fluid Volume related to intake that exceeds fluid loss.
Interventions: baseline and daily weights, accurate intake and output, auscultate lung sounds, measure blood pressure, heart rate, and respiratory rate, inspect skin for edema, cracks, and breakdown See Nursing Process for Client with Hypervolemia beginning on pg. 55

Third-Spacing

Translocation of fluid from intravascular to tissue compartments
Causes: hypoalbuminemia, burns, severe allergic reactions
Assessment Findings: ascites, generalized edema
Diagnostic findings: hemoconcentration, normal central venous pressure (CVP), borderline blood counts
Medical Management: albumin infusion, IV diuretic

Electrolyte Imbalances

Electrolyte imbalances occur as deficits or excess, accompanied by fluid changes
Causes:
- Deficits: administration of IV fluids, vomiting, diarrhea, diuretics.
- Excess: orally consumed, parenteral administration of electrolytes, kidney failure, endocrine dysfunction, crushing injuries, burns
Priority: sodium, potassium, calcium, magnesium imbalances

Acid-Base Balance

Normal plasma pH: 7.35 to 7.45
Death occurs if pH is outside of 6.8-7.8 range
Imbalance Types:
- Acidosis: excessive accumulation of acids or excessive loss of bicarbonate
- Alkalosis: excessive accumulation of bases or loss of acid

Acid-Base Imbalances (Metabolic, Respiratory)

Detailed causes, assessment findings, diagnostic findings, and medical management

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Description

Test your knowledge on hypervolemia and nursing interventions designed to manage it. This quiz covers assessment findings, appropriate nursing measures, and care plan goals for clients with excess fluid volume. Assess your understanding of causes and management strategies related to hypervolemia.