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12 Cards in this Set
- Front
- Back
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Who is at highest risk for fluid overload?
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The elderly because they may have heart or renal failure (more likely for elderly to have these dzs)
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What patients do we NOT use ringers for?
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Patients with alkylosis or liver failure.
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Why do we not use ringers on patients in alkylosis or with renal failure?
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When ringers lactate breaks down, one of its bi-products is bicarbonate.
If you're in metabolic alkylosis, the last thing you want is more bicarb. The liver also plays a huge role in metabolism. Therefore, ringers are contraindicated in alkylosis and liver failure. |
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What does circulatory overload look like in a patient?
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One of the first places fluid might go is to back up into the lungs.
- Hear crackles - Overt signs of resp distress ***** SOB ***** Increased resp rate ***** Retraction ***** Use of accessory muscles ***** etc. Possible edema Possible weight gain Possible bounding pulse Low O2 saturation Possible JVD |
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What's the most common form of dehydration?
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Extracellular dehydration is the most common form --- Not intracellular.
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What types of patients is a hypotonic solution indicated for?
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Someone with really bad DKA (diabetic ketoacedosis)
Basically someone with severe cellular dehydration would benefit from a hypotonic solution. |
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What is a colloid?
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A protein such as Albumin
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Who is most at risk for fluid volume deficit? Why?
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Elderly
1. Diminished thirst 2. Less overall total volume 3. Functional problems (decreased mobility, weakness, etc. leading to decreased intake) |
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Who is most at risk for fluid volume overload? Why?
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Elderly
Heart Failure Patients Renal Failure |
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Clinical findings for nursing diagnosis of fluid volume deficit...
Early signs Characteristics Labs Hx Assessment 5 interventions Possible Complications Possible Nursing Diagnosis |
Early indicator in the elderly = decreased LOC (confusion)
Non-elderly early indicator = thirst other characteristics... * increased HR * Weak, thready pulse * Increased resp rate * dry mucus membranes * BP decreases (elderly at increased risk of falls and orthostatic hypotenstion) * flat veins * decreased urine output (dark, concentrated, high specific gravity > 1.030) * Skin turgor (except in the elderly... if you're going to check skin turgor in elderly, best place is sternum). LAB CHANGES * BUN (high) and creatinine labs. If pt is only dehydrated and NOT in renal failure, the creatinine level would remain normal and only BUN would be elevated. * Serum sodium elevated * Hematecrit elevated We need to monitor weight. 1kg = 1L fluid = 2.2 lbs. Look for increase or decrease in weight. ASSESS PT HX - diarrhea - vomiting - burns/trauma - Fever (diaphoresis) insensible fluid loss - caffiene containing products 5 INTERVENTIONS ### Administer isotonic fluids (PO - mild to mod dehyd, or IV - severe dehyd |
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Clinical findings for nursing diagnosis of fluid volume Excess...
Characteristics Labs Interventions Evaluation of treatment |
CHARACTERISTICS
* Bounding pulse * increased BP * JVD * Edema (more obvious in lower extremeties) * Adventitious lung sounds (crackles) - could lead to pulmonary edema. * Urine very dilute (specific gravity low) * Dyspnea/SOB * Resp Rate increases initially as compensatory mech. LABS - Serum sodium low - prone to seizures (increased risk) INTERVENTIONS - Fluid restriction - restrict sodium (2 g sodium diet or no added salt) - administer diarrhetics such as furosimide or lasix. EVALUATE IF TREATMENT IS WORKING * Daily weight (possible weight loss) * Urine output increases * Ease of breathing * Reduced edema * Absence of crackles INTERVENTIONS - If giving furosimide or lasix, monitor potassium and I/Os. - Also monitor for hypotension - Institute measures to prevent skin breakdown (often caused by the edemedus state) - turning, avoiding shearing, friction, etc. |
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Describe the IV Solution listed and 1 reason why it would be used in a patient.
1. 0.9% Normal Saline 2. D5W (once infused) 3. D5 1/2 Normal Saline |
1. 0.9% Normal Saline - Isotonic solution *** Increase intravascular volume. Complication might be fluid overload.
2. D5W (once infused) - Hypotonic Solution *** Increase intracellular volume *** Containdicated in ICP!!!!!! 3. D5 1/2 Normal Saline - Hypertonic Solution *** Shrinks the cells *** commonly used for maintainance and can also be used when trying to remove fluid from the cells such as ICP (contraversial) --- Possible complications could be intravascular overload and if renal or hepatic problems are present, they won't be able to clear it --- |
