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74 Cards in this Set
- Front
- Back
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major intracellular electrolyte - not much in the vascular space
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Potassium - 3.5-5.5mEq/L
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Low levels of this can be life threatening d/t responsibility for cardiac muscles resulting in cardiac arrythmias
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Potassium <3.5
Urinary potassium - >20mEq/L (24 hr. sample) excreting too much |
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Low levels of this electrolyte can be due to vomiting, diarrhea and gastric sunction; Inadequate dietary intake, alcoholics and anorexics; _____ wasting diuretics
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Potassium
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The clinical manifestations of low potassium are
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weak, thready pulse; EKG changes; muscle weakness, leg cramps, paresthesias; fatigue, N/V; decreased abdominal peristalsis. Can cause death by cardiac or respiratory distress
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Low levels cause EKG changes
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Potassium - Flat or inverted T wave, elevated U wave, depressed ST segments
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Recommended amount/source of potassium
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50-100mEq per day. raisins, bananas, spinach, oranges, avocados, legumes, beef, canteloup, tomatoes, potatoes
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Oral potassium supplements
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40-80 mEq/day. Can produce small bowel lesions. Assess for distention, pain or gi bleeding
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IV potassium supplements
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Never give IV push or IM!!!! Give when serum <2. Assess renal function. Stop if urinary output is <20ml for 2 hours. Use pump. Never hadd to hanging bag!! Shake well. Monitor IV site for phlebitis. Monitor pt for cardiac arrythmias
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Potassium Nursing Dx
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activity intolerance
decreased cardiac output risk for injury risk for ineffective breathing pattern constipation risk for fluid imbalance |
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Potassium Nursing Interventions
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Assess resp./cardiac status;
assess skeletal muscle strength; monitor labs/I&O; provide K rich foods, med admin - daily prophylactic dose 20meq; patient education |
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Hyperchloremia
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>108mEq/L
meds that promote Chloride retention; dehydration; severe vomiting, diarrhea |
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weakness and lethargy; tachypnea; dysrhythmias; hypertension
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Clinical manifestations of hyperchloremia
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Diagnostic test results for Hyperchloremia
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serum chloride - >108mEq
Elevated sodium and potassium Decreased bicarbonate |
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Management of Hyperchloremia
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Decrease chloride intake; diruetics; hypotonic IV; increase free water intake (oral); correct underlying cause
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Nursing Dx of Hyperchloremia
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ineffective breathing pattern; imbalanced nutrition - more; impaired skin integrity; risk for injury; self care deficit; anxiety
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Recommended amount/source of potassium
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50-100mEq per day. raisins, bananas, spinach, oranges, avocados, legumes, beef, canteloup, tomatoes, potatoes
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Oral potassium supplements
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40-80 mEq/day. Can produce small bowel lesions. Assess for distention, pain or gi bleeding
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IV potassium supplements
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Never give IV push or IM!!!! Give when serum <2. Assess renal function. Stop if urinary output is <20ml for 2 hours. Use pump. Never hadd to hanging bag!! Shake well. Monitor IV site for phlebitis. Monitor pt for cardiac arrythmias
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Potassium Nursing Dx
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activity intolerance
decreased cardiac output risk for injury risk for ineffective breathing pattern constipation risk for fluid imbalance |
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Potassium Nursing Interventions
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Assess resp./cardiac status;
assess skeletal muscle strength; monitor labs/I&O; provide K rich foods, med admin - daily prophylactic dose 20meq; patient education |
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Hyperchloremia
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>108mEq/L
meds that promote Chloride retention; dehydration; severe vomiting, diarrhea |
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weakness and lethargy; tachypnea; dysrhythmias; hypertension
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Clinical manifestations of hyperchloremia
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Diagnostic test results for Hyperchloremia
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serum chloride - >108mEq
Elevated sodium and potassium Decreased bicarbonate |
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Management of Hyperchloremia
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Decrease chloride intake; diruetics; hypotonic IV; increase free water intake (oral); correct underlying cause
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Nursing Dx of Hyperchloremia
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ineffective breathing pattern; imbalanced nutrition - more; impaired skin integrity; risk for injury; self care deficit; anxiety
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Nursing interventions for hyperchloremia97
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Monitor VS/I&Os; admin. oral/parenteral fluids - hypo to get more free water; patient safety; patient education
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Major extracellular canion that circulates with water and sodium
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Chloride - 97-107mEq/L
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Causes of Hypochloremia <
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GI suctioning, gastric surgery, severe vomiting and diarrhea
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Clinical manifestations of hypochloremia
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tremors/twitching, hyper DTR; slow shallow breathing; hypotension d/t low vascular volume
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Diagnosis of hypochloremia
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<95meQ; decreased serum sodium and potassium; decreased urine chloride level (lost in gi so body it trying to keep it onboard)
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Management of hypochloremia
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correct or replace cc for cc via oral (salt or potassium chloride tablets) or IV NSS or 45% NS (sodium chloride)
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Nursing Dx for hypochloremia
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imbalanced nutrition: less (gi losses); excess fluid volume (retention); impaired sensory/perception; risk for injury (LOC, weakness, tremors); anxiety (muscle irritability)
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Nursing Interventions for hypchloremia
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Monitor serum and urinary chloride levels; admin supplements; VS/I&O; Assess LOC and muscle strength; Patient education - foods high - processed foods, canned foods, cheese; avoid excessive free water (further dilution)
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Hypernatremia
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>145mEq
Patient ingests/retains more sodium than water Patient loses more water than sodium Inadequate fluid intake - unconscious pts. DI - lack of ADH, urinary losses - 4 gallons/day |
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Clinical manifestations of Hypernatremia
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Thirst first; lethargy, weakness, irritability; seizures, coma, death; dry sticky mucosa, rough dry skin; tachycardia, hypertension; water diarrhea, nausea
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Diagnostic tests for hypernatremia
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>145mEq; serum osmality >295 mOsm/kg; Urine specific gravity >1.015; increased BUN and HCT (less fluid in vasc space)
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Management of hypernatremia
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decrease sodium intake - restrict; diuretic therapy to promote sodium excretion; parental fluids - hypo (.45% sodium) - more free water to dilute sodium
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Nursing diagnosis for hypernatremia
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risk for injury- LOC ; risk for fluid volume deficit - diurese; risk for sensory/perception alterations - LOC
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Hyponatremia
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<135mEq
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Depletional hyponatremia
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decrease or loss of sodium
vomiting, diarrhea and diuretics |
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Dilutional hyponatremia
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excess gain in water
increased water intake |
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Clinical manifestations of hyponatremia
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anorea, N/V, abd. cramping, diarrhea; pale dry skin, dry mucosa; increase pulse/BP, weight gain, edema (dilutional); headache, dizziness, confusion, lethargy; seizures and coma
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Diagnostic tests for hyponatremia
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<135; serum osmolality <270; urine specific gravity <1.010; change in urine sodium levels depending on which type
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Medical management of hyponatremia
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sodium replacement - easy if patient can eat/drink; parenteral fluids - LR or NSS (isotonic); water restriction - dilutional (800ml/24 hrs); small volumes of hypertonic 3-5% Na only rarely in ICU setting. Don't increase more than 12mEq in 24 hrs - can cause cerebral edema causing increase ICP
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Nursing Dx for hyponatremia
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risk for fluid imbalance r/t fluid shifts; risk for injury; altered mental status d/t cerebral cell changes); risk for impaired skin integrity
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Nursing interventions for hyponatremia
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Careful assessment; monitor labs/I&Os; daily weights; neuro changes - confusion, lethargy, seizures; safety precautions; sodium replacement oral or iv; fluid restrictions maybe; patient education
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Mechanisms of hemostasis
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Thirst, Kidneys, Adrenal function; Pituitary function
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Thirst
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center located in brain stimulated with small fluid losses or increases in serum osmolality
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Kidneys
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regulate ECF volume by selective retention and excretion; regulation of pH by retention of Hydrogen ions; excretion of metaboic wasts and toxins
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Adrenal Function
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Aldosterone- hormone produce by adrenal gland; release is triggered by drop in BP, blood volume, serum sodium (gi losses, V/D) or rise in serum potassium; causes kidneys to retain sodium/excrete potassium; water follows sodium
Coritsol - hormone produced by adrenal gland when body is stressed; large quanitites cause sodium retention and K excretion |
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Pituitary Function
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ADH made in hypothalmus and secreted by posterior pituitary - drop in BP or serum osmolality triggers ADH release so kidneys don't diurese and reabsorb more water resulting in higher vascular volume and low output of concentrated urine raising BP and lower serum sodium level; Rise in BP or drop in serum osmolality inhibits ADH causing kidneys to excrete more water and lower vascular volume and high output of dilute uring loweirng BP and raising serum sodium
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Fluid Volume Deficit
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Loss of ECF volume exceeds intake of fluids
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Hypovolemia
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Fluids and solutes are lost in equal amounts. Serum osmolality remains normal
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Dehydration
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Loss of water butg increased serum sodium levels
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Pathophysiology of Fluid Volume Deficit
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Prolonged periods of inadequate fluid intake; excess fluid losses through vomiting, diarrhea, gi suctioning, diuretics and hemmorhage; Third space fluid shifts
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Clinical manifestations of fluid volume deficit
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acute weight loss; poor skin turgor; oliguria; orthostatic hypotension; flattened neck veins; thirst, muscle weakness and cramps; increased temp; cool clammy skin; concentratedurine; weak, rapid pulse; confusion; nausea, fatigue
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Diagnosis of fluid volume deficit
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Bun - ratio <20:1 (BUN/creatinine); hematocrit - normal or elevated due to decreased plasma; USG >1.030; serium sodium >145; serum osmolality >300
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Management of fluid volume deficit
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Mild - oral; moderate -oral/iv; severe - IV (isotonic)
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Nursing Dx ofr fluid volume deficit
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fluid volume deficit; ineffective tissue perfusion d/t low circulating blood volume; risk for injury; impaired skin integrity; knowledge deficit
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Nursing interventions for fluid volume deficit
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assess I&O (notify dr <30ml/hr; VS (weak, rapid pulse, postural hypotension; assess mental status, daily weights, lab values; oral/IV rehydration; comfort measures; control nausea/V/D; education
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Fluid Volume Excess (Hypervolemia)
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Isotonic fluid excess ad
Hypotonic fluid excess |
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Isotonic fluid excess
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abnormal retention of water and sodium in equal proportions; overall gain in ECF; no change in serum olmolality
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Hypotonic fluid excess
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More fluid than sodium is retained or gained; serum osmolality falls; water intoxication
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Pathophysiology of Isotonic Fluid excess
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fluid overload - excess water and sodium intake; diminished functions of homeostatic mechanisms - renal, heart, liver; high corticosteroid or aldosterone levels - therapy, stress, adrenal dysfunction, liver damage
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Pathophysiology of hypotonic fluid volume excess
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repeated plain water enemas, ng irrigations with plain water or bladder irrigations; overinfusion of hypotonic IV; excess plain water intake; SIADH (don't pee out)
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Clinical manifestations of excess fluid volume - Hypervolemia
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peripheral edema and 3rd spacing; increased CVP; distended neck veins; pulmonary edema; full bounding pulses; rapid weight gain and 3rd space accumulation
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Third spacing
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extracellular body spaces in which fluid accumulates - physiologically useless; abdomen, tissues, pleural space, pericardial space; injury/inflammation, malnutritiona; liver, heart, renal dysfunction
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Diagnostic findings for hypervolemia
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decreased hematocrit and BUN (diluted); decreased serum osmolality and sodium; chest xray pulmonary congestion
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Diuretic management for hypervolemia
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Increase urinary excretion of water and sodium
Loop - inhibits sodium and chloride reabsoprtion in loop of henle (Lasix, Bumex); thiazide type - decrease absoprtion of soidum, chloride, potassium and water in distal tube (Diuril, Hydrochlorothiazide) (need K diet); Potassium sparing - inhibit sodium potassium exchange in distal tube (Aldatone) don't need high K diet - watch levels) |
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Diurectic education
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increase amount and frequency of urine; take in morning and afternoot; take even if not feeling well; avoid table salt; increase K intake - oj and bananas; report dizziness (dehydration), trouble breathing and swelling (retaining) to dr
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Management of hypervolemia
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Fluid restriction by physician; divide throughout day-50%, evening 25-33%, night - remainder; ice chips, mouth care; sodium restriction; avoid salt and processed foods, education
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Nursing Dx for hypervolemia
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fluid volume excess; risk for impaired gas exchange; altered comfort; risk for impaired skin integrity; knowledge deficit
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Nursing interventions for hypervolemia
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assess VS, edema, lung sounds, daily weights, I&O, fluid restrictions, diurectics, skin and oral care, elevate HOB, O2, nutritional teaching
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Sodum 135-145mEq/L
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Most abundant in ECf; water balance and plasma osmolality; necessary for muscle contraction and nerve impulse transmission; found in all body fluids including bile, blood, gastric and intestinal secretions, pancreatic fluid, sweat and saliva
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