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136 Cards in this Set

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What is Your body’s balancing act called?
Homeostasis
Water makes up a large percentage of the body’s weight..what % is that in an adult.
40-60% of the total body weight
What affects the amount of water?
age and sex affect amount of water
Water makes up a large percentage of the body’s weight..what % is that in an infant?
infants =70-80%
After age 60 what % is the total body weight composed of water?
percentage decreases to approx. 50% of total body weight after age 60
Who has a lower % of water in Body, Man or woman and why?
women have a lower percentage than men due to higher percentage of body fat
Purposes of water in the body
Metabolism
Metabolism
-hormones
Purposes of water in the body
Transportation
Transportation
- moves oxygen from lungs, nutrients to and from GI tract and wastes from kidneys
Purposes of water in the bodyLubrication
Lubrication
- main constituent of synovial fluid in joints, aqueous humor and tears in eyes, GI tract secretions
Purposes of water in the body
Insulation and protection
Insulation and protection
-cushions and cools the CNS, main constituent of amniotic fluid
Purposes of water in the body
Regulation
Regulation
perspiration and temperature control
What are the are 2 major body fluid compartments?
Intracellular fluid (ICF)

Extra cellular fluid (ECF)
Where is Intracellular fluid (ICF) found?
Found in the cells

-Represents 2/3 of total body fluid; about 40% of body weight

-Contains oxygen, electrolytes and glucose

-Vital to cellular metabolism
What is the % of Intracellular fluid (ICF) wt. is how much of the total body fluid? and what is the %? 20, 30, 40
-Represents 2/3 of total body fluid; about 40% of body weight
Where is Extra cellular fluid (ECF)found?
-Found outside of the cells
ECF wt is how much of the total body fluid?
-Represents 1/3 of total body fluid; about 20% of body weight
What is the function of ECF?
-Is the cellular transport system for nutrients and wastes
Extracellular fluid is Divided into 2 major sub compartments what are they?
interstitial –in between the individual cells and outside of blood vessels (lymph)
intravascular-in the vascular space (plasma)
What is TCF?
Transcellular fluid is NOT considered a major compartment. Transcellular fluid is CSF, pleural fluid, peritoneal and synovial fluid
What does Intracellular (ICF) and Extracellular (ECF) fluid contain?
Oxygen from the lungs
Nutrients from the GI tract
Wastes like CO2
Minerals and salts (electrolytes)
Ions
What are Electrolytes?
Ions are particles that conduct electricity called electrolytes
Where are Electrolytes and where are they found? and what do they help maintain?
Electrolytes are found in all body fluids and are needed to maintain physiologic balance.
Are cations + or - in charge?
positive charged electrolytes are called cations (+)
Are anions + or - charged?
negatively(-) charged electrolytes are called anions (-)
What is the Purposes of Electrolytes in the body ?
Neuromuscular Impulses
Acid -Base Regulation
Maintenance of Fluid Balance
Assisting with the action of enzymes

***Most electrolytes are obtained through foods, some are stored in the cells(K+) or bones(Ca+).
What are the Cations that are present in the body?
Cations
Sodium (Na+)
Potassium(K+)
Calcium (Ca+)
Magnesium (Mg+)
What are the Anions in the body?
Anions
Chloride (Cl-)
Bicarbonate (HCO-)
Phosphate(HPO-)
Sulfate (SO-)
What are Intracellular Fluid
Cations and anions?
Intracellular Fluid
Cations
Magnesium and Potassium
Anions
Phosphate and Sulfate
What are the Extra cellular Fluid Cations and Anions
Extra cellular Fluid
Cations
Sodium (90%)
Anions
Chloride
Bicarbonate
**There are other electrolytes in these compartments but they are present in smaller quantities.
True or False???There is no way to measure intracellular fluid accurately?
TRUE
What is Intravascular Fluid and where is it found?
Found in the vascular compartment.

Also known as plasma.

Contains large amounts of protein that helps maintain fluid balance in the vascular compartment.
In order to have osmosis occur there must be a solute and a solvent
Solutes are substances that can be dissolved in water.

(ex:sodium is a solute)

Solutes can be crystalloid(like salt) or colloid(like protein)Solvents are substances that dissolve the solutes.

(ex:water is a solvent)
In order to have osmosis occur there must be a solute and a solvent
Solutes are substances that can be dissolved in water.

(ex:sodium is a solute)

Solutes can be crystalloid(like salt) or colloid(like protein)Solvents are substances that dissolve the solutes.

(ex:water is a solvent)
What are Solvents?
are substances that dissolve the solutes.

(ex:water is a solvent)
What are Solutes?
can be crystalloid(like salt) or colloid(like protein)(ex:sodium is a solute)

Solutes
What is Osmolality?
Osmolality describes the concentration of solutes in a solvent. In nursing, we compare any solution used to the composition of the body fluids.
Tonicity of solutions
Isotonic
Hypertonic
Hypotonic
What is Isotonic and ex of IV fluids that are...
Isotonic= the same osmolality of body fluid
(ex:0.9% Sodium Chloride Solution; NSS or Normal Saline Solution)
What is Hypertonic and eg. of the IV fluids?
Hypertonic=more osmolality than body fluid; super concentrated
(ex:50%Dextrose Solution)
What is Hypotonic and eg. of IV fluids?
Hypotonic = less osmolality than body fluid; weak solution
(ex:0.45% Sodium Chloride Solution)
What is Osmotic Pressure?
Osmotic pressure is what forces water to move from an area of low concentration to an area of high concentration.
What does a Hypertonic IV solution do in the body?
hyper tonic IV solution will draw fluid out of the cells into the vascular space causing the cells to shrink.Hypertonic=more osmolality than body fluid; super concentrated
(ex:50%Dextrose Solution)
What does a Hypotonic IV soultion do in the body?
hypotonic IV solution will force fluid into cells causing them to swell (and possibly lyse).Hypotonic = less osmolality than body fluid; weak solution
(ex:0.45% Sodium Chloride Solution)
Colloid Osmotic or Oncotic Pressure
Proteins in the blood plasma exert pressure on the vascular walls to control or prevent the release of fluid from the vascular space.
Filtration changes in a capillary bed
Arterial pressure is higher..nutrients flow out Venous pressure is lower..wastes come in.
What is Diffusion??
Molecules (solutes) move from area of high concentration to lower concentration

Diffusion is dependent on the size of the molecule, the concentration of the solution and the temperature of the solution
What is Filtration?
Fluids and solutes move together from one compartment to another

They move from areas of high concentration to low concentration due to filtration pressure and hydrostatic pressure.

Filtration pressure=the pressure that forces the fluid out of one compartment into another

Hydrostatic pressure=the pressure caused by a fluid in a closed container (like a blood vessel
What moves fluid out of the capillaries into the interstitial fluid?
THe Hydrostatic (blood) pressure and
Osmotic (interstitial) pressure:
What moves fluid into the capillaries from the interstitial fluid
2.Colloid (blood osmotic- also called oncotic) pressure:
Hydrostatic interstitial pressure:
What is Edema caused by?
Can be caused by:
Increased hydrostatic pressure
Increased interstitial fluid osmotic pressure
Decreased or blocked lymph drainage
Decreased blood colloid osmotic pressure
What is Active Transport?
Active transport moves substances from an area of low concentration to an area of high concentration using enzymes. This results in the expenditure of energy(ATP) by the body.
Very important in the balance of potassium and sodium.
Look and See
Intracellular?
What moves fluid out of the capillaries into the interstitial fluid?
THe Hydrostatic (blood) pressure and
Osmotic (interstitial) pressure:
What moves fluid into the capillaries from the interstitial fluid
2.Colloid (blood osmotic- also called oncotic) pressure:
Hydrostatic interstitial pressure:
What is Edema caused by?
Can be caused by:
Increased hydrostatic pressure
Increased interstitial fluid osmotic pressure
Decreased or blocked lymph drainage
Decreased blood colloid osmotic pressure
What is Active Transport?
Active transport moves substances from an area of low concentration to an area of high concentration using enzymes. This results in the expenditure of energy(ATP) by the body.
Very important in the balance of potassium and sodium.
Intracellular fluid
Na+ Na+ Na+ Na+ Na+
Na+ ATP >>


K+ K+ K+ K+ K+ K+ K+ K+ K+ K+ K+
K+ K+ K+ K+ K+
remember that there is a cell membrane between the two.... Extra cellular fluid
Na+ Na+Na+Na+Na+ Na+Na+Na+ Na+ Na+Na+ Na+


K+ K+ <<ATP K+ K+ K+ K+
What is responsible for the Regulation and Monitoring body fluids?
Thirst (the desire to drink) is caused by receptors in the hypothalamus that are able to detect the osmolarity (concentration) of the blood plasma. Increased osmolarity causes the release of antidiuretic hormone from the posterior pituitary gland which causes thirst and reabsorption of salt and water from the distal renal tubules. This is why the urine becomes concentrated-the body tries to keep and reabsorb any available fluid.
Regulation and Monitoring body fluids?
Fluid Intake
Average adult needs 2500/ml of fluid day
Average p.o. intake =approx. 1500/ml per day
Water from foods averages 750/ml day
Water as a byproduct of food metabolism
= approx.200/ml day
What are Types of Fluid Output?
Urine and Feces
Adults must excrete approx. 500/ml of urine daily to maintain the removal of waste products from the kidneys.

1500/ml =chyme entering large intestine; about 100/ml left after absorption of water. Most is fluid reabsorbed in the colon resulting in formed feces.

Insensible Losses
breathing, sweat, tears=averages 800/ml per day of fluid loss.
What are the Nursing Responsibilities...
The nurse can assess the client with suspected or anticipated fluid and electrolyte imbalances without a doctor’s order using 3 simple clinical measurements:
Weight
Vitals Signs
Intake and Output
What does measurable output include?
Urine (weighing briefs for strict I&O)
Feces (especially liquid or semi liquid)
Vomit (even if it has large chunks)
Drainage from wounds (describe amount of linen/padding/dressings saturated or amount in collection device)
Drainage from wound drainage collection systems (hemovac, JP drain)
NG tube drainage (time tape the drainage container)
Chest tube drainage
What is the minimum expected amount of hourly urinary output for a healthy adult?
30cc/hr
What does measurable intake include?
Ice chips (amount recorded is one half the volume of the amount of ice in the cup.ex: 200cc cup of ice=100cc po intake)
Frozen juice or “ice pops”
Foods that are liquid at room temperature (like gelatin or ‘jello’)
Tube feedings (also list the 30-60cc water to flush tube)
Intravenous fluids (including ‘mini’ bags with medications)
Any tube irrigation (unless immediately drained or removed)
Who are the Clients at high risk for fluid volume imbalance
INFANTS AND ELDERLY BUT EVERYONE WHO UNDERGOES OR HAS ....Conditions
Procedures
Medications

***Almost every client that you will take care of will have at least one (possibly more) risks for fluid volume imbalance.
What is the Physical Assessment of the Client with Fluid Volume Imbalance findings?
HEENT/Integument

Cardiovascular System

Respiratory System

Gastrointestinal System

Genitourinary

Musculoskeletal
What is the Calcium(Ca+)norm, in an adult? :
8.5-10.5 mEq/L
Where is Calcium found?
Found mostly in the skeletal system. Serum is only 1% (99% is found in the bone).

Calcium is vital to bone formation, blood clotting, muscle contraction, relaxation,
neuromuscular function and cardiac function.

Calcium levels are controlled by parathyroid hormone , calcitonin and calcitriol
Found mostly in the skeletal system. Serum is only 1% (99% is found in the bone).
Calcium Food Sources
Dairy
Leafy Green Vegetables
Salmon and Sardines (canned, with the bones in)
Fortified cereals and some fruit juices
Calcium supplements may also be given
What is Calcium used for in the body?
Calcium is vital to bone formation, blood clotting, muscle contraction, relaxation,
neuromuscular function and cardiac function.

Calcium levels are controlled by parathyroid hormone , calcitonin and calcitriolAffect of aging:

The intestines become less effective at absorbing Ca+ from the intestines, lack of GI absorption causes calcium to move out of the bone which results in bone weakening.
What are the clinical findings of Hypocalcemia: serum Ca+ less than 8.9?
Hypocalcemia: serum Ca+ less than 8.9

Can be caused by low dietary intake, malabsorption, inadequate intake of Ca+ by breast feeding mother(infant affected) and total thyroidectomy
Parathyroidectomy

Symptoms:
confusion
muscle twitching, hyperactive DTR’s
cramping,
parasthesias of the face fingers and toes,
tetany
+Trousseau and Chvostek signs
What are the clinical findings Hyper calcemia: serum Ca+greater than 10.1mg/dl?
Hyper calcemia: serum Ca+greater than 10.1mg/dl

Can be caused by hyperparathyroidism, drugs, cancer,renal failure, prolonged bed rest

Symptoms:
decreased reflexes
Bradycardia; cardiac arrest
fatigue,lethargy
constipation
nausea, vomiting, anorexia
Bradypnea
-back pain (kidney stones)
What are the Magnesium-norm values in a adult?:
1.5-2.5
Where is Magnesium found in the body?
Found mostly in the skeleton and intracellular fluid
What is Magnesium used for in the body?
Needed for DNA and protein synthesis, ATP production, neuromuscular and cardiac function
Caution about clients and Magnesium...
Any one who cannot take in Magnesium orally or parenterally is at risk for Magnesium deficiency.

Clients with altered renal function are at risk for hypermagnesemia
What are the clinical findings of Hypomagnesemia:
serum level below 1.5mEq/l
Hypomagnesemia:
serum level below 1.5mEq/l
Seizures
Tetany
Anorexia/arrhythmias
Rapid Heart Rate
Vomiting
Emotional Liability
Deep tendon reflexes increased
What are the clinical findings of Hypermaganesaemia serum level above 2.5mEq/l?
Weakness( at 3-4mEq/l)
Skin flushing
Drowsiness
Hypotension and Bradycardia
Bradypnea (at 8 mEq/l)
Hypoactive DTR’s
Heart Block
Coma
Death by cardiac arrest (at 20mEq/l)
What is the Potassium-norm?
Potassium-norm:3.5-5.5 mEq/L
Whre is Potassium found in the body and what is it importnance?
Found primarily in the intracellular fluid
80% of K+ is excreted via urine
Maintains ICF water balance
Vital for cardiac, smooth and skeletal muscle activity
Affects of aging on Potassium....
Affect of Aging:
Decreases in renal function that may occur with aging can affect K+ levels.
Any condition that decreases renal function can affect K+ levels (causes hyperkalemia).
Transfusions of blood nearing the expiration date can contribute to hyperkalemia.
Inadequate dietary intake can contribute to hypokalemia.
Potassium Food Sources
CHOCOLATE!!!!!! is to Bananas, plantain, papaya, avocado
Oranges, cantaloupes, watermelon
Potatoes (White and Sweet)
Tomatoes
Mushrooms
Meats
Supplements may also be given
What ate the clinical findings of Hypokalemia:
serum level below 3.5mEq/l???
Muscle cramping and weakness
Cardiac dysrhythmias
Cardiac arrest
Weak and irregular pulse
Orthostatic hypotension
Alkalosis
Hypokalemia can be associated with lack of dietary intake, use of loop diuretics, overuse of laxatives, corticosteroids, gentamicin and by eating too much licorice.
Hyperkalemia: serum level above 5.5mEq/l
Paresthesias
Irritability and confusion
Abdominal cramping
Diarrhea
Nausea
Muscle weakness (especially lower extremities)
Acidosis
Cardiac arrest

**Hyperkalemia can also be associated with certain drugs including ACE inhibitors, beta adrenergic blockers, chemotherapeutic drugs, spironolactone, potassium sparing diuretics, NSAIDS and administration of old or outdated red blood cells.
Any tissue destruction including crush injuries, burns, rhabdomyolysis, tumor necrosis from chemotherapy, CRF and over administration of potassium IV can also cause hyperkalemia.
What is the Sodium-norm:
135-145mEq/L
Where is Sodium-found in the cells??
Found primarily in extra cellular fluid.
What is Sodiums job in the body?
and major contributor to serum osmolality
Controls and regulates water balance
“Where Na+goes; H2O follows”-maintains ECF volume
Sodium Food Sources
Just about everything you eat…
Cheese
Ham
Bacon
Processed foods ( makes them taste better)
Convenience Foods(soups, frozen meals, fast foods, snack foods, pre-seasoned rice mixes and noodle soups, nut mix, baking soda(sodium bicarbonate)
1 tsp salt=2,300mg sodium
What ar ethe clinical signs of Hyponatremia: serum levels below 135mEq/l
Lethargy
Confusion
Abdominal cramps
Anorexia, nausea, vomiting
Seizures
Coma


Loss of Na+ from diuretic use, sweating, GI tract, hypotonic tube feedings and SIADH can cause hyponatremia.
Hypernatremia: serum levels above 145mEq/l
Thirst
Red, dry swollen tongue
Weakness
Orthostatic Hypotension
Fatigue
Disorientation
Seizures

Increased insensible fluid losses and diarrhea, use of hypertonic tube feedings or hypertonic IV solutions and diseases like Diabetes Insipidus can contribute to hypernatremia.
What is Chlorides Normal range in the body???
Normal range:90-110mEq/l
Imbalances are usually related to
Imbalances are usually related to changes in the sodium(Na+) level.
What are the clinical signs of Hypochloremia??
Hypochloremia-related to loss from GI tract
causes muscle twitching, tetany and tremors
What are the clinical signs of Hyperchloremia??
Hyperchloremia-related to sodium retention or excess replacement of fluids with sodium or potassium chloride
causes acidosis, weakness, lethargy, dysrhythmias
What is the normal range of Phosphate in the body??
Normal Range:1.8-2.6mEq/l
Phosphate Imbalances in the body are usually related to??
Imbalances are usually related to treatment for other disorders such as glucose or insulin administration which forces phosphate into the cells from the ECF
What are the clinical findings of Hypophosphatemia??
Hypophosphatemia
can be caused by ETOH withdrawal and over use of antacids
causes parasthesias, muscle weakness and pain, mental changes and seizures
What are the clinical findings of Hyperphosphatemia?
Hyperphosphatemia
can be caused by damage to cells which forces PO- into ECF, overuse of laxatives containing phosphates, infants who are fed cow’s milk
Causes numbness and tingling in fingers and around mouth, muscle spasms and tetany
Effect of client variables on fluids and electrolytes:
The young child:
Young children have a higher percentage of water than adults
-Organ immaturity in the young child will affect the metabolism of electrolytes
Effect of client variables on fluids and electrolytes The older adult:
Older adults have a lower percentage of water than younger adults
-Decrease in organ function (bowel, kidneys) in the older adult will affect the metabolism and absorption of electrolytes
Chronic conditions and medications used in the elderly have the potential to affect fluid and electrolyte balance
Illness and Medications effects on electrolytes in the body...
A client’s chronic and acute illnesses will have an impact on fluid electrolyte balance

Diseases or medications that cause increased respirations (hyperventilation), decreased oral intake (anorexia, bulimia), increased urinary/fecal output (diuretics, laxatives, Crohn’s disease, SIADH) and massive fluid loss (burns, crush injuries, hemorrhage) will affect the clients fluid and electrolyte balance Diseases that affect the bowel may cause malabsorption of electrolytes.

-Some treatments may affect electrolyte balance (gastric suctioning, dietary restrictions, hormonal therapy (steroids), electrolyte replacement therapy)

-Diseases/medications that affect the kidneys may cause over excretion of necessary electrolytes (Na+, K+) or prevent reabsorption of necessary electrolytes (Ca+). Renal dysfunction can lead to retained fluid, electrolytes and wastes.

-Diseases that affect the liver may cause the underproduction of proteins that increase fluid shifts from the vascular space.
Isotonic Fluid Volume Imbalances: Fluid Volume Deficit/Hypovolemia
Losses can occur from GI tract, wound drainage, kidneys, decreased fluid intake, bleeding or third spacing.
What is Third Space Syndrome?
Fluid moves from the vascular space into an area that is inaccessible as extracellular fluid.
This causes an isotonic fluid volume deficit. Fluid may move to the bowel, peritoneal or pleural space or into the interstitial space as edema.
The patient may not have visible fluid loss and fluid may shift back into vascular compartment later causing fluid volume overload. Client’s weight will probably be unchanged.
What is Third Space Syndromes Clinical Manifestations
Postural hypotension
Weak pulse
Slow vein filling
Poor skin turgor
Dry skin and nails
Dry mucosa (xerostomia)
Confusion
Increased hematocrit
Assessing hydration status by evaluating skin turgor Elders
Pinch a fold of skin on the forehead or sternum to observe for ‘tenting’. Do not use skin on the hand as decreased elasticity of the skin on the hand is a normal finding in elderly clients and may not represent true dehydration.
Assessing hydration status by evaluating skin turgor-The young child
Pinch a fold of skin between the thumb and forefinger-tenting indicates fluid volume deficit.
Assessing orthostatic Blood Pressure
Lying
Sitting
Standing
Remember client safety; if the client is dizzy or weak get someone to help you support the client or defer this test.

Pause for 1-2 minutes between each reading and before initial reading.

A drop of 15-20 mm/Hg after position change from sitting or lying to standing indicates orthostatic hypotension and possibly hypovolemia or dehydration.

Tachycardia will also be noted when position is changed from supine to standing.
What happens in Hypervolemia?
Body retains both water and sodium so serum lab values remain normal

Manifests itself as edema and increase in fluid volume.

Condition is usually secondary to elevated sodium content in the body from:
excessive intake of sodium chloride
overuse of sodium containing IV fluids
chronic diseases like renal failure, cirrhosis of the liver, heart failure and Cushings syndrome
What are the clinical manifestations of Hypervolemia ??
Edema
Full bounding pulses
Moist breath sounds (crackles, rhonchi)
Distended neck veins
Moist skin
What is the physiological occurance in EDEMA???
Excess interstitial fluid
Seen most prominently in areas that are dependent and areas where tissue pressure is low (periorbital area).
Can be caused by:
increased capillary permeability due to tissue trauma
decreased tissue oncotic pressure
increased capillary hydrostatic pressure
Evaluating Edema
1+ barely detectible
2+ 2-4mm
3+ 5-7mm
4+ more than 7mm
What is the approximate volume of water for each kilogram (2.2 pounds)of weight gain a client experiences?
1L
What are IVs used for?
Used for faster replacement of fluid volume, administration of blood or Total Parenteral Nutrition (TPN)
Intravenous line can be inserted centrally or tunneled (central lines, infusion ports, PICC lines) or in the periphery (peripheral catheters, “saline locks”)
What are the Categories of Intravenous Therapy Solutions?
Hypotonic
Isotonic
Hypertonic
What is and what are the IV fluids that are Hypotonic?
Hypotonic
Osmolality less than that of body fluids Hypotonic IV Fluids:
0.45% Na Cl
0.33%NaCl
What are Isotonic IV fluids and what are they and what is their Job when adm???
Isotonic means that the IV fluid has
Osmolality the same as body fluidsIsotonic
0.9%NSS
Lactated Ringers
Stay in vascular compartment and expand vascular volume.
Hypertonic
Osmolality higher that that of body fluids
Hypertonic
Osmolality is higher that that of body fluids Hypertonic IV fluids are
5%Dextrose in 0.9%NaCl
5% Dextrose in 0.45% Na Cl
5% Dextrose in LR Their job in the body is to Draw fluid out of interstitial and intracellular compartments into vascular compartments which expands vascular volume.
What are Volume Expanders ??
Crystalloids
Think salt crystals normal saline, Lactated Ringers, and hypertonic saline

Colloids Colloids
pentastarch, albumin, hetastarch, gelatin, and dextran, blood
Think protein
What are Volume Expanders used for???
Used to increase blood volume severe loss of blood or trauma
What solutions are usually given through central venous access.
Whole blood, TPN, fat emulsions, 10% or higher Dextrose solutions and albumin are considered hypertonic solutions.
Potassium is very irritating to the veins and should be properly diluted and ...IV cath size....
preferably in a large bore IV catheter (18 or 20 gauge
Potassium should never be administered IV push TRUE OR FALSE
TRUE ; it can cause cardiac arrest!
Crystalloids
Are used primarily for fluid replacement and rehydration.

They are made of water with dissolved electrolytes.
They provide hydration, calories (Dextrose) and prevent body proteins from being used for energy.
Colloids
Colloids are primarily used for blood volume expansion, blood replacement.

Used illegally by athletes to ‘bulk up’.

Can cause rapid and severe fluid shifts if not used judiciously.

Examples are pentastarch, albumin, blood, hetastarch, gelatin, and dextran.
Avoiding Complications of Intravenous Therapy-
Understanding the ”why’s”
Choosing a site
Maintaining asepsis
Monitoring the client
Teaching the client

Nursing Responsibility
**The registered nurse is responsible for monitoring and documenting the start of a venous access device by ancillary staff and the condition of the infusion site***
Complications of Intravenous Therapy and thier S&S
Infiltration--blanching
Phlebitis--Streaking erythema
Fluid Volume Excess--
SOB, crackles, tachycardia
Bleeding at the site
Infection--Purulent drainage
Air embolism
Transfusion reactions
Chills, fever, itching, urticaria, back pain, tachypnea
Sample Nursing Diagnoses
Fluid Volume Deficient (hyper/ hypovolemia, isotonic)
Urinary elimination, impaired
Diarrhea
Nausea
Swallowing impaired
Mucous membrane impaired
Breathing pattern ineffective (hyperventilation)
Confusion, acute and chronic
Self care deficit, feeding
Risk for Aspiration
Knowledge deficit
client with severe dehydration is to receive a 1000-mL infusion of 0.9% normal saline at 150 mL/hr. The nurse expects which outcome?
A. Increased temperature
B. Increased heart rate
C. Increased respiratory rate
D. Increased blood pressure
D
In administering a hypertonic fluid to a client, the nurse recognizes that this will cause fluid to move from:
A. Intravascular space to interstitial space
B. Intravascular space to intracellular space
C. Interstitial space to intravascular space
D. Interstitial space to intracellular space
C
In assessing the dietary selections for client on a sodium-restricted diet, the nurse would be most concerned with which of the following selections?
A. 6-ounce chicken breast
B. 4-ounce lean steak
C. Baked potato with 2 teaspoons butter
D. 1 cup cottage cheese
D
In evaluating dietary choices of a client on a potassium-restricted diet, which dietary selection indicates the need for further teaching?
A. 2 slices whole wheat bread
B. 2 boiled eggs
C. ½ cup raisins
D. 1 cup oatmeal
C
In evaluating dietary teaching for a client with increased calcium needs, which statement by the client indicates that teaching was effective?
A. “Yogurt has more calcium than milk, and I like yogurt better.”
B. “Cottage cheese has more calcium than cheddar cheese.”
C. “Carrots have a lot of calcium for a vegetable.”
D. “I should avoid all fruits.”
A
In reviewing serum electrolytes on a newly admitted client, the nurse is most concerned with which of the following results?
A. Sodium = 146
B. Potassium = 5.9
C. Glucose = 97
D. Magnesium = 2.1
B
The nurse is caring for a client with excessive antidiuretic hormone secretion. Which of the following clinical manifestations is consistent with this disorder?
A. Increased urine output
B. Elevated urine specific gravity
C. Increased serum osmolarity
D. Elevated serum sodium
B
The nurse recognizes which of the following physical assessment findings most indicative of fluid overload?
A. Elevated temperature
B. Decreased respiratory rate
C. Increased pulse rate
D. Decreased blood pressure
c
Women and older adults have less total body water than do men and younger adults because:
A. Protein stores are greater in women.
B. Fat cells have very little water.
C. Urine output is greater in older adults.
D. Insensible fluid loss is greater in younger adults
b