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107 Cards in this Set
- Front
- Back
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What does water content vary with? |
Age, sex, amount of adipose tissue
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What are the solutes in water in the body? |
Electrolytes - conduct a charge
Nonelectrolytes - glucose |
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What are the body fluid compartments? |
Intracellular - within cells |
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What are the body fluid functions?
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-Maintain body fluids
-regulating temperature -transporting materials to and from cells -assisting with food digestion -helps excrete waste |
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Osmosis |
-WATER molecules move from less concentrated area to most concentrated area |
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Diffusion |
-Movement of molecules/solvents through a semi-permeable membrane from an area of higher concentration to an area of lower concentration |
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Filtration |
Movement of water and smaller particles from area of high PRESSURE to an area of low pressure |
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Hydrostatic pressure |
force created by fluid within a closed system
normal circulation of blood |
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Osmotic Pressure |
- power of a solution to draw water - a highly concentrated solution draws water and has a high osmotic pressure |
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filtration pressure |
when hydrostatic pressure exceeds osmotic pressure and fluid leaves the vessels |
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Active transport |
movement of electrolytes (Na+, K+) against a concentration gradient through the use of ATP |
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Fluid Intake |
Women: 2700 mL/day Men: 3500 mL/day
20% from food/metabolism of food |
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Fluid intake regulated by |
thirst mechanism by a change in plasma osmolality and the hypothalamus |
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Fluid output |
Urine: 1500 mL/day Feces: 100-200 mL/day Skin: 300-500 mL/ay Lungs |
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Sensible losses |
measurable losses through urine, feces, skin |
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Insensible losses |
immeasuable losses through the lungs |
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Antidiuretic hormone (ADH) |
* When body osmolarity increases in bloodstream, it triggers osmoreceptors in hypothalamus that stimulates pituitary gland to release ADH. Increases permeability of distal tubules in kidneys and allows more REABSORPTION of water from kidney to bloodstream *Low fl vol = release of ADH = increased fluid retention in kidneys = more concentrated urine *high fl vol = no ADH release = more urine = less concentrated urine
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Renin-angiotensin system |
*When low blood flow to kidneys, triggers increased renin release *Promotes Na+ and H2O retension in kidneys |
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Aldosterone |
*Triggered by the release of renin *Promotes the reabsorption of Na+ and H2O *Excretes K+ and H+ ions |
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Thyroid Hormone |
*Influences fl vol by increasing cardiac output, increasing the flow of blood to the kidneys, and increasing urine output |
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Brain Naturetic factor Atrial naturetic System |
*Hormone released in heart in response to increase in blood volume, stretching arterial walls *Promotes Na+ wasting *acts as a diuretic *Inhibits thirst mechanism |
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What are the regulating electrolytes |
sodium potassium calcium magnesium chloride phosphate bicarbonate |
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Sodium |
*Recommended daily intake: 1500 mg *Should not consume > 5.8g/day *Major cation in ECF
135-145 mEq/L HEAD |
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Sodium Function |
*Regulates fl vol *Helps maintain blood volume *Stimulates conduction of nerve impulses |
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Sodium Regulation |
*Regulated by aldosterone and ADH levels *Reabsorbed and excreted through kidneys |
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Sodium Sources |
table sat, soy sauce, cured pork processed foods, canned products, preserved foods milk, cheese |
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Potassium |
*Major cation in the ICF *Recommended Daily Intake: 4.7g *No upper limit of consumption in healthy people
3.5-5 mEg/L HEART |
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Potassium function |
*Regulates conduction of cardiac rhythm *Assists with acid/base balance
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Potassium Regulation |
*Regulated by Aldosterone *Excreted and conserved through kidneys *Lost through vomitting/diarrhea |
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Potassium sources |
bananas, orages, apricots, figs, dates carrots, potatoes, tomatoes, spinach dairy products meat |
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Calcium |
*most abundant electrolyte in body *recommended daily intake varies by age: 210-1200 mg. 1000-1200 for adults
8.5-10.5 mg/dL NEUROMUSCULAR |
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Calcium function |
*Promotes transmission of nerve impulses *regulates muscle contractions *maintains cardiac automaticity
*Bone health; neuromuscular function |
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Calcium Regulation |
*Combines with phosphorus to form salts *Parathyroid hormone stimulates Ca2+ release from bones and reabsorption from kidneys/intestines *absorption stimulated by vitamin D |
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Calcium - Phosphorus relationship |
Inversely propotional:
As blood level of one increases, the other decreases |
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Calcium Sources |
milk, milk products dark green leaf vegetables salmon calcium fortified foods (breads, cereals) |
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Magnesium |
ICF; bone Has many cellular functions
Only 1% in blood
Low levels are rare except in alcoholics 1.6-2.6 mEq/L |
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Chloride |
Most abundant ECF anion; bound to other ions Assists in acid/base balance
95-105 mEq/L |
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Phosphate |
ICF Anion
Bound with calcium in teeth and bones |
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Bicarbonate |
ICF and ECF Acid-Base balance Regulated by kidneys to maintain acid/base balances Produced by the body to act as buffer
22-26 mEq/L |
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Buffer systems |
*Prevents excessive changes in pH b removing or releasing H+ *Major buffers in ECF are: ---carbonic acid: H2CO3 ---bicarbonate: HCO3 *major ICF buffer is the phosphate system *plasma proteins and hemoglobin also buffer |
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What are respiratory mechanisms |
*Eliminates or retains CO2 by altering rate/depth of respirations *The first responder in a shift of acid/base balance
*more breathing = releasing more CO2 |
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What are renal mechanisms |
*the major regulator of acid/base balance *slower to respond than resp. mechanimss *excretes or retains H2 or HCO3-
*When pH decreases, there is an increase in H+, resulting in acidosis. *Kidneys respond by reabsorbing/regenerating HCO3 and excreting H+ |
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pH ranges |
Normal: 7.35-7.45
Death: <6.9 >7.8
Acidosis: 6.9-7.34 Alkalosis: 7.46-7.8 |
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Fluid Volume Imbalance: Deficit |
loss of both fluids and electrolytes from the ECF |
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FVI: Deficit Causes |
Hypovolemia: loss of blood volume from surgery, trauma, or uterine rupture
Dehydration: loss of water from IC, EC, IV spaces. Electrolytes may also be lost. -due to lack of fluid intake, excessive fluid loss
At risk: older adults, infants, children |
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FVI Deficit S/S |
Skin Tenting Thirst Dry mucous membranes low BP, high HR Weight loss increased temperature decreased urine output |
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FVI Deficit Interventions |
push fluids, water based foods monitor vitals treat and monitor the factors causing FVD |
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Fluid Volume Imbalance: Excess |
excess retention of Na+ and water in ECF |
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FVI Excess causes |
excessive salt intake kidney and liver disease poor cardiac output |
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FVI Excess s/s |
Increased BP, bounding pulse Increased, shallow respirations neck vein distention edema pale and cool skin increased, diluted urine output rapid weight gain |
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FVI Excess Interventions |
Monitor I&O Observe for s/s related to FVE Administer diuretics as ordered Weigh daily Fluid and Na+ restrictions
monitor IV flow |
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Hyponatremia |
Na + <135 mEq/L Urine specific gravity < 1.010 |
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Hyponatremia causes |
Diuretics GI fluid loss (N/V diarrhea, GI suction) Adrenal insufficiency (kidney disease) Excess intake of hypotonic solutions (water) cirrhosis heart failure burns Inappropriate ADH (head injury, AIDS, tumors) |
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Hyponatremia S/S |
Personality Change Confusion anorexia, nausea, vomiting weakness lethargy muscle cramps/twitching
Seizures, coma |
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Hyponatremia Interventions |
Monitor I&O monitor Sodium levels Limit by mouth intake as ordered administer IV saline solutions encourage foods high in sodium |
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Hypernatremia |
Na+ > 145 mEq/L Urine Specific grvity > 1.030 |
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Hypernatremia Causes |
Excessive sodium intake water deprivation increased water losses (sweating) heat stroke diabetes insipidus diarrhea fever |
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Hypernatremia S/S |
Increased thirst Dry mouth, sticky mucous membranes elevated temperature swollen tongue
Severe: hallucinations, irritability, lethargy, seizures |
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Hypernatremia Interventions |
Monitor I&O Monitor sodium levels encourage fluids monitor vital signs and LOC restrict high sodium foods |
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Hypokalemia |
K+ < 3.5 mEq/L |
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Hypokalemia Causes |
Diuretics (K+ wasting) GI fluid loss through vomiting gastric suctioning diarrhea steroid administration hyperaldosteronism anorexia/bulimia |
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Hypokalemia S/S |
Dysrhythmia, flat T wave fatigue anorexia, nausea, vomiting muscle weakness, leg cramps decreased GI motility, abdominal distention increase sensitivity to digitalis hypotension |
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Hypokalemia Interventions |
*Monitor I&O, vital signs, K+ level *If taking digoxin, monitor apical pulse *Encourage intake of foods rich in potassium *administer potassium supplement |
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Hyperkalemia |
K+ > 5.0 mEq/L |
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Hyperkalemia causes |
Renal Failure K+ sparing diuretics hyperaldosteronism high K+ intake coupled w/ renal insufficiency excessive salt substitute intake acidosis *major trauma |
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Hyperkalemia s/s |
Dysrhythmias, tall T waves muscle weakness flaccid paralysis intestinal colic, cramps irritability, excitability *tachycardia and then bradycardia anxiety |
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Hyperkalemia Interventions |
Monitor HR/rhythm, I&O, K+ level Avoid foods high in K+ Monitor vital signs |
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Hypocalcemia |
Ca+ < 8.5 mEq/dL |
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Hypocalcemia Causes |
Hypoparathyroidism Malabsorption of Ca+ Pancreatitis Alkalosis Vitamin D Deficiency Renal Failure Alcohol Abuse (ETOH abuse) |
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Hypocalcemia S/S |
Numbness and tingling of extremities Muscle Tramps Positive Trousseau's and Chvostek's Signs tetany convulsions laryngeal spasms cardiac irritability |
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Trousseau's Signs |
Put a blood pressure cuff on and pump it up above systolic pressure flexion of wrist and hand constitutes a positive sign |
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Chvostek's signs |
tap front of ear extreme facial twitching constitutes a positive sign |
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Hypocalcemia Interventions |
Monitor I &O, ca+ Encourage increased Ca+ foods Administer Ca+ supplements, parenteral Ca+ IV If severe, monitor patency of airway, institute seizure and safety precautions |
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Hypercalcemia |
Ca+ > 10.5 mEq/dL |
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Hypercalcemia Causes |
Prolonged Immobilization hyperparathyroidism Malignant bone disease *excessive calcium supplementation (Tums) Thiazide diuretics |
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Hypercalcemia S/S |
Muscle Weakness Bizarre Behavior constipation Anorexia, nausea, and vomiting Polyuria, polydipsia (excessive thirst) Kidney Stones Bradycardia |
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Hypercalcemia Interventions |
Monitor I&O Encourage fl. intake to prevent stone formation Encourage fiber to prevent constipation Eliminate Ca+ supplements limit Ca+ rich foods Avoid Ca+ based antacids
Renal dialysis may be required |
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Acid |
Compound that contains H+ |
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Base |
Compound that accepts H+ |
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ABG PaCO2 ranges |
35-45 |
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ABG HCO3 ranges |
22-26 |
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Acidosis |
Serum pH below 7.35
Respiratory Cause: retention of CO2
Metabolic cause: loss of bicarbonate |
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Respiratory Acidosis |
pH < 7.35 CO2 > 45
Retention of CO2 in the respiratory system |
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Respiratory Acidosis Causes |
*Excess CO2 due to impaired gas exchange *Pneumonia *COPD *drug overdose *suppressed breathing |
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Resipratory Acidosis S/S |
*Drowsiness, dizziness, disorientation, confusion *hypoventilation, rapid shallow respirations * Decreased BP *Dyspnea *hyperkalemia -> heart dysrhythmias *muscle weakness
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Respiratory Acidosis Interventions |
*Provide Supplemental Oxygen *Maintain hydration *Provide pulmonary hygiene (coughing, deep breathing exercises, chest physiotherapy) *Institute measures to improve gas exchange: high fowlers position *Monitor ABGs |
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Metabolic Acidosis |
pH < 7.35 HCO3 < 22
When the body produces too much acid or the kidneys are not removing enough acid from the body |
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Metabolic Acidosis causes |
Diabetic Ketoacidosis Poorly managed diabetes severe diarrhea renal failure excessive intake of acids (aspirin) shock |
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Metabolic Acidosis S/S |
Headache, confusion, drowsiness decreased BP hyperkalemia muscle twitching nausea, vomiting, severe diarrhea Kussmaul breathing (deep, gasping, rapid) warm, flushed skin
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Metabolic Acidosis Interventions |
*Correct underlying cause of acid imbalance *Administering IV fl. (lactate solution) *Monitor ABG and serum K+ *Evaluate fl balance I & O
*Report significant values within 30 minutes |
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Alkalosis |
Serum pH > 7.45
Respiratory cause: blowing of CO2
Metabolic Cause: increase in bicarbonate |
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Respiratory Alkalosis |
ph > 7.45 CO2 < 35
Increased loss of CO2 from the lungs |
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Respiratory Alkalosis Causes |
*Hyperventilation due to anxiety * fever/sepsis *thyrotoxicosis *lesion in resp. center of brain *Excessive ventilation with mechanical ventilator |
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Respiratory Alkalosis S/S |
*Deep, rapid breathing (hyperventilation) *tachycardia *low or normal BP *Hypokalemia *numbness/tingling of extremities *lethargy/confusion, light headedness *nausea/vomitting *Seizures (late stage) |
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Respiratory Alkalosis Interventions |
*Treat underlying anxiety *teach deep slow breathing *Rebreathing into a paper bag *Monitor vital signs and I&O |
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Metabolic Alkalosis |
pH > 7.45 HCO3 > 26
a metabolic disturbance alters bicarbonate portion of the buffering system |
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Metabolic Alkalosis causes |
*excessive acid loss due to vomiting/gastric suction *use of K+ wasting diuretics *hypokalemia *Excessive bicarbonate intake (tums) *hypoaldosteronism |
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Metabolic Alkalosis S/S |
*nausea, vomiting, dizziness *anxiety *tingling of extremities *hypertonic muscles - tetany *decreased respiratory rate/depth |
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Metabolic Alkalosis Interventions |
*Administration of NaCl-rich foods *Correct underlying problem *monitor I&O |
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NANDA Nursing Dx |
*Deficient Fluid Volume: dehydration FVD, isotonic loss *Excess Fluid Volume: overhydration, FVE, isotonic gain, increased fl. vol. retention *Risk for Imbalanced fluid Volume (potential) *Risk for Deficient Fluid Volume (potential) *Impaired Gas Exchange: alteration in O2 &/or CO2 retention/elimination |
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Fluid and Acid-Base Imbalance etiologies |
*Impaired oral mucous membrane *Impared skin integrity *Decreased Cardiac Output *Ineffective Tissue Perfusion *Activity Intolerance *Risk for Injury *Acute Confusion |
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Planning goals in general terms |
*Maintain or restore normal fl. balance *Maintain or restore normal balance of electrolytes *Maintain or restore gas exchange and oxygenation *Prevent associated risks (tissue breakdown, decreased cardiac output, confusion, other neurologic signs) |
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Promoting Fl. and Electrolyte Balance |
*Consume at least 8-10 glasses of water daily *Avoid foods w/ excess salt, sugar, caffeine *Eat a well-balanced diet *Limit alcohol intake *Increase fl intake before, during & after exercise *Replace lost electrolytes *maintain normal body weight *Learn about, monitor, manage med side effects *Recognize risk factors |
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Facilitating Fluid Intake |
*Explain reason for required intake and amount needed *Establish 24 plan for ingesting fluids *Set short term goals *Identify fl pt likes and use those *help pt select foods that become liquid at room temperature *Supply cups, glasses, straws *Sever liquids at proper temperature *Encourage participation in recording intake *Be alert to cultural implications |
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Restricting Fluid Intake |
*Explain reason and amount of restriction *Help pt establish ingestion schedule *Identify preferences and obtain *Set short term goals, place fluids in small containers *Offer Ice chips and mouth care *Teach avoidance of ingesting chewy, salty, sweet foods or fluids *Encourage participation in recording intake |
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each kilogram of weight is equivalent to how much fluid? |
1000 mL |
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What is the most accurate method of assessing fluid status? |
Daily Weights |
