Hydration

Question 1

fluid refers to what?

Answer 1

• water and electrolytes
• approximately 60% of body weight in adults

Question 2

water serves as

Answer 2

• MEDIUM FOR METABOLIC REACTIONS
• TRANSPORT VEHICLE
• LUBRICANT
• INSULATOR & SHOCK ABSORBER
• TEMPERATURE REGULATOR –> why we sweat

Question 3

most of the water in our body is what?

Answer 3

• intracellular fluid

Question 4

overview: intracellular

Answer 4

• 2/3 TO 3⁄4 OF BODY’S TOTAL FLUID
  
  • SKELETAL MUSCLES
  • 40% OF BODY WEIGHT IN ADULT
  • PRINCIPLE CATION K+
  • PRINCIPLE ANIONS—PO4- & SO4-
• ppl w/ a lot of muscles has higher water content

Question 5

overview: extracellular

Answer 5

• PRINCIPLE CATION NA+/ ANION CL-
• INTERSTITIAL
  
  • FILLS SPACES BETWEEN CELLS
  • 15% OF BODY WEIGHT IN ADULT
• INTRAVASCULAR
  
  • BLOOD & LYMPH
  • 5 % OF BODY WEIGHT

Question 6

24 hr I&O is what?

Answer 6

• approximately equal
• impossible to measure everything

Question 7

routes of gains

Answer 7

• ORAL—ADULT NEEDS 2500 ML/ DAY –> most get 1500 ML/day
• ENTERAL –> thru the gut –> what you’re taking orally
• PARENTERAL –> beside the gut –> IV fluids, total parental nutrition

Question 8

Routes of Losses

Answer 8

• KIDNEYS—1-2 L/DAY FOR ADULT, 30 ML/HOUR
  MINIMUM (how to know if they have adequate intake and output)
• LUNGS—300-400 ML/ DAY (droplets when you’re talking, when you can see ur breath)
• SKIN (sensible (seeing someone sweat) and insensible (losing moisture on skin when its cold))
• GI TRACT—100-200 ML/DAY (more if you have diarrhea)

Question 9

aldosterone

Answer 9

• major influence
• adrenal cortex
• kidneys excrete K+
• secretes potassium and reabsorbs sodium
• regulates sodium and potassium in kidney tubules

Question 10

kidneys

Answer 10

• REGULATE ECF VOLUME & OSMOLALITY
• REGULATE ELECTROLYTE LEVELS IN ECF
• REGULATE PH OF ECF

Question 11

lungs

Answer 11

• regulate H+ concentration

Question 12

Factors that Affect Fluid & Electrolyte Balance: age

Answer 12

1. Infants– proportion of total body water (70-80%) greater than adults, more vulnerable to loss
2. Adults—women less fluid volume than men due to differences in muscle mass
   
   • Pregnancy–48% plasma volume increase; even greater w/ multiples
3. Older adult
   
   • approx 6% reduction in TBW–due to loss of muscle mass; decrease ratio of ICF to ECF
   • decrease renal function and inability to concentrate urine
   • decreased aldosterone
   • decreased sensation of thirst; decreased volume of saliva

Question 13

Factors that Affect Fluid & Electrolyte Balance: climate

Answer 13

High heat and low humidity increase loss through perspiration

Question 14

Factors that Affect Fluid & Electrolyte Balance: diet

Answer 14

1. Adequate intake of fluid, salt, K+, Ca++, Mg++, carbohydrates, fats & proteins maintains balance
2. Protein depletion–> hypoalbuminemia –> edema

Question 15

Factors that Affect Fluid & Electrolyte Balance: stress

Answer 15

• increase aldosterone & glucocorticoid production –> water retention

Question 16

Factors that Affect Fluid & Electrolyte Balance: exercise

Answer 16

• increase sensible water loss & electrolyte loss

Question 17

Factors that Affect Fluid & Electrolyte Balance: illness

Answer 17

1. Surgery–> stress response, increase fluid retention
2. Burns–loss of skin leads to increase fluid loss
3. CV disorders– decrease CO leads to decrease kidney perfusion–> circulatory overload
4. Respiratory disorders–increase risk of respiratory acidosis
5. Renal disease
6. Cancer–> increase risk of Ca++ disturbances with bone destruction
7. Head injury–> alteration in ADH secretion
8. GI disturbances–loss of fluid, K+, H+, Cl-
9. Diabetes–poorly controlled leads to increase fluid loss in order to clear glucose through kidney
10. Fever leads to insensible water loss

Question 18

Factors that Affect Fluid & Electrolyte Balance: medications

Answer 18

1. Diuretics–Loss of water & Δ K+
2. Laxatives–fluid loss
3. Corticosteroids–Na+ & fluid retention

Question 19

Factors that Affect Fluid & Electrolyte Balance: medical treatments

Answer 19

• GI suctioning increase H+ and K+ losses

Question 20

Factors that Affect Fluid & Electrolyte Balance: body composition

Answer 20

• differs
• more water = more muscles

Question 21

nursing history

Answer 21

• FOOD & FLUID INTAKE
• FLUID OUTPUT
• SIGNS OF FLUID IMBALANCES
• DECREASE
  
  • THIRST, DRY SKIN & MM, decrease URINE
    OUTPUT
• INCREASE
  
  • SWOLLEN ANKLES, WEIGHT GAIN, SOB
• DISEASE PROCESSES—KIDNEY, HEART, LIVER
• MEDICATIONS

Question 22

physical examination

Answer 22

• SKIN TURGOR
  
  • FONTANELS: soft spot on babies head. sunken if dehydrated
  • TONGUE TURGOR: should have one line running down the middle. dehydrated = have cracks and furoughs
• MOISTURE IN ORAL CAVITY
• FACIAL APPEARANCE
• EDEMA: too much fluid. press finger and there would be an indentation
• HAND & NECK VEINS: will stand out if they have too much fluid
• NEUROMUSCULAR IRRITABILITY
• MENTAL STATUS: confusion is a sign of fluid volume excess and dehydration
• LUNG SOUNDS: crackles in lungs. too much fluid. going into places it shouldn’t be

Question 23

5 signs of dehydration

Answer 23

1. dry, chapped lips
2. headaches
3. dry skin
4. achy joints
5. fatigue

Question 24

daily weights

Answer 24

• best measurement for fluid volume excess
• 1 liter of fluid = 1KG = 2.2 lbs
• weigh them everyday at the same time in the same clothing

Question 25

vital signs

Answer 25

* FLUID DEFICIT (not enough fluid moving around)-TACHYCARDIA, WEAK PULSE, decrease BP * FLUID EXCESS (too much fluid)—FULL BOUNDING PULSE, increase BP

Question 26

intake & output

Answer 26

* MEASURE ANYTHING THAT IS LIQUID * 1 CUP = 8 OUNCES - 1 OUNCE = 30 ML

Question 27

Lab Studies

Answer 27

* H&H --> increase hematocrit indicates dehydration * SERUM ELECTROLYTES --> normal potassium levels (3.5-5). sodium: 135-145 * PROTEIN LEVELS * ABG - increased albumin levels = not enough fluid --> dehydration

Question 28

HYPOVOLEMIA (DEFICIENT FLUID VOLUME NANDA)

Answer 28

* DECREASED INTRAVASCULAR, INTERSTITIAL AND/ OR INTRACELLULAR FLUID. THIS REFERS TO DEHYDRATION, WATER LOSS ALONE WITHOUT CHANGE IN SODIUM * PATIENT MUST NOT BE NPO FOR THIS TO BE A NURSING DIAGNOSIS

Question 29

HYPERVOLEMIA (EXCESS FLUID VOLUME NANDA)

Answer 29

* INCREASED ISOTONIC FLUID RETENTION * FLUID & NA RETAINED IN ISOTONIC PROPORTIONS (WHEN NA ↑ AND FLUID ↓= DFV)

Question 30

IMPAIRED ORAL MUCOUS MEMBRANES

Answer 30

* DISRUPTIONS OF THE LIPS AND/ OR SOFT TISSUE OF THE ORAL CAVITY * ELECTROLYTE DISTURBANCES - if it's dry it's not impaired, it's at risk for impairment

Question 31

projected outcomes

Answer 31

- INTAKE AT LEAST ______ML * NA+ 135-145 * MOIST MM * GOOD (too vague) SKIN TURGOR --> need to be specific --> will return to normal w/in 3 seconds * WEIGHT WITHIN NORMAL LIMITS FOR THE INDIVIDUAL --> what have they previously weighed

Question 32

NOC: fluid balance

Answer 32

* 24 HOUR INTAKE AND OUTPUT STABLE * ADVENTITIOUS BREATH SOUNDS NOT PRESENT * BODY WEIGHT STABLE * NECK VEIN DISTENTION NOT PRESENT

Question 33

interventions

Answer 33

* MONITOR I&O --> do not need an order from a doctor to do this * DAILY WEIGHTS— BEST MEASUREMENT * MANAGE ORAL FLUIDS * FF= FORCE FLUIDS (find out what they like to drink) * RESTRICT FLUIDS * ICE CHIPS ONE-HALF OF FROZEN VOLUME * DIET MODIFICATION—K+, NA+ * PATIENT TEACHING

Question 34

interventions: types of IV fluids

Answer 34

* ISOTONIC—EXPAND VASCULAR VOLUME * NS, D5W, LR * HYPOTONIC—SHIFT FLUID INTO CELLS * 1⁄2 NS, 2.5% DEXTROSE * HYPERTONIC—DRAW FLUID FROM CELLS * D5/.45NS, D5/NS, D5/LR * BLOOD PRODUCTS--ALBUMIN

Question 35

interventions: maintaining IV infusions

Answer 35

* STERILE PROCEDURE * CHANGING TUBING * FLUID RATE—ORDERED BY MD * FOR ADULT TYPICALLY 75-100 ML/ HOUR * KVO—SLOW RATE DEFINED BY INSTITUTIONAL POLICY— AROUND 30 ML/ HOUR * BOLUS RATE—LARGE AMOUNT INFUSED OVER 15-30 MINUTES. OFTEN 250 ML IN ADULT PATIENT

Question 36

NIC

Answer 36

* FLUID MANAGEMENT * FLUID MONITORING * HYPOVOLEMIA MANAGEMENT

Question 37

evaluation

Answer 37

* I= O= * NA+= * SKIN TURGOR_______ * MUCUS MEMBRANES MOIST______ * WEIGHT=

Question 38

WHEN WEIGHING THE CLIENT WITH A NURSING DIAGNOSIS OF FLUID VOLUME EXCESS, THE NURSE SHOULD WEIGH THE CLIENT

Answer 38

A. TWO HOURS AFTER A MEAL B. AT BEDTIME (A and B are influenced by what pt eats) C. ON THE SAME SCALE EACH DAY (correct) D. WITHOUT CLOTHING

Question 39

WHICH OF FOLLOWING IS A CORRECTLY STATED NURSING DIAGNOSIS FOR THE CLIENT WITH AN ALTERATION IN FLUID & ELECTROLYTE STATUS?

Answer 39

A. DEFICIENT FLUID VOLUME R/T NPO STATUS (nothing I can do to improve this bc they are NPO) B. EXCESS FLUID VOLUME R/T HEART FAILURE (can't unfail a heart) C. DEFICIENT FLUID VOLUME R/T DIFFICULTY SWALLOWING (correct) D. EXCESS FLUID VOLUME R/T PHYSICIAN ORDERING TOO MANY IV FLUIDS.

Question 40

AN ELDERLY NURSING HOME RESIDENT HAS REFUSED TO EAT OR DRINK FOR SEVERAL DAYS AND IS ADMITTED TO THE HOSPITAL. THE NURSE SHOULD EXPECT TO FIND WHICH OF THE FOLLOWING (fluid deficit)

Answer 40

A. INCREASED BLOOD PRESSURE (would decrease) B. WEAK, RAPID PULSE (correct) C. MOIST MUCOUS MEMBRANES (would be dry) D. JUGULAR VEIN DISTENTION

Question 41

A MAN BRINGS HIS ELDERLY WIFE TO THE EMERGENCY DEPARTMENT. HE STATES THAT SHE HAS BEEN VOMITING AND HAS HAD DIARRHEA FOR THE PAST 2 DAYS. SHE APPEARS LETHARGIC AND IS COMPLAINING OF LEG CRAMPS. WHAT SHOULD THE NURSE PLAN TO DO FIRST?

Answer 41

A. START AN IV OF NORMAL SALINE B. OBTAIN BLOOD FOR SERUM ELECTROLYTES (correct) C. OFFER THE WOMAN FOODS HIGH IN SODIUM & POTASSIUM D. ADMINISTER A MEDICATION TO STOP VOMITING

Question 42

* YOU ARE RECORDING I&O FOR CLIENT AT 3 PM. THEY WERE NPO FOR BREAKFAST. AT LUNCH THEY HAD 1⁄2 CUP OF JELLO, A BOWL OF SOUP (6 OUNCES) & A CAN OF SODA (12 OUNCES). THEY DRANK 1 CUP OF WATER AFTER LUNCH. THEY HAD 800 ML OF IV FLUIDS. WHAT WAS HIS INTAKE ON YOUR SHIFT?

Answer 42

- 4 oz jello + 6 oz soup + 12 oz soda + 8 oz water = 30 oz - 30 oz times 30 ml/oz = 900 ml - 900 ml + 800 ml = 1700 ML