Med Surg Exam 2 Notes|Galen College of Nursing - NUR 242 MS Exam 2

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Fluid + Electrolytes-Acid Base Dehydration= FVD; Hypovolemia Fluid intake/retention does not meet body’s fluid needs; results in fluid volume deficit o Lack of fluid intake or excess fluid loss ... o Alteration in the fluid balance regulators:  Thirst  Hormones  Lymphatic system  Kidneys o Common causes of dehydration:  Vomiting  Diarrhea o Clinical manifestations:  Peripheral pulses cold and clammy extremities  Weak and tready  Dry mucous membrane  Abnormal lab values Interventions Push fluids without IV Daily morning weights Monitoring input and output every 24 hours Monitor for falls Braden scale (skin problems) Fluid Overload: FVE- Hypervolemia (ThirdSpacing) Can develop from administration of too much or a failure to excrete fluids and usually results in an elevated sodium level o Failure to excrete fluids  Renal failure  Edema as with heart failure  Excess of body fluid=” everything is watered down”  “Over hydration”  Hypervolemia- excess fluids in vascular system  Third-spacing- excess fluids in interstitial spaces, water intoxication  Water intoxication-excess fluids in the cells o Peripheral vascular resistance increases too, which can lead to pulmonary edema and heart failure. o Nursing interventions: assess lungs sounds at least every two hours Labs BUN will be low (diluted) Hematocrit will be low (diluted) Sodium will be low (diluted)  Respiratory + cardiovascular  Crackles, pallor  Elevated blood pressure  Moist mucous membrane  Shallow, rapid respirations  Peripheral edema (pitting)  Weight gain  JVD Interventions for Excess Fluids Volume /FVE  Reduce sodium + fluid intake  Mobilize fluids  Turning, positioning  Prevent complications  Elevate head of bed (HOB) 30 degrees  Monitor lab values  Provide skin care  Modification for older adult patients  Teach  Low-sodium diet  Use of alternative seasonings  Avoid mixing, ACE inhibitors - K+ salt substitutes  Fluid restrictions  Daily weights [Show More]

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