Jenna Cohen Exam 1 Study Guide Med Surg Fluid and Electrolyte Review System Specific Physiology FLUID VOLUME DEFICIT Increased sodium intake and high sodium levels Increased aldosterone secretion Heart Failure Renal Failure Cirrhosis Decreased albumin levels Syndrome of Inappropriate Antidiuretic Hormone SIADH Primary causes of fluid volume excess Heart failure the heart is not able to pump blood around the body in an effective manner so fluid builds up in interstitial spaces like the lungs that you need to deal with How do we know when a patient has this problem Recognize when you re working with that patient in the bed what are you looking for how do you know they have this specific issue signs and symptoms they will display Labs and Diagnostic Procedures of FVE Decreased Values o Decreased Hct o Decreased Serum Osmolality o Decreased Serum Sodium Na o Decreased BUN FVE Signs and Symptoms be diluted since there is extra volume on board sodium level could be fine though but with all the fluid it will look really low The serum sodium will be low because it will will be on a wide variety of places typically distal dependent will be elevated because more fluid around Increased pulse Increased BP bc more blood volume in the blood stream so it s putting extra pressure on the vascular Increased edema edema in the feet and ankles depending on how severe it could move up the legs and abdomen can be in sacral area if lying supine Increased ascites Increased crackles in lungs when working with FVE we talk about this as a filling process from the bottom up so when we look at the lungs we will most likely hear the crackles in the base of the lungs there are 2 lobes on the right side 3 on the left listen in those lower lobes when you get those crackles you have to do something ASAP like give Lasix diuretic it will help pull fluid down then in 2 hours you will listen to the lung sounds and expect to hear clear lung sounds Increased JVD Increased confusion headache seizures to these problems jugular neck vein distension bc lots of fluids due to hyponatremia low sodium will lead First Nursing Actions Reduce IV flow rates if they do have these full lungs edema etc go over IV pump and let s say they have NS and the rate is at 200 you would want to slow down the NS hr a nurse has the right to slow down an IV temporarily report to the doctor and he ll follow up Evaluate breath sounds using a pulse ox and ABG s Semi Fowler s position Treat with oxygen and diuretics as ordered Reduce fluid and sodium intake comfort foods I O and weight monitoring Circulation color and presence of edema Low fowlers 30 High fowlers 90 Semi fowlers 40 high sodium foods processed foods fried foods stretched from edema they re at risk for skin breakdown be very careful lotion pillows etc if you have extra fluid and the skin is so Turn and position at least every 2 hours Expected Findings Increased Pulse Increased BP Increased Weight Increased Edema Increased Ascites Increased Crackles in the lungs Increased Dyspnea Increased Confusion Labs Decreased Hct Decreased Serum Osmolality Decreased Serum Sodium Na Decreased BUN Teaching Moment Which clinical finding indicates the client is experiencing potential fluid volume excess A BP change from 108 78 to 140 90 B Decreased crackles in lower lung fields C Pulse increased from 72 min to 80 min D Weight from 150 lbs to 151 lbs What is the expected outcome after administration of IV furosemide Lasix for a client who has fluid volume excess A BP change from 108 78 to 140 90 B Pulse change from 72 min to 108 min C Decreased crackles in lower lung fields D Weight from 142 lbs to 150 lbs System Specific Physiology FLUID VOLUME DEFICIT Not uncommon between reatments to have Causes Most Common Loss of fluids from anywhere Vomiting Diarrhea hemorrhage vomiting of fluid Procedures such as thoracentesis and paracentesis Some procedures may pull off a lot Medical problems such as Diabetes insipidus Third Spacing when fluid moves out of the vascular passes into other areas fluids move into areas that don t help our vascular system and it creates problems for the patient When people start new medications it can upset their stomach most people are getting abx because they re already sick so they don t want to take in any extra fluids What the Nurse will Look for to Confirm FVD very common Decrease in weight Decreased skin turgor tenting Dry mucous membranes Decreased urine output Decrease in blood pressure may have dizziness or orthostatic hypotension Decreased in warmth to extremities Temperature will increase Decreased fluid to pump so the pulse rate is elevated Decreased strength in pulse weak thread dry tongue cracked lips less than 30 cc hr the urine would look yellow dark amber very difficult to find one on these patients Pulse rate will increase Check labs before they go into the room RR might be increased Decreased fluid so HR will be elevated Lab and Diagnostic Procedures FVD expected increased values Increased Hct more than 3x Hgb BUN 20 Specific Gravity 1 030 Osmolality 295 mOsm kg water Serum Na 145 mEq L of the lack of fluid First Priority Nursing Interventions Sodium level is the water leading to it being a false high bc Fluids All types PO Isotonic IV Fluids Blood Levels of consciousness Look at weights Urine less then 30 mL hr needs to be reported and outputs need to be trended Document vital signs and watch for trends of hypotension weak pulses IV fluids as ordered monitor I O May have problems with orthostatic hypotension want to return blood back to the heart by raising the foot of the bed takes the stress off the knees good to put 3 pillows underneath Shock position skin Check skin because if you have really poor turgor you re at risk for breakdown Patient population that could not handle a lot of fluids Dialysis patients chronic renal Older people because their systems are slowing down so they might not be able to handle fluids at a higher rate like others Monitoring weight to help determine fluid volume status Look at color and character of the urine to see if it s changing from the dark amber to the clear urine color that you want to see If we had dry mucous membranes we could perform oral care by getting Vaseline lip product help them out sometimes patients are dry because they are on fluid restrictions or NPO so we can ask if they can have ice chips to help maintain that oral mucosa also lemon glycerol sponges Initial Assessment Findings for FVD Decrease in weight