NUR 2421 - MED SURG NCLEX-RN ATI COMPRHENSIVE REVIEW.

NCLEX-RN COMPREHENSIVE ATI REVIEW MED SURG: SECTION 1 FLUID & ELECTROLYTES Intravenous Fluids  Hypertonic  Higher osmolality than ECF  Use only when serum osmolality is critically low  D10W, D50W, D5NS, D5W in 0.45% NaCl, D5LR  Hypotonic  Lower osmolality than ECF  For intracellular dehydration  0.45% NS, 2.5% dextrose in 0.45% NS  Isotonic  Concentration equal to plasma  For deficit of fluid in vascular system  0.9% NS, LR, D5W Fluid Volume Deficit (FVD)  Causes: excess GI/renal loss, fever, diaphoresis, long term NPO, hemorrhage, insufficient intake, burns, diuretics, aging (older adults have less body water and decreased thirst)  S/S: weight loss, dry mucous membranes, rapid/weak/thready pulse, cap refill 3 seconds, weakness/fatigue, orthostatic hypotension, poor skin turgor, specific gravity 1.030, 30 ml/hr, increased RR  LATE SIGNS: oliguria, decreased CVP, flattened neck veins  Diagnosis: serum electrolytes, BUN, creatinine, Hct (may be high due to hemoconcentration), urine specific gravity and osmolality  Monitor vitals (pulse quality), I&Os (output at least 0.5 mL/kg/hr), skin turgor, weigh daily, fall precautions (RISK FOR FALL IS PRIORITY)  Correct cause with: Fluid replacement (oral or IV for severe); electrolyte replacement/IV fluids Fluid Volume Excess (FVE)  Causes: kidney failure, heart failure, cirrhosis, burns, hypertonic solutions, excessive water intake, long term corticosteroid therapy  S/S: cough, dyspnea, crackles, increased BP, tachycardia/tachypnea, bounding pulse, weight gain, JVD, increased CVP, pitting edema  Diagnosis: serum electrolytes, BUN, creatinine, Hct (may be low due to dilution), urine specific gravity and osmolality. Chest x-ray if respiratory complications present.  Monitor vitals (RR, symmetry, and effort), breath sounds for pulmonary edema  Monitor for edema: pitting edema scale 1+ (minimal) to 4+ (severe); dependent edema measured by circumference of extremities  Monitor for ascites (measure abdominal girth)  Weigh daily, admin diuretics, strict I&O (limit fluid intake), semi-fowlers, restrict sodium