Final Exam
Review
Promoting Health & Health Restoration of
Adults I
NUR 4226
, Fluid Volume Excess
(Hypervolemia)
• Causes: fluid overload or diminished homeostatic mechanisms, heart
failure, kidney injury, cirrhosis of liver, consumption of excessive amounts
of table salt or other sodium salts, excessive administration of sodium-
containing fluids with impaired regulatory mechanisms
• Clinical manifestations: acute weight gain, peripheral edema and
ascites, distended jugular veins (JVD), crackles, elevated CVP, shortness of
breath, ↑ BP, bounding pulse, cough, ↑ respiratory rate, ↑ urine output
• Nursing management: assess lung sounds, monitor for edema, I&O, daily
weights, administer diuretics, patient education regarding sodium and fluid
restriction, promote rest
, Fluid Volume Deficit
(Hypovolemia)
• Occurs when water and electrolytes are lost in the same proportion as th
exist in normal body fluids; therefore, the ratio of serum electrolytes to
water remains the same (loss of extracellular fluid exceeds intake of wat
• causes: diarrhea, vomiting, sweating, GI suctioning, decreased fluid
intake, burns, ascites, osmotic diuresis, hemorrhage
• Clinical manifestations: weight loss, decreased skin turgor, oliguria,
concentrated urine, capillary filling time prolonged, low CVP, ↓ BP,
flattened neck veins, dizziness, weakness, thirst and confusion, ↑ pulse,
muscle cramps, sunken eyes, nausea, increased temperature, and cool,
clammy, pale skin
, Hyperkalemia
• Serum potassium > 5.0 mEq/L
• Causes: impaired renal function, rapid administration of
potassium, hypoaldosteronism, medications, tissue trauma,
respiratory and metabolic acidosis
• Clinical Manifestations: muscle weakness, tachycardia →
bradycardia, dysrhythmias, flaccid paralysis, paresthesia,
intestinal colic, cramps, abdominal distention, irritability, anxiety.
• ECG: tall tented T waves, prolonged PR interval and QRS duration, absent
P waves, ST depression
Review
Promoting Health & Health Restoration of
Adults I
NUR 4226
, Fluid Volume Excess
(Hypervolemia)
• Causes: fluid overload or diminished homeostatic mechanisms, heart
failure, kidney injury, cirrhosis of liver, consumption of excessive amounts
of table salt or other sodium salts, excessive administration of sodium-
containing fluids with impaired regulatory mechanisms
• Clinical manifestations: acute weight gain, peripheral edema and
ascites, distended jugular veins (JVD), crackles, elevated CVP, shortness of
breath, ↑ BP, bounding pulse, cough, ↑ respiratory rate, ↑ urine output
• Nursing management: assess lung sounds, monitor for edema, I&O, daily
weights, administer diuretics, patient education regarding sodium and fluid
restriction, promote rest
, Fluid Volume Deficit
(Hypovolemia)
• Occurs when water and electrolytes are lost in the same proportion as th
exist in normal body fluids; therefore, the ratio of serum electrolytes to
water remains the same (loss of extracellular fluid exceeds intake of wat
• causes: diarrhea, vomiting, sweating, GI suctioning, decreased fluid
intake, burns, ascites, osmotic diuresis, hemorrhage
• Clinical manifestations: weight loss, decreased skin turgor, oliguria,
concentrated urine, capillary filling time prolonged, low CVP, ↓ BP,
flattened neck veins, dizziness, weakness, thirst and confusion, ↑ pulse,
muscle cramps, sunken eyes, nausea, increased temperature, and cool,
clammy, pale skin
, Hyperkalemia
• Serum potassium > 5.0 mEq/L
• Causes: impaired renal function, rapid administration of
potassium, hypoaldosteronism, medications, tissue trauma,
respiratory and metabolic acidosis
• Clinical Manifestations: muscle weakness, tachycardia →
bradycardia, dysrhythmias, flaccid paralysis, paresthesia,
intestinal colic, cramps, abdominal distention, irritability, anxiety.
• ECG: tall tented T waves, prolonged PR interval and QRS duration, absent
P waves, ST depression
