NUR2571 Module 2 FLUIDS & ELECTROLYTES ACID-BASE BALANCE

FLUIDS & ELECTROLYTES ACID-BASE BALANCE NUR2571 Module 2 FLUID BALANCES ► Fluid Volume Deficit & Fluid Volume Excess Comparison between the disorders What questions would you ask yourself (remember the Nursing process which will help strengthen your clinical judgment)? Fluid Volume deficit ► How does fluid loss/overload occur? ► How will your patient present with fluid loss/overload? Cardiac, respiratory, etc. ► What are your priority nursing interventions? Dehydration – Fluid Volume Deficit Assessment with clinical Planning and implementation manifesStuatbiojencs tive – fatigue, dizziness, weakness, thirst ► Objective –hypotension, orthostatic hypotension tachycardia, tachypnea, weak pulses, dry mucous membranes, oliguria, decreased skin turgor, flat veins ► Laboratory – serum osmolarity, urine specific gravity increased, BUN/Cr, sodium, elevated electrolytes ► Diagnostics – depends on underlying cause ► Monitor/Reassess – VS, I&O, evaluate the cause daily weight ► Do/Action – urine output needs to be at least 30mL/hr, fall precautions, encourage PO fluid intake, reposition slowly ► Give/Administer – IVF, colloids, crystalloids, electrolytes ► During an assessment of a newly admitted patient, the nurse notes that the client’s heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The patient’s spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? 1. Dehydration 2. Fluid Overload 3. Hypernatremia 4. Hypokalemia .........................................continued..................................................