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? ..............................................continued......................................