Exam 1 NR 324 Adult Health 1
Questions And Answers
What age group has the highest percentage of water content?
Preterm / Neonates
Two fluid compartments in the body
Intracellular space (inside cells) located in the ICF
Extracellular space (outside cells) located in the ECF
ICF makes up what percent of total body weight?
40%
What are the two main compartments containing ECF? What other compartments
are there?
Interstitial fluid (fluid in the spaces between cells)
Intravascular fluid (plasma)
Other compartments include lymph and transcellular fluids
Transcellular fluid includes
Cerebrospinal fluid, fluid in the gastrointestinal tract, and joint spaces as well as pleural,
peritoneal, intraocular, and pericardial fluid.
1L of water = _____ lb.
2.2 lb (1kg)
The concentrations of electrolytes in body fluids is expressed in _________
milliequivalents (mEq) per Liter
What are the main Ions found in the ECF and ICF
ECF cation- sodium, with small amounts of potassium, calcium, and magnesium
ECF anion- chloride, with small amounts of bicarbonate, sulfate, and phosphate anions.
ICF cation- potassium, with small amounts of magnesium and sodium
ICF anion- phosphate, with some protein and a small amount of bicarbonate.
,Hypovolemia (ECF volume deficit)
abnormal loss of normal body fluids, (D/V, hemorrhage, polyuria) inadequate intake, or
plasma-to-interstitial fluid shift
Fluid volume deficit
Assessment- Causes-Treatment-Client education
Assessment- Restlessness, drowsiness, lethargy, confusion
• Thirst, dry mucous membranes
• Cold clammy skin
• Decreased skin turgor, ↓ capillary refill
• Postural hypotension, ↑ pulse, ↓ CVP
• ↓ Urine output, concentrated urine
• ↑ Respiratory rate
• Weakness, dizziness
• Weight loss
• Seizures, coma
Causes- • ↑ Insensible water loss or perspiration (high fever, heatstroke)
• Diabetes insipidus
• Osmotic diuresis
• Hemorrhage
• GI losses: vomiting, NG suction, diarrhea, fistula drainage
• Overuse of diuretics
• Inadequate fluid intake
• Third-space fluid shifts: burns, pancreatitis
Treatment- replace water and electrolytes with balanced IV solutions
Client education- Good skin care, if orthostatic hypotension is present, teach to
change positions slowly, remind patient to drink
Hypervolemia (ECF volume excess)
Excessive intake of fluids, abnormal retention of fluids (HF or renal failure), or
interstitial-to-plasma fluid shift
Fluid volume excess
Assessment- Causes-Treatment-Client education
,Assessment- • Headache, confusion, lethargy
• Peripheral edema
• Jugular venous distention
• S3 heart sound
• Bounding pulse, ↑ BP, ↑ CVP
• Polyuria (with normal renal function)
• Dyspnea, crackles, pulmonary edema
• Muscle spasms
• Weight gain
• Seizures, coma
Causes- • Excessive isotonic or hypotonic IV fluids
• Heart failure
• Renal failure
• Primary polydipsia
• SIADH
• Cushing syndrome
• Long-term use of corticosteroids
Treatment-Remove fluid without changing electrolyte composition or osmolality of ECF
Client education- elevate edematous extremities
Nutrition related to potassium
Diet is the source
-Fruit, dried fruits and vegetables
-Many salt substitutes contain substantial K+
Nutrition related to sodium
-Daily intake far exceeds bodys daily requirments
-Glucose promotes sodium and water absorption
Hypertonic solutions
initially raises the osmolality of ECF and expands it
-higher osmotic pressure draws water out of the cells into the ECF
-Useful in treatment of hyponatremia and trauma patients with head injuries
Isotonic solutions
, has a similar concentration of water and electrolytes to plasma, with an osmolality of
250 to 375 mOsm/L
-administering an isotonic solution expands only ECF and the fluid does not move into
cells
-the ideal fluid replacement for patients with ECF volume deficits
Hypotonic solutions
solution has more water than electrolytes, with an osmolality of less than 250 mOsm/kg.
-Infusing a hypotonic solution dilutes ECf
-good for treating patients with hypernatremia
As a nurse it is important to remember what administration guidelines when
administering IV KCL?
• IV KCl must always be diluted and never given in concentrated amounts.
• Never give KCl via IV push or as a bolus.
• Invert IV bags containing KCl several times to ensure even distribution in the bag.
• Do not add KCl to a hanging IV bag to prevent giving a bolus dose.
Hypernatremia
Occurs when either too much water is lost or not enough water intake, or too much salt
is taken in
What S/S should the nurse look for when a patient is experiencing hypernatremia
with decreased, normal and increased ECF volume?
Hypernatremia with decreased ECF volume: • Restlessness, agitation, lethargy,
seizures, coma
• Intense thirst, dry swollen tongue, sticky mucous membranes
• Postural hypotension, ↓ CVP, weight loss, ↑ pulse
• Weakness, muscle cramps
Hypernatremia with normal or increased ECF volume: • Restlessness, agitation,
twitching, seizures, coma
• Intense thirst, flushed skin
• Weight gain, peripheral and pulmonary edema, ↑ BP, ↑ CVP
Sodium plays a key role in the body by...
Transmitting nerve impulses
Questions And Answers
What age group has the highest percentage of water content?
Preterm / Neonates
Two fluid compartments in the body
Intracellular space (inside cells) located in the ICF
Extracellular space (outside cells) located in the ECF
ICF makes up what percent of total body weight?
40%
What are the two main compartments containing ECF? What other compartments
are there?
Interstitial fluid (fluid in the spaces between cells)
Intravascular fluid (plasma)
Other compartments include lymph and transcellular fluids
Transcellular fluid includes
Cerebrospinal fluid, fluid in the gastrointestinal tract, and joint spaces as well as pleural,
peritoneal, intraocular, and pericardial fluid.
1L of water = _____ lb.
2.2 lb (1kg)
The concentrations of electrolytes in body fluids is expressed in _________
milliequivalents (mEq) per Liter
What are the main Ions found in the ECF and ICF
ECF cation- sodium, with small amounts of potassium, calcium, and magnesium
ECF anion- chloride, with small amounts of bicarbonate, sulfate, and phosphate anions.
ICF cation- potassium, with small amounts of magnesium and sodium
ICF anion- phosphate, with some protein and a small amount of bicarbonate.
,Hypovolemia (ECF volume deficit)
abnormal loss of normal body fluids, (D/V, hemorrhage, polyuria) inadequate intake, or
plasma-to-interstitial fluid shift
Fluid volume deficit
Assessment- Causes-Treatment-Client education
Assessment- Restlessness, drowsiness, lethargy, confusion
• Thirst, dry mucous membranes
• Cold clammy skin
• Decreased skin turgor, ↓ capillary refill
• Postural hypotension, ↑ pulse, ↓ CVP
• ↓ Urine output, concentrated urine
• ↑ Respiratory rate
• Weakness, dizziness
• Weight loss
• Seizures, coma
Causes- • ↑ Insensible water loss or perspiration (high fever, heatstroke)
• Diabetes insipidus
• Osmotic diuresis
• Hemorrhage
• GI losses: vomiting, NG suction, diarrhea, fistula drainage
• Overuse of diuretics
• Inadequate fluid intake
• Third-space fluid shifts: burns, pancreatitis
Treatment- replace water and electrolytes with balanced IV solutions
Client education- Good skin care, if orthostatic hypotension is present, teach to
change positions slowly, remind patient to drink
Hypervolemia (ECF volume excess)
Excessive intake of fluids, abnormal retention of fluids (HF or renal failure), or
interstitial-to-plasma fluid shift
Fluid volume excess
Assessment- Causes-Treatment-Client education
,Assessment- • Headache, confusion, lethargy
• Peripheral edema
• Jugular venous distention
• S3 heart sound
• Bounding pulse, ↑ BP, ↑ CVP
• Polyuria (with normal renal function)
• Dyspnea, crackles, pulmonary edema
• Muscle spasms
• Weight gain
• Seizures, coma
Causes- • Excessive isotonic or hypotonic IV fluids
• Heart failure
• Renal failure
• Primary polydipsia
• SIADH
• Cushing syndrome
• Long-term use of corticosteroids
Treatment-Remove fluid without changing electrolyte composition or osmolality of ECF
Client education- elevate edematous extremities
Nutrition related to potassium
Diet is the source
-Fruit, dried fruits and vegetables
-Many salt substitutes contain substantial K+
Nutrition related to sodium
-Daily intake far exceeds bodys daily requirments
-Glucose promotes sodium and water absorption
Hypertonic solutions
initially raises the osmolality of ECF and expands it
-higher osmotic pressure draws water out of the cells into the ECF
-Useful in treatment of hyponatremia and trauma patients with head injuries
Isotonic solutions
, has a similar concentration of water and electrolytes to plasma, with an osmolality of
250 to 375 mOsm/L
-administering an isotonic solution expands only ECF and the fluid does not move into
cells
-the ideal fluid replacement for patients with ECF volume deficits
Hypotonic solutions
solution has more water than electrolytes, with an osmolality of less than 250 mOsm/kg.
-Infusing a hypotonic solution dilutes ECf
-good for treating patients with hypernatremia
As a nurse it is important to remember what administration guidelines when
administering IV KCL?
• IV KCl must always be diluted and never given in concentrated amounts.
• Never give KCl via IV push or as a bolus.
• Invert IV bags containing KCl several times to ensure even distribution in the bag.
• Do not add KCl to a hanging IV bag to prevent giving a bolus dose.
Hypernatremia
Occurs when either too much water is lost or not enough water intake, or too much salt
is taken in
What S/S should the nurse look for when a patient is experiencing hypernatremia
with decreased, normal and increased ECF volume?
Hypernatremia with decreased ECF volume: • Restlessness, agitation, lethargy,
seizures, coma
• Intense thirst, dry swollen tongue, sticky mucous membranes
• Postural hypotension, ↓ CVP, weight loss, ↑ pulse
• Weakness, muscle cramps
Hypernatremia with normal or increased ECF volume: • Restlessness, agitation,
twitching, seizures, coma
• Intense thirst, flushed skin
• Weight gain, peripheral and pulmonary edema, ↑ BP, ↑ CVP
Sodium plays a key role in the body by...
Transmitting nerve impulses
