HACC PN 145 EXAM STUDY SET
patient presentation of fluid volume excess
-Hypertension
-Tachycardia
-Confusion
-bounding pulse
-Crackles in lung
-Edema
-Weight gain
-Dyspnea
Fluid volume excess
-Hypervolemia: excessive retention of water and sodium in ECF
interventions for fluid volume excess
-vital signs
-weight
-low sodium diet
-assess respiratory and lung sounds
-diuretics
-in/output
-circulation
Isotonic fluid volume deficit
A type of fluid imbalance that occurs when electrolytes are lost along with fluid
hypovolemia
intravascular fluid is lost
dehydration
loss of water without electrolytes
Patient presentation for fluid volume deficit
, -cold
-clammy skin
-diaphoresis (sweating)
-tachycardia
-weak pulse
-hypotension
-tachypnea
-weight loss
-hypoxia
-concentrated urine
nursing interventions for fluid volume deficit
-monitor LOC
-vital signs
-Lab work
-Weight
-In/out
-oral care
-skin breakdown
patient presentation for dehydration
-altered mental state
-increased capillary refill
-Fever
-UTI
-hypotension
-nausea
-decreased urine output
-muscle weakness
-dry skin
lab findings for dehydration
BMP: electrolytes,high BUN, high creatinine
Urinalysis: USG: 1.02 or higher, high glucose levels
CBC: high hematocrit (70%)
risk factors for urinary incontinence
patient presentation of fluid volume excess
-Hypertension
-Tachycardia
-Confusion
-bounding pulse
-Crackles in lung
-Edema
-Weight gain
-Dyspnea
Fluid volume excess
-Hypervolemia: excessive retention of water and sodium in ECF
interventions for fluid volume excess
-vital signs
-weight
-low sodium diet
-assess respiratory and lung sounds
-diuretics
-in/output
-circulation
Isotonic fluid volume deficit
A type of fluid imbalance that occurs when electrolytes are lost along with fluid
hypovolemia
intravascular fluid is lost
dehydration
loss of water without electrolytes
Patient presentation for fluid volume deficit
, -cold
-clammy skin
-diaphoresis (sweating)
-tachycardia
-weak pulse
-hypotension
-tachypnea
-weight loss
-hypoxia
-concentrated urine
nursing interventions for fluid volume deficit
-monitor LOC
-vital signs
-Lab work
-Weight
-In/out
-oral care
-skin breakdown
patient presentation for dehydration
-altered mental state
-increased capillary refill
-Fever
-UTI
-hypotension
-nausea
-decreased urine output
-muscle weakness
-dry skin
lab findings for dehydration
BMP: electrolytes,high BUN, high creatinine
Urinalysis: USG: 1.02 or higher, high glucose levels
CBC: high hematocrit (70%)
risk factors for urinary incontinence
