lOMoARcPSD|17222949
lOMoARcPSD|17222949
EDAPTS STARTING FROM WEEK 1
MEDSURG
Altered fluid and electrolyte balance
Section 1: Nursing care- altered fluid balance
Nursing Care of Altered Fluid Balance
Nursing care of altered fluid balance involves the understanding of the
pathophysiology of a disease process or injury that causes the
disruption to homeostasis in the body. Altered fluid balance can be
caused by heart failure and renal failure that can cause fluid volume
excess, or it can be a complication of a diagnostic procedure like
colonoscopy whom clients need to have enema prior the procedure
that can lead to fluid volume loss. Enema promotes bowel movement
that can cleanse the lower gastrointestinal tract which can lead to fluid
volume loss.
To complete this activity, you will be able to learn the concepts of
nursing care of alteration in fluid balance. In addition, there are
different activities embedded on this that include pre-assessment
questions to prepare you on the concept of nursing care of altered fluid
balance. In addition, there will be some self-check questions to test
your knowledge and understanding about the concepts. Last, but not
the least are the post-assessment questions that will evaluate what you
learned in this activity.
Assessment of Fluid Balance
As a nurse, assessment is vital to be able to identify if there is any
alteration in fluid balance. Alterations in fluid balance can disrupt the
body's responses to the metabolic processes that support body
function. The assessment of fluid volume overload will focus on looking
for the presence of edema (upper/lower extremities, periorbital
edema), shortness of breath, labored breathing, blood pressure
changes, polyuria, and alteration of level of consciousness. On the
other hand, the assessment of fluid volume deficit will focus on
checking the skin turgor, blood pressure changes, and intake and
output changes. In addition, as a nurse, you also need to look for more
cues by finding out the past medical and surgical history of the client,
medications (over-the-counter and prescribed), and lifestyle.
Furthermore, diagnostic studies will be done to identify the effects of
, lOMoARcPSD|17222949
the alteration in fluid balance in the body. The diagnostic studies
include checking the blood (complete blood count [CBC],
basic/comprehensive metabolic panel [BMP/CMP], magnesium and
phosphorus levels, serum osmolality), urine (urine osmolality and
specific gravity) and radiology studies (chest x-ray and
echocardiogram). For a CBC, as a nurse, you must look at the
hemoglobin and
, lOMoARcPSD|17222949
hematocrit level to assess for fluid volume status levels, while BMP/CMP
will help to assess electrolytes, albumin, renal and liver function. In
addition, looking at the urine and blood osmolality, you will be able to
determine if there is either a low or high concentration of solutes.
When the osmolality is high, there is fluid volume loss, while if there is
low osmolality in the blood, it means that there is fluid volume
overload.
Sometimes hormone imbalances like antidiuretic hormone (ADH) can
affect urine and blood osmolality, so you need to review all cues to
understand what might be happening to fluid balance in the patient.
The interprofessional care management of alteration in fluid balance
Interprofessional Care
will depend on the assessment findings. Here is an explanation of how
the neurological system can affect fluid balance, and some common
Management - Neurological
nursing actions and rationale used for this system.
Nursing
Neurological System Interventions Rationale
Fluid volume Monitor level of Electrolyte
imbalances can lead to consciousness imbalances or fluid
electrolyte abnormalities (LOC) deficit can cause
causing altered levels of seizures.
consciousness (ALOC),
confusion, seizures, Monitor vital Follow trends
and other signs and that may indicate
complications.
laboratory tests impending fluid
for signs of fluid volume imbalance
imbalance. requiring early
intervention.
Seizure Protect the client
Precautions from further injury
related to seizure
activity.
Administer anti- Treat a client who
seizure may be experiencing
medication as a seizure due to fluid
needed volume imbalance
, lOMoARcPSD|17222949
Nursing
Neurological System Interventions Rationale
and/or electrolyte
abnormalities.
Here is an explanation of how the cardiovascular system can affect
Interprofessional Care
fluid balance, and some common nursing actions and rationale used
for this system.
ManagementNursing
- Cardiovascular
Cardiovascular Interventions Rationale
Heart failure and Monitor blood This will help to
arrhythmias can reduce pressure, heart determine if a
the cardiac output of the rate, and cardiac client has fluid
heart. When this occurs output. volume loss or
fluid could back up into overload or
the lungs and peripheral developing any
circulation. Looking for complications.
signs of heart function
and rhythm problems and Check the 12-lead 12-Lead ECG will
acting can help restore electrocardiogram determine if there’s
normal fluid balance. (ECG). any dysrhythmias
present and this
will also help to
determine possible
electrolyte
imbalances.
Check B-type This will
natriuretic Peptide determine if the
(BNP) level client is
developing heart
failure.
Administer diuretics This is given if
as prescribed and there is presence of
monitor electrolytes fluid volume
before and after overload.
lOMoARcPSD|17222949
EDAPTS STARTING FROM WEEK 1
MEDSURG
Altered fluid and electrolyte balance
Section 1: Nursing care- altered fluid balance
Nursing Care of Altered Fluid Balance
Nursing care of altered fluid balance involves the understanding of the
pathophysiology of a disease process or injury that causes the
disruption to homeostasis in the body. Altered fluid balance can be
caused by heart failure and renal failure that can cause fluid volume
excess, or it can be a complication of a diagnostic procedure like
colonoscopy whom clients need to have enema prior the procedure
that can lead to fluid volume loss. Enema promotes bowel movement
that can cleanse the lower gastrointestinal tract which can lead to fluid
volume loss.
To complete this activity, you will be able to learn the concepts of
nursing care of alteration in fluid balance. In addition, there are
different activities embedded on this that include pre-assessment
questions to prepare you on the concept of nursing care of altered fluid
balance. In addition, there will be some self-check questions to test
your knowledge and understanding about the concepts. Last, but not
the least are the post-assessment questions that will evaluate what you
learned in this activity.
Assessment of Fluid Balance
As a nurse, assessment is vital to be able to identify if there is any
alteration in fluid balance. Alterations in fluid balance can disrupt the
body's responses to the metabolic processes that support body
function. The assessment of fluid volume overload will focus on looking
for the presence of edema (upper/lower extremities, periorbital
edema), shortness of breath, labored breathing, blood pressure
changes, polyuria, and alteration of level of consciousness. On the
other hand, the assessment of fluid volume deficit will focus on
checking the skin turgor, blood pressure changes, and intake and
output changes. In addition, as a nurse, you also need to look for more
cues by finding out the past medical and surgical history of the client,
medications (over-the-counter and prescribed), and lifestyle.
Furthermore, diagnostic studies will be done to identify the effects of
, lOMoARcPSD|17222949
the alteration in fluid balance in the body. The diagnostic studies
include checking the blood (complete blood count [CBC],
basic/comprehensive metabolic panel [BMP/CMP], magnesium and
phosphorus levels, serum osmolality), urine (urine osmolality and
specific gravity) and radiology studies (chest x-ray and
echocardiogram). For a CBC, as a nurse, you must look at the
hemoglobin and
, lOMoARcPSD|17222949
hematocrit level to assess for fluid volume status levels, while BMP/CMP
will help to assess electrolytes, albumin, renal and liver function. In
addition, looking at the urine and blood osmolality, you will be able to
determine if there is either a low or high concentration of solutes.
When the osmolality is high, there is fluid volume loss, while if there is
low osmolality in the blood, it means that there is fluid volume
overload.
Sometimes hormone imbalances like antidiuretic hormone (ADH) can
affect urine and blood osmolality, so you need to review all cues to
understand what might be happening to fluid balance in the patient.
The interprofessional care management of alteration in fluid balance
Interprofessional Care
will depend on the assessment findings. Here is an explanation of how
the neurological system can affect fluid balance, and some common
Management - Neurological
nursing actions and rationale used for this system.
Nursing
Neurological System Interventions Rationale
Fluid volume Monitor level of Electrolyte
imbalances can lead to consciousness imbalances or fluid
electrolyte abnormalities (LOC) deficit can cause
causing altered levels of seizures.
consciousness (ALOC),
confusion, seizures, Monitor vital Follow trends
and other signs and that may indicate
complications.
laboratory tests impending fluid
for signs of fluid volume imbalance
imbalance. requiring early
intervention.
Seizure Protect the client
Precautions from further injury
related to seizure
activity.
Administer anti- Treat a client who
seizure may be experiencing
medication as a seizure due to fluid
needed volume imbalance
, lOMoARcPSD|17222949
Nursing
Neurological System Interventions Rationale
and/or electrolyte
abnormalities.
Here is an explanation of how the cardiovascular system can affect
Interprofessional Care
fluid balance, and some common nursing actions and rationale used
for this system.
ManagementNursing
- Cardiovascular
Cardiovascular Interventions Rationale
Heart failure and Monitor blood This will help to
arrhythmias can reduce pressure, heart determine if a
the cardiac output of the rate, and cardiac client has fluid
heart. When this occurs output. volume loss or
fluid could back up into overload or
the lungs and peripheral developing any
circulation. Looking for complications.
signs of heart function
and rhythm problems and Check the 12-lead 12-Lead ECG will
acting can help restore electrocardiogram determine if there’s
normal fluid balance. (ECG). any dysrhythmias
present and this
will also help to
determine possible
electrolyte
imbalances.
Check B-type This will
natriuretic Peptide determine if the
(BNP) level client is
developing heart
failure.
Administer diuretics This is given if
as prescribed and there is presence of
monitor electrolytes fluid volume
before and after overload.
