GALEN NUR 242 EXAM 2 () | MED-SURG NURSING |
(A+ GUARANTEE) | PDF
Causes of fluid overload •Excessive fluid replacement
• Kidney failure (late phase)
• Heart failure
• Long term corticosteroid therapy
• Syndrome of inappropriate antidiuretic
hormone (SIADH)
• Psychiatric disorders with polydipsia
• Water intoxication
s/s fluid overload •CV: tachycardia, bounding pulse, HTN,
decrease pulse pressure, JVD, weight gain
• Resp: increase and shallow resp; SOB,
crackles lung sounds
• Skin: pitting edema, skin pale and cool to
touch
• Neuromuscular: LOC, HA, visual disturbance,
muscle weakness, paresthesia
, • GI: increase motility, enlarge liver
Assessment for fluid overload •Assess risk r/t age and diagnosis, history
(overhydration, CHF, kidney disease)
• Assess vital signs why: watch for
bounding tachycardia, HTN, dysrhythmias,
tachypnea
• Assess lung sounds (crackles) , weight, LOC,
Observe JVD
• Assess lab values: electrolytes imbalance
and signs and symptoms
• Focus Assessment: skin/extremities/ abdomen
and sacrum area for edema
• Assess perfusion: edema may impair
perfusion to extremities, assess peripheral
and central pulses, capillary refill, skin color,
temp, sensory and motor function
• Observe for urine output
, Lab values fluid overload •Serum osmolality (275-295 mOsm/kg)
• Decrease found in overhydration <275; and <
265 is critical finding
• CBC
• Decrease hemoglobin and hematocrit
• BUN
• decreased BUN
• Electrolytes
• Decreased sodium (shifts due to dilution)
• Urine specific gravity Decrease < 1.005
fluid overload interventions/goal •Goal: reduce excess body fluids, promote
desired elimination
• Manage underlying cause
• Restrict dietary sodium intake
• Monitor I/O
• Administer diuretic
• Monitor client's s/s and electrolytes values
• Restrict oral and other fluid intake as
prescribed
Fluid overload complications •Isotonic overhydration
(A+ GUARANTEE) | PDF
Causes of fluid overload •Excessive fluid replacement
• Kidney failure (late phase)
• Heart failure
• Long term corticosteroid therapy
• Syndrome of inappropriate antidiuretic
hormone (SIADH)
• Psychiatric disorders with polydipsia
• Water intoxication
s/s fluid overload •CV: tachycardia, bounding pulse, HTN,
decrease pulse pressure, JVD, weight gain
• Resp: increase and shallow resp; SOB,
crackles lung sounds
• Skin: pitting edema, skin pale and cool to
touch
• Neuromuscular: LOC, HA, visual disturbance,
muscle weakness, paresthesia
, • GI: increase motility, enlarge liver
Assessment for fluid overload •Assess risk r/t age and diagnosis, history
(overhydration, CHF, kidney disease)
• Assess vital signs why: watch for
bounding tachycardia, HTN, dysrhythmias,
tachypnea
• Assess lung sounds (crackles) , weight, LOC,
Observe JVD
• Assess lab values: electrolytes imbalance
and signs and symptoms
• Focus Assessment: skin/extremities/ abdomen
and sacrum area for edema
• Assess perfusion: edema may impair
perfusion to extremities, assess peripheral
and central pulses, capillary refill, skin color,
temp, sensory and motor function
• Observe for urine output
, Lab values fluid overload •Serum osmolality (275-295 mOsm/kg)
• Decrease found in overhydration <275; and <
265 is critical finding
• CBC
• Decrease hemoglobin and hematocrit
• BUN
• decreased BUN
• Electrolytes
• Decreased sodium (shifts due to dilution)
• Urine specific gravity Decrease < 1.005
fluid overload interventions/goal •Goal: reduce excess body fluids, promote
desired elimination
• Manage underlying cause
• Restrict dietary sodium intake
• Monitor I/O
• Administer diuretic
• Monitor client's s/s and electrolytes values
• Restrict oral and other fluid intake as
prescribed
Fluid overload complications •Isotonic overhydration
