Summary Final Exam Review Promoting Health & Health Restoration of Adults I NUR 4226

Final Exam Review Promoting Health & Health Restoration of Adults I NUR 4226 Fluid Volume Excess (Hypervolemia) • Causes: fluid overload or diminished homeostatic mechanisms, heart failure, kidney injury, cirrhosis of liver, consumption of excessive amounts of table salt or other sodium salts, excessive administration of sodium- containing fluids with impaired regulatory mechanisms • Clinical manifestations: acute weight gain, peripheral edema and ascites, distended jugular veins (JVD), crackles, elevated CVP, shortness of breath, ↑ BP, bounding pulse, cough, ↑ respiratory rate, ↑ urine output • Nursing management: assess lung sounds, monitor for edema, I&O, daily weights, administer diuretics, patient education regarding sodium and fluid restriction, promote rest Fluid Volume Deficit (Hypovolemia) • Occurs when water and electrolytes are lost in the same proportion as they exist in normal body fluids; therefore, the ratio of serum electrolytes to water remains the same (loss of extracellular fluid exceeds intake of water) • causes: diarrhea, vomiting, sweating, GI suctioning, decreased fluid intake, burns, ascites, osmotic diuresis, hemorrhage • Clinical manifestations: weight loss, decreased skin turgor, oliguria, concentrated urine, capillary filling time prolonged, low CVP, ↓ BP, flattened neck veins, dizziness, weakness, thirst and confusion, ↑ pulse, muscle cramps, sunken eyes, nausea, increased temperature, and cool, clammy, pale skin Hyperkalemia • Serum potassium 5.0 mEq/L • Causes: impaired renal function, rapid administration of potassium, hypoaldosteronism, medications, tissue trauma, respiratory and metabolic acidosis • Clinical Manifestations: muscle weakness, tachycardia → bradycardia, dysrhythmias, flaccid paralysis, paresthesia, intestinal colic, cramps, abdominal distention, irritability, anxiety. • ECG: tall tented T waves, prolonged PR interval and QRS duration, absent P waves, ST depression Hypokalemia • Serum potassium 3.5 mEq/L • Causes: GI losses (vomiting & diarrhea), medications (i.e. diuretics, corticosteroids, beta agonists, insulin), prolonged intestinal suctioning (nasogastric tube), recent ileostomy, tumor of the intestine, alterations of acid–base balance (respiratory or metabolic alkalosis), poor dietary intake, hyperaldosteronism (increases renal K+ loss), bulimia • Clinical Manifestations: fatigue, anorexia, nausea and vomiting, muscle weakness, polyuria, decreased bowel motility, ventricular asystole or fibrillation, paresthesias, leg cramps, ↓ BP, ileus, abdominal distention, hypoactive reflexes • ECG: flattened T waves, prominent U waves, ST depression, prolonged PR interval