Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Fluid&ElectrolyteCharts
Document related concepts
Transcript
Imbalance Signs and Symptoms Risk Factors Interventions Electrolyte Imbalances Hypomagnesemia (<1.3 mEq/L) Hypermagnesemia (>2.5 mEq/L) (rare) • • Malnutrition • Alcoholism • Low K revels • Matabsorption related to GI disorders (Crohn, gluten-sensitive enteropathy) • Antibiotics (gentamicin, aniphotericin, cyclosporine) • Antineoplastics (cisplatin) • Vomiting • Diarrhea • Polyuria • NG drainage • Aldosterone excess • Renal disease • Overtreatment of hypomagnesemia • Overuse of magnesiumbased laxative • Antacids (Riopan, Milk of Magnesia, Epsom salt) • Tremors • Cramps • Hyperactive reflexes • Seizures • Premature ventricular contractions • Ventricular fibrillation • Anorexia • Nausea and vomiting • Confusion • Memory loss • Fatigue • Diarrhea • Flushing • Slurred speech • Profuse sweating • Vomiting • Weakness • Shallow breathing • Bradycardia Deep tendon reflexes • Hallucinations (severe cases) • Coma (severe cases) • Cardiac/respiratory arrest (severe cases) • Treat underlying causes as prescribed • Monitor IV infusions carefully to prevent cardiac or respiratory arrest • Oral supplements • Patient teaching regarding dietary intake • Check vital signs and reflexes frequently • Monitor neurologic status • Educate patient against excessive use of laxatives and antacids CHAPTER_14/fluid, ELectroLyte and Add-Base Balance Imbalance Risk Factors Signs and Symptoms Interventions Electrolyte Imbalances Hyperkalemia (>5.0 mEq/L) • Renal disease • K sparing diuretic use • Addison disease • Excess K supplement • Hemolysis ' Burns • Crush injuries • Rapid IV infusion of K • Chemotherapy • Acidosis • Infusion of old blood • Dysrhythmia • Caution patient against • EKG changes excessive salt substitute use • Cardiac arrest with • Check expiration date on rapid IV infusion blood products before giving of K • Restrict oral and IV K intake • Diarrhea • Monitor.I & 0 • Abdominal cramping • Monitor vital signs • Irritability • Monitor EKG changes • IV calcium gluconate 1sevete cases) • Dialysis (severe cases) Kayexalate (severe cases) Hypocalcemia (<8.6 mg/dL or 4.5 mEq/L) • Inadequate dietary intake • MaLabsorption disorders • Vitamin D deficiency • Hyperphosphatemia • secondary to chronic laxative use Hypoparathyroidism • Alcoholism • Renal disease • Pancreatitis • Respiratory distress or bronchospasms • Cardiac dysrhythmia or [KG changes • Tetany Tingling or numbness • Seizures • Irritability • Pathologic fractures • OsteomaLacia • Osteoporosis • Rickets (children) Hypercalcemia (>10 mg/dL or 5 5 mEq/L) Hyperparathyroidism • Cancer • Excessive intake of Ca4 Prolonged Immobilization • Osteoporosis • Thiazide diuretics • Steroid therapy • Anorexia • Nausea and vomiting • 1' Thirst • Dry mucous membranes • Constipation • Abdominal pain • Kidney stones • Polyuria • Pathologic fractures • Dysrhythmia • Impaired memory • Mood swings • Coma N • Patient teaching regarding adequate intake of calcium • Sunlight exposure • Monitor vital signs • IV calcium as ordered o Monitor IV site closely • Thiazide diuretic as ordered • Patient education (plenty of fluids only medication cleared by doctor no smoking weight beanng and strength exercise after cleared by doctor) Severe Cases • Calcitonin or glucocorticoids as ordered • Loop diuretics as ordered • Monitor I & 0 • Possible hemodialysis • Prevent stress and strain on bones • Exercise after cleared by doctor • Parathyroid removal • Emotional support N ursi ngFundamentaLsDemystified Imbalance Risk Factors Signs and Symptoms Interventions Electrolyte Imbalances Hyponatremia (<134 rnEq/L) • Renal disease • Adrenal insufficiency • 1' Water intake • Excess D5W IV Infusion • Diuretics • Anorexia • GI losses • Vomiting • Diarrhea • Tap water enemas • Burns • Heart failure • Cirrhosis • SIADH • Headache • Tiredness • Dry mucous membranes ' Nausea or vomiting • Abdominal cramping • Dry pale skin • Disoriented • Muscle cramps and muscle weakness • Tachycardia • Seizures • Administer IV fluids as ordered: • Restrict free water intake as ordered • Monitor for excessive fluid and Na intake • Monitor I & 0 • Monitor weights • Monitor laboratory values (glucose, electrolytes) • Monitor for neurologic changes 'Seizure precautions Hypernatremia (>146 mEq/L) • Diabetes insipidus • High Na* intake • Vomiting • Diarrhea • Excessive amounts of hypertonic IV solution • I Water loss a Excessive sweating • Overcorrection of acidosis with sodium bicarbonate • Thirst • Dry flushed skin • Sticky tongue or mucous membranes • Fever • Nausea or vomiting • Anorexia • Excessive urination (polyuria) • Tachycardia Neurologic changes (restlessness, agitation, irritability, confusion, seizures) • Verify fluid orders before initiating IV infusion. • Infuse fluids at prescribed rate (should be infused slowly) • Avoid overhydrating patient • Seizure precautions • Monitor for neurologic changes • Provide oral hygiene care Hypokalemia (<3 4 mEq/L) • Diuretics • Excessive sweating • Diarrhea • Fasting or starvation • Crash diets • Anorexia nervosa • Magnesium deficiency • Alkalosis • Insulin therapy • Cirrhosis • Heart failure • Hyperaldosteronism • Alcoholism • Disonentation or confusion • Tiredness • Abdomen distention • Paralytic Ileus • Nausea and vomiting • Constipation • Polyuria • Tachypnea • Tachycardia or dysrhythmia • EKG changes • Coma • Oral potassium replacement as prescnbed • Intravenous potassium as prescribed with serious deficits • Patient teaching-potassium rich foods • Monitor pulse rhythm (apical also) • Monitor EKG changes • Monitor IV site for phlebitis and infiltration cTtyiance Imbalance Risk Factors Signs and Symptoms 243 Interventions Fluid Imbalances Fluid volume excess or water excess Fluid volume deficit or water deficit • Excessive IV fluid intake . Excessive water intake (uncommon) • Excessive Na intake • Renal disease • Neurologic disorders • Respiratory disorders • Heart failure • SIADH • Cirrhosis of the liver • '1' Aldosterone or steroid levels • Diarrhea • Vomiting • L Oral fluid intake Draining tubes • Burns • Hemorrhage • Excessive perspiration • Fever • Diuretics • Third space shifting • Rapid weight gain I BP • Bounding pulses • Neck vein distention • Edema • Dyspnea • Ra[es* • • Ascaria Ascites • Headache • Lethargy • Personality changes • Irritability • Confusion • Seizure • Coma • Weight loss • Thirst • Poor skin turgor • Dry mucous membranes • .L BP with standing (orthostatic hypotension) Slow vein filling • Weak rapid pulse • L Urine output . 1' Urine specific gravity • Neuroogic changes (dizziness, confusion, seizures, coma, • Restrict Na intake as ordered • Administer diuretics as ordered • Dialysis as ordered • Monitor I & 0 • Daily weights • Monitor for signs of overcorrection (see Hypovolemia) • Monitor for electrolyte imbalances • Hyponatremia • Hypophosphatemia • Hypercalcemia ° Hypomagnesemia ' Oral and IV fluid repacement as ordered • Blood transfusion as ordered • Fall precautions agitation) (Continued) • infection • Laboratory and diagnostic test resufts • Impacf of existfng infection on patient •or family functioning • Signs and symptoms of ClinicaL Findings Risk Factors • Defense mechanisms • Age • Heredity ' Stress ° Current health status Medication or procedures • Nutritional status Assessment /H - Infection, Risk for KnowLedge, Deficient • Skin Integrity, Impaired SociaL Interaction, Impaired • Caregiver Role Strain, Risk for Potential Nursing Diagnoses (Examples) • • Prevention or controL of infection • Patient or family knowLedge of preventing and controLLing infection Maintenance of skin integrity SociaL interaction through means that do not interfere with infection • controL • Adequate resources to prevent caregiver roLe strain Planning (Goats and Outcomes) 0 • MedicaL and surgicaL aseptic techniques • Monitor for sigHs, symptoms, and laboratory and diagnostic resuLts that suggest the presence of infection • Teach the patient and famiLy how to prevent infection and how to recognize earLy signs of infection • Provide means for sociaL interaction (visitor using appropriate infection control precautions, teLephone interactions, and written communication) • Assist the patient or famiLy to identify resources that wiLL minimize caregiver roLe strain Implementation • Determine progress toward achieving goals and outcomes Determine the effectiveness of interventions Modify the pLan of care as needed Evaluation I EnvironmentaL temperture I Body temperature Environment temperature I Pulse with acute pain, hemorrhage, infection Cardiovascular disease cause irregular pulse I Temperature with infections, hyperthyroidism L Temperature with hypothyroidism Disease and others BP = blood pressure. Stimulants I pulse Depressants 1- pulse I Temperature related to hypersensitivity reaction to medication 4- Environmental temperature 4- pulse I I Environmental temperature I pulse 1' Pulse with increased activity I- Pulse with increased age Pulse L Respiratory rate with acute pain, anemia, smoking, I altitude !- Respiratory rate with head trauma injury involving brain stem Narcotics, sedatives, hypnotics, and general anesthetics L respiratory rate - I Environmental temperature I body temperature, which may I respiratory rate I Respirations with increased activity L Respirations with increased age Respirations Vital Signs Medications I 4- Environmental temperature 4- Body temperature • • I Activity or stress I Temperature Activity and stress I • Greater variation during infancy L Temperature related to increase surface loss for infants and elderly people Temperature Age Influencin g Factors Kidney disease, cardiovascular disease, pain may all I BP BP may I hemorrhage, heart attack, and change to upright position (orthostatic or postural hypotension) Antihypertensives and opioids L BP Decongestants, certain illicit drugs, oral contraceptives may I BP I BP with increased activity 1' BP with increased age Blood Pressure ied H247 TI CHAPTER_14/FLuid,_ELectroLyte and Acid-Base BaLance Imbalance Signs and Symptoms Risk Factors Interventions Electrolyte Imbalances .ly Hypophosphatemia (<2.5 mg/dL) Hyperphosphatemia (>4.5 mg/dL) • Diabetic ketoaciddsis • Respiratory alkatosis • Sepsis Refeeding syndrome (secondary to mätabsorption • Malabsorption disorders • Overuse of aluminumbásedàntadds • Hyperparathyroidism • Alcoholism • Loop diuretics • Vitamin D deficiency • Anorexia nervosa • Severe burns • • • • Muscle weakness Repiratorydistress Ilypotension Pale skin secondary tO hemotytic anemia • Altered mental status (?anging from irritability to coma) • WorsenThg infection (secondary to WBC destruction) - • Patient teaching (foods containing phosphojoüs and food preparation to minimize phosphorous loss • Monitor for respiratory distress • Monitor fqr bleeding • Implement measures to protect against infection • Administer IV phosphate as ordered • Administer slowly Dilute • Do not infuse with calcium • Renal disease • Hypoparathyroidism • Excess intake (foods, laxatives, enemas) • Prolonged exercise (rhabdomyolysis) • Chemotherapy Respiratory acidosis • Calcium or magnesium deficiency • I Vitamin D level • Numbness • Tingling • Muscle spasms • Tetany • Seizures • Tachycardia • Anorexia • Nausea • Vomiting • Diarrhea • [KG changes • Patient teaching (excessive intake, foods containing phosphorous, reading labels, laxative and enema use) • Monitor vital signs • Check reflexes • Monitor urine output • Administer calcium as ordered .• Acid-Base Imbalances Metabolic acidosis pH <7.35 HCO ^20 mEq1L CO <23 E 'L mLq / L < Diabetic ketoacidosis Lactic acidosis Hypoxemia Respiratory or heart failure (causing 1- tissue perfusion) • Renal failure • Hyperaldosteronism • Diarrhea • Laxative overuse • Excessive intake of iron or aspirin • Acetazolamide • • • • Note: Signs and symptoms depend on the underlying cause of the acidosis and are nonspecific. Possible signs and symptoms include: • Blurred Mp vision over ose • Tinnitus/ • Vertigo • Neurologic changes (headache, confusion, coma) • Dyspnea • Tachypnea • Hyperpnea • Hyperventilation • Monitor vital signs closely • Monitor respiratory status closely (especially if patient is on 02 therapy • Monitor blood gases and report and abnormal values • Correct underlying causes • Bicarbonate as ordered with severe cases • Monitor patient closely for complications if bicarbonate is given: e Fluid overload • Hypokalemia • '1' CO2 • Tissue hypoxia • Alkalosis (Continued) 252 Nursing FundamentaLs Demystified € Oral fluid replacement C Fluid restriction C Intravenous fluid therapy (Box 14-2) C Blood transfusion (Box 14-3) BOX 14-2 'Procedure Tip: Administering Intravenous FLuids Y1) ) tfr !Tr< r cCJLIJ I]r ri1'lThir' 1ft: !J1 Yrrz) Ij,ric j•cj L CHAPTER 1 CHAPTER 14/Fluid, ELectyte, and Acid-Base BaLance 2 53rC BOX 14-3 Procedure Tip: Administering a BLood Transfusion EVALUATION Evaluation of the patient's status and the effectiveness of interventions must be ongoing. To prevent the occurrence of life-threatening situations, the nurse must evaluate data accurately and respond quickly because excessive treatment of fluid, electrolyte, or acid-base imbalance can result in the occurrence of the opposite condition (eg, overcorrection of hyponatremia may cause hypematremia). Careful determination that treatment has been effective can
