Microsoft PowerPoint - Unit I.5 Fluid, e-, acid-base balance_103 []YANG CHIA CHEN
0 Identify risk factors
Nursing Process Assessment
0 Age 0 Infant: at greater risk for fluid volume deficits (FVDs), and  hyperosmolar imbalance because body water loss
0 Older adults are at greater for decreased excretion of  medication, which leads to imbalances causing metabolic or  respiratory acidosis, FVD, hyperosmolar imbalance,  hyponatremia and hypernatremia.
0 Past medical history 0 Surgery (NG suction may be develop metabolic alkalosis),  burns, respiratory disorders, head injury (result in cerebral  edema creaese pr. on the pituitary gland, altering ADH  secretion), cancer, cardiovascular disease, renal disorders, GI  disorders
0 Environment: Temp. over 30 results in excessive  sweating with loss. 
0 Diet: recent change in appetite or the ability to chew  and swallow affects nutrition status and fluid  hydration. 0Hypoalbuminemia: Serum protein levels drop below normal.  Causes the serum colloid osmotic pressure to decrease. Fluid  shifts from the circulating blood vascular and enters the  interstitial fluid space in the peritoneal cavity edema.
0 Lifestyle: excess use of tobacco and alcohol cause  respiratory depression, which can result in respiratory  acidosis and an alteration in adequate fluid and e balance.
0 Medication: Duretics(metabolic alkalosis,  hyperkalemia, hypokalemia), Steroids(Meatabolic alkalosis), respiratory center depressants(respiratory  acidosis), antibiotic…
Assessment 0Dehydration 0Overhydration 0Hyponatremia 0Hpernatremia 0Hypokalemia 0Hyperkalemia
Assessment 1
0 Table 418 (p.981)  presents possible physical finding for clients with   fluid, electrolyte, and acidbase imbalances.
0 Daily weights and fluid intake and output measurement 0 An indicator of fluid status, each kg of weight gained or lost is equal to
1 L of fluid retained or lost. 0 Obtain a weight at the same time each day. If using a bed scale, use the
same number of sheets on the scale with each weighting. 0 BW change over 0.5kg/day usually indicate body fluid loss or gain.
Check BW QD order
Assessment 2
0 Intake and output (I/O) measurement 0 Measuring I and O at 24-hour intervals gives an overall status of fluid
balances 0 Oral intake : all liquids taken by mouth, through NG or jejunostomy
feeding tubes, IV fluids, and blood.
0 Liquid output : urine, diarrhea, vomitus, gastric suction, and drainage from the surgical wounds or other tubes.
0 Teach the client and family the purpose of the measurement and how to record.
Record I & O QD order
P’t receive numerous liquid medications, and water may be used to flush the tube before and after medication, need record?Q:
Assessment 0 Laboratory studies
0 monitor for fluid and electrolyte imbalances, see Box 41-4. 0 These lab studies include serum and urine electrolyte,
hematocrit, blood creatinine, BUN, specific gravity, ABGs.
Nursing Diagnosis 0 Multiple body systems may be involved. 0 Critical thinking must be used when suspected fluid,
electrolyte, and acid-base imbalances occur. 0 Use NANDA-I–approved list of nursing diagnoses. 0 Careful clustering of defining characteristics lead to
selection of the appropriate diagnoses (Box 41-5) 0 Deficient fluid volume related to loss of gastrointestinal fluid from
vomiting 0 Deficient fluid volume related to elevated body temperature
Deficient fluid volume related to loss of  gastrointestinal fluid via vomiting
Assessment activities Defining Characteristics
Client is hypotension with  increased heart rate
Obtain daily weight  measurement
Client experiences sudden  weight loss.
Observe volume of urine  output, and measure intake  and specific gravity 
Decreased volume of output  in comparison to intake;  increased urine specific  gravity (spgr)
Palpate skin turgor Inelastic skin turgor noted Ask if client is thirsty or  weak
Client verbralize thirst and  weakness
Q:
Planning 0 Goals and outcomes
0 “ The client will demonstrate stable daily weights within 48 hours”
0 Setting priorities 0 The client’s clinical condition will
determine which diagnoses have the highest priority.
0 Collaborative care 0 involve other services, including
discharge planning, nutritional support, and pharmacy
Implementation 1 0 Health Promotion
0 Client education: their children when vomiting or diarrhea occur. 0 Recognize risk factors for development of imbalances and
implement appropriate preventive measures.
0 Enteral replacement of fluids 0 Oral replacements may be contraindicated
0 when the client is vomiting, has a GI tract obstruction, is at risk for obstruction, or has impaired swallowing.
0 Restriction of fluids 0 fluid volume excess (FVE) 0 chronic illnesses patients: such as CHF or renal dialysis. 0 explain the reason, arrange the fluid volume(meal, before sleep, take
medication)
0 Parenteral replacement of fluids 0 crystalloids, and colloids (blood and blood components).
0 Total parenteral nutrition(TPN) 0 Nutrition consisting of a hypertonic solution
containing glucose, electrolytes, and other nutrients delivered through a central IV (peripheral, percutaneous, implanted, tunneled).
Implementation 2
Intravenous therapy
skill
IV Therapy 0 The goal : correct or prevent fluid and electrolyte disturbances. 0 IVs allow direct access to the vascular system 0 short therapy: Peripherally inserted catheters, such as fluid
restoration postoperatively and antibiotic use. 0 Long-term use:central lines, PICC catheter, or implanted ports
Intravenous equipment 0Needles, intravenous cannulas
0 Commonly used 22 gauge.
0Tourniguet 0Gloves 0Dressings 0 IV Pumps (if necessary) 0Solution containers 0Volume control devices
IV Pumps
0 15 gtt/mL 0 Rapidly needs to be
infused, large drops
0Microdrip tubing 0 60 gtt/mL 0 at slow rate.
Types of IV solutions 0 Isotonic solutions: the same osmolality as body fluids
0 D5W, NS, LR 0 Hypotonic solutions: less osmolality than body fluids
0 ½ NS(half saline), NS 0 Hypertonic solutions: greater osmolality then body fluids
0 D10W; 0 3%, 4%, 5% NaCl; 0 D5/0.9NaCl, 0 D5/0.45%NaCl, 0 D5/LR
Q:
0 Venipuncture site 0 Common:
0 Use of the foot for iv site is common with children and avoided in the adult because of the danger of
0 Remember the young, elderly, and frail have fragile veins.
0 monitoring fluid flow to prevent over or under infusion. 0 According to the orders. 0 too slowly : increased risk of becoming clotted 0 too rapid : fluid overload, resluting in cardiovascular, kidney,
and neurological complications in vulnerable clients.
0 Review how long each liter of fluid should run. 0 Calculate
0 Keep IVR with N/S 1000mL for 8 Hrs.
0 Keep IVR with ½ N/S 1500cc QD.
Total infusion (mL)*gtt/cc
Hours of infusion*60min
500/8=62.5 mL/hr = 62.5 gtt/min
125 mL/hr = 125 ×15 gtt/60 min = 31.25 gtt/min
0 51,000 c.c.515 gtt/ml
0 10500 c.c.10
0 swelling at site, pallor, and coolness at the site. 0 Flood volume excess occurs when the fluid is administered
too rapidly. 0 Phlebitis is an inflammation of the vein.
0
Evaluation 0 To determine the
effectiveness of interventions
0 To determine if clients have met their goals/outcomes 0 If no progress has been