(Summary) NUR242 Exam 2 Galen, Questions
and Correct Answers. With Complete Solution.
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
•HF and pulmonary edema
•Seizure
•Coma
Fluid overload medications
Furosemide
Mannitol
S/S of dehydration
•Vital signs: hyperthermia, ST, thread pulse, hypotension, decrease CVP
•Neuromusculoskeletal: Dizziness, syncope, confusion, weakness, fatigue
•GI: thirst, dry furrowed tongue, N/V, anorexia, weight loss
•Renal: Oliguria
•Other signs: Diminish capillary refill, cool clammy skin, diaphoresis, sunken eyeballs,
flat neck vein
Dehydration assessment
•Assess for condition leading to dehydration: diarrhea, poor intake, vigorous exercise,
vomiting, polyuria, fluid losses (burns, trauma) clients with drains/NG tube, burns/fluid
shifts, overuse of diuretic
Dehydration labs
•Serum electrolytes (hypernatremia)
•Increased serum osmolality normal 275- 295 mOsm/kg; elevated > 295 found in
dehydration; > 320 is critical finding
•CBC elevated H/H
•Elevated urine specific gravity > 1.030
•Increased BUN
Dehydration interventions/goal
•Goal of interventions: replace fluid and electrolytes to achieve homeostasis
•Closely monitor status and rehydration, avoid overcorrection
•Monitor I/O and weight
•Identify and manage cause- diarrhea, vomiting, blood loss, poor intake
•Oral rehydration is priority if tolerating PO fluids
Dehydration priority interventions
•IV fluid resuscitation/replacement, general guidelines
•Hypertonic dehydration- hypotonic fluids- D5W once dextrose is metabolized; 0.45%
NaCL (1/2 normal saline)
•Isotonic dehydration: isotonic fluids (normal saline, lactated ringers)
•Hypotonic dehydration: hypertonic fluids (3% or 5% saline solution)
•Blood products in increased blood loss/trauma
•Medications to treat cause: antidiarrheal, anti emetic, AB, antipyretics
•Ingestion of food to replace electrolytes
Complications of dehydration
•Hypovolemia
•Hypovolemia shock
•Seizures/coma
•Multiorgan system failure
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