NURS 272 QUIZ #2 (3) electrolyte imbalances 4) integumentary syst & wound care) Questions With Complete Solutions

NURS 272 QUIZ #2 (3) electrolyte imbalances 4) integumentary syst & wound care) Questions With Complete Solutions *FLUID & ELECTROLYTE IMBALANCES* hh Explain the basics of fluid balance. hhCorrect Answers hh*fluid balance is important for temp regulation, nutrient transport, waste excretion, join lubrication, protections, etc! > Types... - intracellular - extracellular = intravascular, interstitial - transcellular = CBS, pericardial, synovial, intraocular, pleural fluids, etc... > Sources of fluid loss - insensible = via skin & lungs - sensible = via kidney & GI tract > avg I&O = 1,500 -3,500/24 hrs What are the risk factors for fluid & electrolyte imbalances? hhCorrect Answers hh Explain the pathophysiology of hypervolemia. hhCorrect Answers hhE) heart failure, kidney failure, cirrhosis (end -stage liver failure), long -term corticosteroid therapy (kidney retenti on), & excessive fluid replacement (ex: athletes, iatrogenic) P) fluid overload/excess > Types... - isotonic = excess isotonic fluid in the extracellular compartment (common in clinical) - hyponatremia = decr Na+ & diluted body fluids Labs) > CBCs = h emodilution (decr Hgb & Hct), decr protein & electrolytes > ABGs = respiratory alkalosis (decr PaCO2 & incr pH) > CXR (chest X -ray) = pulmonary congestion S/Sx) - weight gain = > 0.5lb gain in a day is considered abnormal - pitting edema in dependent extremities - CV = tachycardia, bounding pulse, hypertension, distended neck/hand veins - R = tachypnea, dyspnea, shortness of breath, orthopnea (SOB when lying down), moist crackles *call out pulmonary congestion & altered neuro status! > Complications... - pleural effusion (fluid buildup in lung lining) = thoracentesis (manual removal of fluid) & monitor for hypovolemic shock - ascites (distended abdomen resulting from fluid backup caused by end -stage liver disease) = paracentesis (manual removal of fluid) - kidney failure = dialysis Tx) - administer diuretics - limit fluid & sodium intake - monitor edema & I&Os - auscultate lung sounds & administer O2 therapy PRN - monitor vitals & HR What causes edema? hhCorrect Answers hhhypervole mia > incr capillary pressure > capillaries leak fluid into extracellular/interstitial space *edema = pitting in dependent areas, pale/cool to touch, weeping & moist When administering tx, how should the nurse prioritize their actions? hhCorrect Answers hh1. prioritize physiological needs using the ABCs = Airway > Breathing > Circulation 2. focus on safety & security = prioritize what is the most threatening to the pt's life! 3. address pt's feelings = provide necessary education & emotional support Expl ain the pathophysiology of hypovolemia. hhCorrect Answers hhE) severe hemorrhage, iatrogenic (diet restrictions/NPO), excessive vomiting/diarrhea/diaphoresis, diuretic therapy, diabetes, renal disease, NG suctioning, 3rd spacing (intestinal obstruction, peri tonitis, ascites, burns) > Risk factors = age (infants & older adults), diuretics, burns & severe infections P) fluid volume deficit from an absolute decr in total body fluid OR from a "relative" movement of fluid from the intravascular compartment to the interstitial compartment > Types... - isotonic = fluid loss from the extracellular compartment Labs) > CBC = hemoconcentration (incr Hgb & Hct) > serum osmolality = measures protein, electrolytes, glucose levels/conc > BUN = measures protein break dow n