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NUR 242
Galen NUR 242 Exam2 Med-Surg (Latest ):
Most Comprehensive Qs & Answers to Pass the
Exam, 100% Verified.
Causes of fluid overload - ANS •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 - ANS •CV: tachycardia, bounding pulse, HTN, decrease
pulse pressure, JVD, weight gain
•Resp: increase and shallow resp; SOB, crackles lung sounds
NUR 242
, 2
NUR 242
•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 - ANS •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 - ANS •Serum osmolality (275-295 mOsm/kg)
•Decrease found in overhydration <275; and < 265 is critical finding
NUR 242
, 3
NUR 242
•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 - ANS •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 - ANS •Isotonic overhydration
NUR 242
NUR 242
Galen NUR 242 Exam2 Med-Surg (Latest ):
Most Comprehensive Qs & Answers to Pass the
Exam, 100% Verified.
Causes of fluid overload - ANS •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 - ANS •CV: tachycardia, bounding pulse, HTN, decrease
pulse pressure, JVD, weight gain
•Resp: increase and shallow resp; SOB, crackles lung sounds
NUR 242
, 2
NUR 242
•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 - ANS •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 - ANS •Serum osmolality (275-295 mOsm/kg)
•Decrease found in overhydration <275; and < 265 is critical finding
NUR 242
, 3
NUR 242
•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 - ANS •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 - ANS •Isotonic overhydration
NUR 242
