NURS 242 Nursing Concepts – Comprehensive
Learning Pack | All Topics Covered | Fully Graded,
Reviewed, and Trusted Content
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
Learning Pack | All Topics Covered | Fully Graded,
Reviewed, and Trusted Content
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
