What should be included in an assessment with a patient with fluid and electrolyte imbalances?

Review

Inhaltsverzeichnis Show

Assessment of fluids and electrolytes
Similar articles
Publication types
MeSH terms
Substances
LinkOut - more resources
Full Text Sources
What assessments would you undertake to assess a person's fluid and electrolyte status?
What are nursing interventions for electrolyte imbalance?
What are the signs and symptoms of electrolyte and fluid imbalances in the body?
Which focused assessment would the nurse make on an initial physical examination of an individual's fluid balance?

Assessment of fluids and electrolytes

Heidi Nebelkopf Elgart. AACN Clin Issues. 2004 Oct-Dec.

Abstract

Bedside evaluation of a patient's intravascular volume status is challenging, even for the seasoned practitioner. There is no single diagnostic test to determine whether a patient is hypovolemic, hypervolemic, or euvolemic. Often, underlying or concomitant disease states, medications, and other therapeutics can make available data difficult to interpret. Therefore, a combination of clinical evaluation, laboratory studies, and other diagnostics are required to make a clinical judgment regarding volume status. Patients who demonstrate alterations in their volume status are likely to have electrolyte abnormalities as well, and assessment of serum electrolyte values and potential therapeutic interventions is a vital piece in caring for critically ill patients.

Publication types

MeSH terms

Substances

LinkOut - more resources

Full Text Sources
- Ovid Technologies, Inc.
- Wolters Kluwer
Medical
- MedlinePlus Health Information

Chapter11:AssessmentandCareofPatientswithFluidandElectrolyte

Imbalances

MULTIPLECHOICE

1.Anurseteachesclientsatacommunitycenteraboutrisksfordehydration.Whichclientisatgreatestriskfor

dehydration?

a.A36-year-oldwhoisprescribedlong-termsteroidtherapy

b.A55-year-oldreceivinghypertonicintravenousfluids

c.A76-year-oldwhoiscognitivelyimpaired

d.An83-year-oldwithcongestiveheartfailure

ANS:C

Olderadults,becausetheyhavelesstotalbodywaterthanyoungeradults,areatgreaterriskfordevelopment

ofdehydration.Anyonewhoiscognitivelyimpairedandcannotobtainfluidsindependentlyorcannotmakehis

orherneedforfluidsknownisathighriskfordehydration.

DIF:Understanding/ComprehensionREF:168

KEY:Hydration

MSC:IntegratedProcess:NursingProcess:Assessment

NOT:ClientNeedsCategory:PhysiologicalIntegrity:BasicCareandComfort

2.Anurseiscaringforaclientwhoexhibitsdehydration-inducedconfusion.Whichinterventionshouldthe

nurseimplementfirst?

a.Measureintakeandoutputevery4hours.

b.Applyoxygenbymaskornasalcannula.

c.IncreasetheIVflowrateto250mL/hr.

d.Placetheclientinahigh-Fowlersposition.

ANS:B

Dehydrationmostfrequentlyleadstopoorcerebralperfusionandcerebralhypoxia,causingconfusion.

Applyingoxygencanreduceconfusion,evenifperfusionisstilllessthanoptimal.IncreasingtheIVflowrate

wouldincreaseperfusion.However,dependingonthedegreeofdehydration,rehydratingtheclienttoorapidly

withIVfluidscanleadtocerebraledema.Measuringintakeandoutputandplacingtheclientinahigh-Fowlers

positionwillnotaddresstheclientsproblem.

DIF:Applying/ApplicationREF:168

KEY:Hydration

MSC:IntegratedProcess:NursingProcess:Implementation

NOT:ClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation

3.Afterteachingaclientwhoisbeingtreatedfordehydration,anurseassessestheclientsunderstanding.

Whichstatementindicatestheclientcorrectlyunderstoodtheteaching?

a.Imustdrinkaquartofwaterorotherliquideachday.

b.IwillweighmyselfeachmorningbeforeIeatordrink.

c.Iwilluseasaltsubstitutewhenmakingandeatingmymeals.

d.Iwillnotdrinkliquidsafter6PMsoIwonthavetogetupatnight.

ANS:B

Oneliterofwaterweighs1kg;therefore,achangeinbodyweightisagoodmeasureofexcessfluidlossor

fluidretention.Weightlossgreaterthan0.5lbdailyisindicativeofexcessivefluidloss.Theotherstatements

arenotindicativeofpracticesthatwillpreventdehydration.

DIF:Analyzing/AnalysisREF:168

KEY:Hydration

MSC:IntegratedProcess:Teaching/Learning

NOT:ClientNeedsCategory:HealthPromotionandMaintenance

TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e68

What assessments would you undertake to assess a person's fluid and electrolyte status?

Serial bodyweights are an accurate method of monitoring fluid status. If patients are able to weigh themselves regularly at home these measurements may be used for review, but nurses must ensure that they use the same scales, wear the same amount of clothing and weigh themselves at the same time every day.

What are nursing interventions for electrolyte imbalance?

Nursing Interventions for Risk for Electrolyte Imbalance. Supply balanced electrolyte IV solutions as directed. Lactated Ringer's solution has an electrolyte concentration similar to that of extracellular fluid. Isotonic saline (0.9% sodium chloride) may contribute to hypernatremia if used in a long period of time.

What are the signs and symptoms of electrolyte and fluid imbalances in the body?

Signs of a serious electrolyte imbalance include:.

blood pressure changes..

shortness of breath..

confusion..

fatigue..

nausea and vomiting..

rapid or irregular heartbeat..

weakness or difficulty moving..

frequent or infrequent urination..

Which focused assessment would the nurse make on an initial physical examination of an individual's fluid balance?

Focused assessments such as trends in weight, 24-hour intake and output, vital signs, pulses, lung sounds, skin, and mental status are used to determine fluid balance, electrolyte, and acid-base status. Accurate daily weights can provide important clues to fluid balance.