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First Priority Interventions
- S sodium intake increase, seizure precautions
- O overload- restrict water intake
- D Daily weight
- I Intake and OUtput
- U use isotonic fluids (0.9% NaCl)
- M Monitor vital signs and LOC
- decreased serum sodium(NA) <135mEq/L
- decreased serum osmolality <275mOsm/kg
- decreased BP
- decreased muscle strength
- decreased deep muscle reflexes (DTR)
- increased pulse
- confusion(elderly) & lethargy
- Sodium deficit Na<135mEq/L
- May effects these systems: Neurological, Cardiac, Endocrine
- Risk Factors: Vomiting, GI suctioning, Renal disease (kidney), skin losses such as burns.
What is the expected outcome for the administration of IV furosemide (Lasix) with a client who has fluid volume excess?
a. BP change from 108/78 to 140/90
b. Pulse change from 72/min to 108/min
c. decreased crackles in lower lung fields
d. weight from 142lbs to 150lbs
- answer: c. decreased crackles in lower lung fields, (we have increased crackles with EFV, so lasix decreases fluid, and would decrease the crackles heard)
- (a)- a sign of FVE is increased BP, if we give lasix we decrease fluid so BP would decrease too.
- (b)- a sign of FVE is increased or normal pulse, if we give lasix we decrease fluid so pulse should become more normal range.
- (d)- if we give lasix we decrease fluid excess and weight gain would not be an expected outcome.
Which clinical finding indicates that client is experiencing potential fluid volume excess?
a. BP change from 108/78 to 140/90
b. decreased crackles in lower lung fields
c. pulse increased from 72/min to 80/min
d. weight from 150lbs to 151lbs.
- with fluid volume excess our signs increase...
- answer: a. BP change from 108/78 to 140/90
- BP increases with (FVE)
- (b)-increase crackles not decreased
- (c)-pulse does increase or stay normal with bounding, ^from 72 to 80 still within normal range of 60-100bpm.
- (d)-weight isn't an increase of +2lbs.
First Priority Interventions for (FVE)
- RISTRICT FOR FVE
- R reduce IV flow rate
- E evaluate breath sounds and ABGs
- S Semi-fowler's position
- T treat with oxygen and diuretics as ordered
- R Reduce fluid and sodium intake
- I I & O and weight
- C ciculation, color, and presence of edema
- T turn, cough & reposition every 2 hrs. (gets fluid out of lungs)
- Hct <36 women, <40 men
- serum osmolality <275
- serum sodium (NA) <135
- BUN <10
- (all Increased)
- BP, RR, ^dyspnea, orthopnea, crackles, HR (may be increased or normal but bounding), confusion, weight >2lb increase in 24hrs, edema, ascites, distended neck veins.
- fluid volume excess (FVE) Causes:
- heart or renal failure, cirrhosis
- ^Na (fluid follows sodium)
- excess IV fluids (fluid overload)
- decreased albumin (decreased proteins in blood)
What would be the priority nursing intervention for a client with a B/P change from 140/88 to 86/62?
a. put client in supine position with legs elevated
b. notify provider of care.
c. put client in fowler's position
d. evaluate characteristics of mucous membranes
- Answer=a. put client in supine position with legs elevated.
- (if client BP drops drastically they may be in shock)
- (b.)-you would call provider, after you initially put them in supine position to decrease the work load of the heart
- (c.)-you would not put client in flowler's position, increases work load of heart
- (d.)-you may evaluate the mucous membranes to find out the cause of the shock and decreased BP, but putting them in supine is first priority)
Which system specific assessment findings would the client present with who has been vomiting for 24hrs?
a. B/P increased from 110/70 to 130/80
b. Urine output decreases from 95cc/hr to 75cc/hr
d. weight two days ago was 145, now 142lbs.
- ANSWER= d. weight two days ago was 145, now 142lbs.
- *a weight fluctuation of a loss of 2lbs or a gain of 2lbs is cause for concern.
- - (a.) BP decreases with fluid loss
- -(b.) urine output decrease is correct, but 75cc is still within normal range (>30cc/hr)
- -(c.) BUN 15 is within normal limits, >20 would be cause for concern.
First Priority Interventions for (FVD)
- F fluid replacement
- L level of consciousness, (safety) LOC
- U Urine <30 ml/hr, report trends
- I I & O (input and output of fluids)
- D Document daily weight, vital signs
- S Safety-position changes slowly. If in shock legs up! (helps fluid get to heart and brain)
Fluid volume deficit (FVD)
Lab Results to look for
- All INCREASED!!! (With fluid deficit labs go up)
- ^Hct (more than 3x hgb)
- ^BUN > 20
- ^Specific Gravity > 1.030
- ^Osmolality > 295mOsm/kg water
- ^Serum Na > 145 mEq/L
- fluid volume deficit (blood and fluid)
- Signs: Dry mucous membrances-^ thirst
- decrease in weight
- decreased urine output
- decrease fluid to pump so PULSE ^
- decrease in blood pressure (late sign)
- decreased skin turgor
Weight Loss or Gain
A loss of 2 pounds or a gain of 2 pounds is cause for concern with too much fluid loss or too much fluid retention.
- Kidneys produce a minimum of 30cc/hr (30mL or 1oz)=1oz/hr
- Insensible loss- 600cc/m2/day, by sweating, lungs through breathing, and feces.
- concentration of solutions
- (solute & solutes per kg of water)
- Serum Osmolality 275-295 (normal range)
- Fluids within the 275-295 normal range are Isotonic
- fluids with greater that 295 mOsm/kg= hypertonic
- fluids with less than 275 mOsm/kg=hypotonic