Health Care > EXAM > MEDICAL SURGICAL NURSING - Fluid and Electrolyte Balance (All)

MEDICAL SURGICAL NURSING - Fluid and Electrolyte Balance

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Adriane Paminiano 11/18/2020 LVN 62 Fluid and Electrolyte Balance You are a registered nurse working on an acute-care medical-surgical unit. You receive a call from the emergency department (ED) t... hat you will be receiving Adele Long, an 82 y.o. woman with a 3-day history of intermittent abdominal pain, abdominal bloating, nausea, and vomiting. The patient’s medical history includes a colectomy for colon cancer 6 years ago, ventral hernia repair 2 years ago, and mild arthritis. She has no history of coronary artery disease, diabetes mellitus, or pulmonary disease. She takes only Tylenol occasionally for the arthritis. Allergies include shellfish, sulfa drugs, and meperidine. The admitting diagnosis is gastroenteritis. She is admitted to your unit for diagnostic work-up. Her VS are BP 92/60, P 90, R 16. She has an I.V. started with a 22 over-the-needle catheter in her right hand, infusing D5/1/2 NS with 20 mEq KCl at 100 mL/hr and has 2 L O2/nc. 1. Based on the information from the ED and presenting picture, what orders would you anticipate?  Complete Blood count  Urinalysis  Chem 7 labs  NPO  Ultrasound  Stool sample 2. What problems might you anticipate with her I.V. placed in the ED  Phlebitis  Infection  Infiltration The new orders include the placement of a Foley catheter and the following laboratory work.  CBC  Blood chemistry profile  Prealbumin  UA 3. What further physical assessments would be important to establish a baseline for determining fluid and electrolyte balance?  VS  I&O  Assess for edema This study source was downloaded by 100000820529148 from CourseHero.com on 10-03-2022 17:17:01 GMT -05:00 https://www.coursehero.com/file/74232107/11-18-20-Fluid-and-Electrolyte-Balance-A-Paminianodocx/ Adriane Paminiano 11/18/2020 LVN 62  Weight  Assess Mucous Membranes  Assess Skin Turgor  Muscle weakness  Spasm  Blood pressure changes  Assess A&O 4. 4. Review laboratory test results in the textbook and identify which laboratory values indicate possible fluid and electrolyte imbalances. Are any values of concern to you? LAB RANGE RESULT Hgb 12.0 – 16.0 12.5 NORMAL Hct 37 – 47 47 NORMAL Potassium 3.5 – 5.5 mEq/L 3 mEq/L ABNORMAL - LOW Sodium 135 – 145 mEq/L 133 mEq/L ABNORMAL - LOW Calcium 4.5 – 5.5 mEq/L 9.1 mEq/L ABNORMAL - HIGH Mag 1.5 – 3.0 mEq/L 1.6 mg/L NORMAL Chloride 98 – 106 mEq/L 92 mEq/L ABNORMAL - LOW Serum Osmo 285 - 295 295 NORMAL BUN 10 – 20 20 mg/dL NORMAL Creatinine 0.5 – 1.1 0.8 NORMAL This study source was downloaded by 100000820529148 from CourseHero.com on 10-03-2022 17:17:01 GMT -05:00 https://www.coursehero.com/file/74232107/11-18-20-Fluid-and-Electrolyte-Balance-A-Paminianodocx/ Adriane Paminiano 11/18/2020 LVN 62 Your physical assessment of the patient includes slightly confused to place and time, BP 115/70 supine and 90/60 standing, P 80 (a bit weak), R 14, weight 110 lb (son reports that she usually weighs 125), dry mucous membranes, slow capillary refill, and flat neck veins. 5. What is your conclusion based on the data collected? Her lab values of K, Na, Ca, Cl are what concerns me because they are abnormal. Hypokalemia can cause weakness and cardiac arrythmias. Low sodium can cause lethargy and confusion. Hypercalcemia can create kidney stones, nausea, vomiting and arrythmias. Low chloride could indicate heart failure, lung diseases and adrenal insufficiency. She does have orthostatic hypotension which is a risk for fall. Her weight has significantly decreased by 15 lbs. Her data shows that she is dehydrated. She also needs to be on a continuous EKG because of her potassium levels. The Foley catheter is inserted with 100 mL dark amber urine returned. 6. What would be the concerns regarding urinary output? Any concerns regarding the current administration of I.V. potassium? - I’m concerned about the color because it does indicate that there is a concentration of urine and she is dehydrated. Indicates kidney damage and muscle breakdown. Concerning IV Potassium, she might night to change the site and the gauge of the needle. Because of the large gauge it could cause infiltration and potassium can burn the skin. Three hours later, the I.V. site in the right hand appears to be swollen, blanched, and This study source was downloaded by 100000820529148 from CourseHero.com on 10-03-2022 17:17:01 GMT -05:00 https://www.coursehero.com/file/74232107/11-18-20-Fluid-and-Electrolyte-Balance-A-Paminianodocx/ Adriane Paminiano 11/18/2020 LVN 62 cool to touch; when questioned, the patient states there is some pain at the site. 7. What further assessments are needed of the site? What nursing actions would you take? I would take out the IV to prevent tissue damage and find a new IV site. I would also assess for signs of infection as well. 8. What are your concerns regarding the infiltration of potassium? The patient was not receiving the potassium as ordered and is still dehydrated. I’m concerned about the potassium burning her skin as well. 9. Review the INS Standards of Practice scale for infiltration. How would you determine and rate this infiltration? Grade 1 Infiltration, Grade one is defined as:  Skin blanched  Edema 1-6 inches in any direction  Cool to touch  With or without pain 10. To initiate a new peripheral-short I.V., what would you consider? I would consider the size of the vein, also I would consider using IV insertion under ultra-sound guidance to confirm the placing of the IV. This study source was downloaded by 100000820529148 from CourseHero.com on 10-03-2022 17:17:01 GMT -05:00 https://www.coursehero.com/file/74232107/11-18-20-Fluid-and-Electrolyte-Balance-A-Paminianodocx/ Adriane Paminiano 11/18/2020 LVN 62 11. Based on this case, what nursing diagnoses, outcomes, and nursing interventions would you implement for this patient? Collaborate with other students to develop the top four priorities for this patient and a care plan. Nursing Diagnosis Nursing outcome Nursing intervention Risk for infection r/t to foleycatheter Pt will not acquire foleycatheter infection during admission Assess Foley-catheter every 2 hours, assess for redness around the site, assess for fever. Risk for infection of R hand IV r/t Infiltration evidenced by Cold and blanched skin Patient will not have infection due to IV. Apply cold compress, elevate site, assess pain and site every 2 hours Risk for fall r/t to fluid electrolyte imbalance Patient will be free from falls through discharge Assess level of consciousness every 3 hours Risk for seizure r/t electrolyte imbalance Pt will not experience seizure trauma during admission Monitor level of consciousness, reduce visual stimulus. List the adult normal values for the following electrolytes: Hypermagnesemia This study source was downloaded by 100000820529148 from CourseHero.com on 10-03-2022 17:17:01 GMT -05:00 https://www.coursehero.com/file/74232107/11-18-20-Fluid-and-Electrolyte-Balance-A-Paminianodocx/ Adriane Paminiano 11/18/2020 LVN 62 1. Sodium (Na+) = 135 – 145 mEq/L 2. Potassium (K+) = 3.5 – 5.5 mEq/L 3. Chloride (Cl−) = 99 – 109 mEq/L 4. Calcium (Ca++) = 4.5 – 5.5 mEq/L 5. Phosphate (PO4−) = 1.2 – 3.0 mEq/L 6. Magnesium (Mg++) = 1.7 – 2.2 mEq/L Case Study: A 36-year-old client was admitted with gastroenteritis. He has been vomiting and having severe diarrhea for 2 days. He is very weak. The current laboratory results are Na+ 128 mEq/L, K+ 2.8 mEq/L, Cl− 90 mEq/L. The physician orders IV of 0.9% normal saline solution at 100 mL/hr, NPO, and I & O. Pertinent Terminology: Define these terms Sodium (Na+) – Hyponatermia, Most abundant electrolyte. Major role in regulating Body fluid volumes, muscular activity, nerve impulse conduction and acid-case balance. Potassium (K+) – Hypokalemia, Major intracellular cation. Maintains fluid osmolarity and volume within a cell. Essential for normal membrane excitability, transmits nerve impulses, needed for protein synthesis and to breakdown glycogen. Also maintains plasma acid-base balance. Chloride (Cl−) – Hypochloremia, Usually bonds with sodium or potassium. Regulates osmotic pressure between fluid compartments and regulates acid-base balance. Calcium (Ca++) – Usually combines with phosphorus to form mineral salts of bones and teeth. Works with phosphorus in a reciprocal relationship. Hypokalemia Hypochloremia Hyponatremia Hypercalcemia Hyperphosphatemia This study source was downloaded by 100000820529148 from CourseHero.com on 10-03-2022 17:17:01 GMT -05:00 https://www.coursehero.com/file/74232107/11-18-20-Fluid-and-Electrolyte-Balance-A-Paminianodocx/ Adriane Paminiano 11/18/2020 LVN 62 Phosphate (PO4−) – Helps build and repair bones and teeth. For nerve function and muscle contraction. Magnesium (Mg++) – Metabolism of carbohydrates and proteins and stores intracellular energy and neural transmission. Important for the function of heart, nerves and muscles. Third space syndrome – When too much fluid moves from intravascular space into the interstitial space (the nonfunctional area) between cells. Can cause edema, reduced cardiac output and hypotension. Edema – Swelling caused by fluid, excess water in the extracellular space. Pitting edema – Caused by excess fluid in the body. Indicated by pressing on swollen areas which leaves an indentation or “pit” in the body. From the case study, identify the abnormal laboratory results. List the major clinical signs or symptoms that you would assess with each abnormal value: Na+ 128 mEq/L = Nausea, Vomiting, Muscle weakness, lethargy, hypotension, upper abdominal pain, headache, confusion, coma, seizures, muscle twitching, vision changes, K+ 2.8 mEq/L = Muscle cramps and weakness, Arrythmias, kidney problems, drowsiness, arrythmias, irregular heartbeat, tachycardia. Cl− 90 mEq/L = Diarrhea, weakness, difficulty breathing, hypotension, tachycardia, convulsions, strider. This study source was downloaded by 100000820529148 from CourseHero.com on 10-03-2022 17:17:01 GMT -05:00 https://www.coursehero.com/file/74232107/11-18-20-Fluid-and-Electrolyte-Balance-A-Paminianodocx/ Adriane Paminiano 11/18/2020 LVN 62 Follow-up case study: The client's vomiting and diarrhea has begun to subside in the evening and the MD has ordered a clear liquid diet. The client's 24-hour I & O for the day is charted below: 24-Hour Intake/Output Record On the basis of the case study and Intake and Output Record, select the most appropriate NANDA nursing diagnoses for the client: _____ Excess fluid volume X - Deficient fluid volume X - Diarrhea _____ Impaired skin integrity X - Imbalanced nutrition: Less than body requirements X - Risk for injury This study source was downloaded by 100000820529148 from CourseHero.com on 10-03-2022 17:17:01 GMT -05:00 https://www.coursehero.com/file/74232107/11-18-20-Fluid-and-Electrolyte-Balance-A-Paminianodocx/ Adriane Paminiano 11/18/2020 LVN 62 Interactive Activity: With a partner, read the case study below and write a rationale for each of the nursing interventions listed: CASE STUDY NURSING INTERVENTION RATIONALE Ms. M was admitted with heart failure. The nursing diagnosis of “Fluid volume excess r/t noncompliance to dietary Na+ restriction” is listed in her NCP/ Digoxin 0.25 mg qAM po, furosemide 40 mg qAM po and K-dur 10 mEq po tid are her medications Weigh Daily Determine if pt has edema if she is retaining water, change in body weight, Monitor I&O Determines if a pt is retaining liquid which could lead to edema. Determines therapeutic response of Furosemide. Monitor dehydration, monitor sodium and potassium levels Take Apical Pulse Determines arrythmias & bounding pulse due to the heart working harder due to excess liquid in the blood stream. Assess for tachycardia and elevated BP. Determines therapeutic response of Digoxin. Assess Skin Assess for edema and skin turgor and proper hydration. Assess if skin is pale, cold. Assess Lungs Hyperkalemia manifests in respiration difficulties. Assess if you can hear pulmonary edema. Neck Veins Assess if JVD is present. This study source was downloaded by 100000820529148 from CourseHero.com on 10-03-2022 17:17:01 GMT -05:00 https://www.coursehero.com/file/74232107/11-18-20-Fluid-and-Electrolyte-Balance-A-Paminianodocx/ Powered by TCPDF (www.tcpdf.org) [Show More]

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