NUR 148 Exam 7 - a deficit of fluid volume, especially plasma vo...

NUR 148 Exam 7

• dehydration

Answer

• fluid intake or retention is less than what is needed to meet the body's fluid needs, resulting in

a deficit of fluid volume, especially plasma volume.

• dehydration causes decreased perfusion which can cause death

• may be an actual decrease in total body water due to little intake or too great of fluid loss

• may also be caused by no actual loss of body water such as water shifting from plasma into

interstitial space

• s/s of dehydration

Answer

• increased HR

• weak peripheral pulses
• decreased BP
• orthostatic hypotension (lightheadedness & dizziness)
• flat neck veins
• flat hand veins
• increased RR
• skin tenting
• oral mucous membranes are dry and cracked
• tongue may develop deep furrows
• altered mental status (most common in older adults)
• decreased urine output
• reduced temp
• hypovolemia

• risk factors for dehydration

Answer

• hemorrhage 1 / 3

• vomiting
• diarrhea
• profuse salivation
• fistulas
• ileostomy
• profuse diaphoresis
• burns
• severe wounds
• long term NPO
• diuretic therapy
• GI suction
• hyperventilation
• diabetes insipidus
• difficulty swallowing
• impaired thirst
• unconsciousness
• fever
• impaired motor function

• interventions for dehydration

Answer

• fluid replacement

• oral hydration for mild dehydration

• oral rehydration solutions (good when mixed w/ glucose and electrolytes for vomiting and

diarrhea)

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• labs showing dehydration

Answer

• elevated levels of hemoglobin, hematocrit, serum osmolarity, glucose, protein, blood urea

nitrogen, and electrolytes because more water is lost and other substances remain, increasing blood, concentration (hemo- concentration). Hemoconcentration is not present when dehydration is caused by hemorrhage because loss of all blood cells and plasma products occurs together. 2 / 3

• best care for a patient with dehydration

Answer

• Provide oral fluids that meet the patient's dietary restrictions (eg, sugar-free, low-sodium,

thickened).

• Collaborate with other members of the interprofessional team to determine the amount of

fluids needed during a 24-hour period.

• Ensure that fluids are offered and ingested on an even schedule at least every 2 hours

throughout 24 hours.

• Teach assistive personnel to actively participate in the hydration therapy and not to withhold

fluids to prevent incontinence.

• Infuse prescribed IV fluids at a rate consistent with hydration needs and any known cardiac,

pulmonary, or kidney problems.

-Monitor the patient's response to fluid therapy at least every 2 hours for indicators of adequate rehydration or the need for continuing therapy, especially

Pulse quality and pulse pressure Urine output Weight (every 8 hours)

• Monitor for and report indicators of fluid overload, including

Bounding pulse Difficulty breathing Neck vein distention in the upright position Presence of dependent edema

• Asses IV infusion site hourly for indications of infiltration or phlebitis (e.g. swelling around

the site, pain, cordlike veins, reduced drip rate).

• Give drugs prescribed to correct the underlying cause of the dehydration (e.g., antiemetics,

antidiarrheals, antibiotics, antipyretics).

• what is vascular dehydration?
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