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MedSurg Notes for Edapt
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MedSurg Notes for Edapt
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lOMoARcPSD|17222949lOMoARcPSD|17222949
EDAPTS STARTING FROM WEEK 1 MEDSURG
Altered fluid and electrolyte balance
Section 1: Nursing care- altered fluid balance
Nursing Care of Altered Fluid Balance
Nursing care of altered fluid balance involves the understanding of the
pathophysiology of a disease process or injury that causes the disruption to
homeostasis in the body. Altered fluid balance can be caused by heart failure
and renal failure that can cause fluid volume excess, or it can be a
complication of a diagnostic procedure like colonoscopy whom clients need to
have enema prior the procedure that can lead to fluid volume loss. Enema
promotes bowel movement that can cleanse the lower gastrointestinal tract
which can lead to fluid volume loss.
To complete this activity, you will be able to learn the concepts of nursing care
of alteration in fluid balance. In addition, there are different activities
embedded on this that include pre-assessment questions to prepare you on the
concept of nursing care of altered fluid balance. In addition, there will be some
self-check questions to test your knowledge and understanding about the
concepts. Last, but not the least are the post-assessment questions that will
evaluate what you learned in this activity.
Assessment of Fluid Balance
As a nurse, assessment is vital to be able to identify if there is any alteration
in fluid balance. Alterations in fluid balance can disrupt the body's responses to
the metabolic processes that support body function. The assessment of fluid
volume overload will focus on looking for the presence of edema (upper/lower
extremities, periorbital edema), shortness of breath, labored breathing, blood
pressure changes, polyuria, and alteration of level of consciousness. On the
other hand, the assessment of fluid volume deficit will focus on checking the
skin turgor, blood pressure changes, and intake and output changes. In
addition, as a nurse, you also need to look for more cues by finding out the
past medical and surgical history of the client, medications (over-the-counter
and prescribed), and lifestyle.
Furthermore, diagnostic studies will be done to identify the effects of the
alteration in fluid balance in the body. The diagnostic studies include checking
the blood (complete blood count [CBC], basic/comprehensive metabolic panel
[BMP/CMP], magnesium and phosphorus levels, serum osmolality), urine (urine
osmolality and specific gravity) and radiology studies (chest x-ray and
echocardiogram). For a CBC, as a nurse, you must look at the hemoglobin and
, lOMoARcPSD|17222949
hematocrit level to assess for fluid volume status levels, while BMP/CMP will
help to assess electrolytes, albumin, renal and liver function. In addition,
looking at the urine and blood osmolality, you will be able to determine if there
is either a low or high concentration of solutes. When the osmolality is high,
there is fluid volume loss, while if there is low osmolality in the blood, it means
that there is fluid volume overload.
Sometimes hormone imbalances like antidiuretic hormone (ADH) can affect
urine and blood osmolality, so you need to review all cues to understand what
might be happening to fluid balance in the patient.
Interprofessional Care Management -
Neurological
The interprofessional care management of alteration in fluid balance will
depend on the assessment findings. Here is an explanation of how the
neurological system can affect fluid balance, and some common nursing
actions and rationale used for this system.
Nursing
Neurological System Interventions Rationale
Fluid volume Monitor level of Electrolyte
imbalances can lead to consciousness imbalances or fluid
electrolyte abnormalities (LOC) deficit can cause
causing altered levels of seizures.
consciousness (ALOC),
confusion, seizures, and Monitor vital Follow trends that
other complications. signs and may indicate
laboratory tests impending fluid
for signs of fluid volume imbalance
imbalance. requiring early
intervention.
Seizure Protect the client
Precautions from further injury
related to seizure
activity.
Administer anti- Treat a client who
seizure may be experiencing
medication as a seizure due to fluid
needed volume imbalance
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Nursing
Neurological System Interventions Rationale
and/or electrolyte
abnormalities.
Interprofessional Care Management -
Cardiovascular
Here is an explanation of how the cardiovascular system can affect fluid
balance, and some common nursing actions and rationale used for this system.
Nursing
Cardiovascular Interventions Rationale
Heart failure and Monitor blood This will help to
arrhythmias can reduce pressure, heart determine if a
the cardiac output of the rate, and cardiac client has fluid
heart. When this occurs output. volume loss or
fluid could back up into overload or
the lungs and peripheral developing any
circulation. Looking for complications.
signs of heart function
and rhythm problems and Check the 12-lead 12-Lead ECG will
acting can help restore electrocardiogram determine if there’s
normal fluid balance. (ECG). any dysrhythmias
present and this
will also help to
determine possible
electrolyte
imbalances.
Check B-type This will
natriuretic Peptide determine if the
(BNP) level client is
developing heart
failure.
Administer diuretics This is given if
as prescribed and there is presence of
monitor electrolytes fluid volume
before and after overload.
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Nursing
Cardiovascular Interventions Rationale
administration.
Administer This is given if
intravenous fluids if there is fluid
there is fluid volume volume loss.
loss.
Interprofessional Care Management -
Respiratory
Here is an explanation of how the respiratory system can affect fluid balance,
and some common nursing actions and rationale used for this system.
Nursing
Respiratory Interventions Rationale
Fluid imbalance can force Elevate the head of This will help to
the respiratory system to the bed (45-90 expand the lungs
compensate by increasing or degrees/semi to and move any
decreasing respirations to high fowler’s unwanted fluid to
help balance acid-base position) if the the bottom,
abnormalities that arise. client is having clearing the
Monitoring and acting on shortness of breath. upper lung fields.
problems that arise from the
compensation can help Monitor To identify if
improve fluid imbalance. respirations, there’s any acid-
breathing pattern base imbalances
and oxygen present to
saturation. compensate fluid
imbalance.
Check arterial blood This will help to
gas (ABG) identify if gas
exchange is
affected.
Oxygen therapy as This will help to
needed. support the gas
exchange until
fluid imbalances
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