Notes on Fluid and Electrolytes 3: FLUID VOLUME EXCESS

FLUID VOLUME EXCESS

A. Description
1. Fluid intake or fluid retention exceeds the fluid needs of the body.
2. Fluid volume excess also is called overhydration or fluid overload.
3. The goal of treatment is to restore fluid balance, correct electrolyte imbalances if present, and eliminate or control the underlying cause of the overload.

B. Types
1. Isotonic overhydration
a. Known as hypervolemia, isotonic overhydration results from excessive fluid in the extracellular fluid compartment.
b. Only the extracellular fluid compartment is expanded, and fluid does not shift between the extracellular and
intracellular compartments.
c. Isotonic overhydration causes circulatory overload and interstitial edema; when severe or when it occurs in a client with poor cardiac function, congestive heart
failure and pulmonary edema can result.

2. Hypertonic overhydration
a. Occurrence of hypertonic overhydration is rare and is caused by an excessive sodium intake.
b. Fluid is drawn from the intracellular fluid compartment; the extracellular fluid volume expands, and the intracellular fluid volume contracts.

3. Hypotonic overhydration
a. Hypotonic overhydration is known as water intoxication.
b. The excessive fluid moves into the intracellular space, and all body fluid compartments expand.
c. Electrolyte imbalances occur as a result of dilution.

C. Causes
1. Isotonic overhydration
a. Inadequately controlled IV therapy
b. Renal failure
c. Long-term corticosteroid therapy

2. Hypertonic overhydration
a. Excessive sodium ingestion
b. Rapid infusion of hypertonic saline
c. Excessive sodium bicarbonate therapy

3. Hypotonic overhydration
a. Early renal failure
b. Congestive heart failure
c. Syndrome of inappropriate antidiuretic hormone secretion
d. Inadequately controlled IV therapy
e. Replacement of isotonic fluid loss with hypotonic fluids
f. Irrigation of wounds and body cavities with hypotonic fluids

D. Assessment
1. Cardiovascular
a. Bounding, increased pulse rate
b. Elevated blood pressure
c. Distended neck and hand veins
d. Elevated central venous pressure

2. Respiratory
a. Increased respiratory rate (shallow respirations)
b. Dyspnea
c. Moist crackles on auscultation

3. Neuromuscular
a. Altered level of consciousness
b. Headache
c. Visual disturbances
d. Skeletal muscle weakness
e. Paresthesias

4. Integumentary
a. Pitting edema in dependent areas
b. Skin pale and cool to touch

5. Increased motility in the gastrointestinal tract

6. Isotonic overhydration results in liver enlargement and ascites.

7. Hypotonic overhydration results in the following:
a. Polyuria
b. Diarrhea
c. Nonpitting edema
d. Dysrhythmias
e. Projectile vomiting
8. Laboratory findings
a. Decreased serum osmolality
b. Decreased hematocrit
c. Decreased BUN level
d. Decreased serum sodium level
e. Decreased urine specific gravity

E. Interventions
1. Monitor cardiovascular, respiratory, neuromuscular, renal, integumentary, and gastrointestinal status.
2. Prevent further fluid overload, and restore normal fluid balance.
3. Administer diuretics; osmotic diuretics typically are prescribed first to prevent severe electrolyte imbalances.
4. Restrict fluid and sodium intake.
5. Monitor intake and output and weight.
6. Monitor electrolyte values, and prepare to administer medication to treat an imbalance if present.

Human Immunodeficiency Virus / Acquired immunodeficiency syndrome Lecture Notes

This is a Medical Surgical Nursing lecture note on AIDS/HIV in outlined format. Information and concepts are compressed to provide a quick review of the topic. Some information are so compressed that some concepts are not expounded in detail. If it is your first time to meet such information please refer to your textbook for further explanation of the concept. This review material requires a student to have a prior knowledge and good foundation of the subject matter for this only emphasizes important/ key information deemed important in understanding concepts in Pathophysiology and Medical Surgical Nursing.

Acquired immunodeficiency syndrome (AIDS)

•  AIDS is a viral disease caused by human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy
•  The syndrome is manifested clinically by opportunistic infection and unusual neoplasms.
• AIDS is considered a chronic illness.
• The disease has a long incubation period, sometimes 10 years or longer.
• Manifestations may not appear until late in the infection.

High-risk groups
Heterosexual or homosexual contact with high-risk individuals
Intravenous drug abusers
Persons receiving blood products
Health care workers
Babies born to infected mothers

Assessment
Malaise, fever, anorexia, weight loss, influenza-like symptoms
Lymphadenopathy for at least 3 months
Leukopenia
Diarrhea
Fatigue
Night sweats
Presence of opportunistic infections
Protozoal infections (Pneumocystis jiroveci pneumonia, major source of mortality)
Neoplasms (Kaposi's sarcoma, purplish-red lesions of internal organs and skin, B-cell non-Hodgkin's lymphoma, cervical cancer)
Fungal infections (candidiasis, histoplasmosis)
Viral infections (cytomegalovirus, herpes simplex)
Bacterial infections

Interventions
1. Provide respiratory support.
2. Administer oxygen and respiratory treatments as prescribed.
3. Provide psychosocial support as needed.
4. Maintain fluid and electrolyte balance.
5. Monitor for signs of infection.
6. Prevent the spread of infection.
7. Initiate standard precautions.
8. Provide comfort as necessary.
9. Provide meticulous skin care.
10. Provide adequate nutritional support as prescribed.

"Success is not final, failure is not fatal: it is the courage to continue that counts"

Pre-Board Exam Drill: Fundamentals of Nursing 1

This is a 30 point Pre-Board Exam Drill on Fundamentals of Nursing SET A.

Test your knowledge on nursing concepts, test your test-taking skills and develop your attitude in attacking board exam questions. Answer these questions on a piece of paper. Check your answers and don't forget to review the rationale behind the correct answer. Good luck with your exam!

1. A staff nurse in the medical ward is preparing to move a male adult client who has right-sided paralysis from the bed to the wheelchair. Which statement describes the best action for the staff nurse to take?
a. position the wheelchair on the left side of the bed
b. keep the head of the bed elevated at 10 degrees 
c. protect the client’s left arm with a sling during the transfer
d. bend at the waist while helping the client into a standing position


2. Which statement by the student nurse best indicates a correct understanding of “log rolling” when moving a client?
a. one nurse may perform this task alone
b. pillows are needed for positioning in order to provide support
c. the legs should be moved before the head is moved
d. keeping the neck in a straight position is the primary concern

3. The nurse is caring for a female client who has temperature of 105 F (40.5 C). The physician orders the application of a cooling blanket. Which of the following statements is true about the use of a cooling blanket?
a. cold application will increase the metabolic rate
b. vital signs should be monitored every 8 hours
c. the client should remain in one position to conserve energy
d. skin hygiene and protection of body surface areas is essential


4. A staff nurse of the pediatric wing is preparing to administer a sponge bath to an infant with a high fever. Administration of the bath should include:
a. large amounts of alcohol to increase evaporation of heat
b. adjustment of the water temperature to 60-70 0F
c. wet clothes applied to all areas where blood circulates close to skin surfaces
d. small areas of the body sponged at a time to avoid rapid heat loss


5. The nurse educator of the hospital is instructing the family of a home-bound bedridden client in the general prevention of pressure sores. Measures to include in the teaching include:
a. promoting lifting rather than dragging when turning the client
b. massaging directly over pressure sites
c. changing the client’s position every 4 hours
d. cleaning soiled areas with hot water


6. Which of the following findings would the nurse note when assessing a client with Stage I pressure ulcer? The ulcer displays:
a. superficial skin breakdown
b. deep pink, red, or mottled skin
 c. subcutaneous damage or necrosis
d. damage to muscle or bone


7. An adult has developed a Stage II pressure ulcer. He is scheduled to receive wet to dry dressings every shift. The nurse realizes that the purpose of receiving this type of dressing is to:
a. draw in wound exudate and decrease bacteria
b. debride slough and eschar
c. promote healing by gas exchange
d. promote a moist environment and soften exudate


8. The nurse is performing a wound irrigation and dressing change. Which action, when taken by the nurse, would be a break in the technique?
a. consistently facing the sterile field
b. washing hands before opening the sterile set
c. opening the bottle of irrigating solution and pouring directly into a container on the sterile field
d. opening the sterile set so that the initial flap is opened away from the nurse


9. Total Parenteral Nutrition (TPN) is ordered for an adult client. The nurse expects the solution will contain all of the following nutrients except:
a. dextrose 10% c. electrolytes
b. trace minerals d. amino acids


10. The nurse caring for an adult client who is receiving TPN will need to monitor him for which of the following metabolic complications:
a. hypocalcemia and hypercalcemia 
b. hyperglycemia and hypokalemia 
c. hyperglycemia and hyperkalemia
d. hyperkalemia and hypercalcemia


11. The nurse is caring for a client who is receiving IV fluids. Which observation the nurse makes best indicates the IV has infiltrated?
a. pain at the site
b. a change in flow rate
c. coldness around the insertion site


12. Within 20 minutes of the start of transfusion, the client develops a sudden fever. The most appropriate initial response by the nurse is to:
a. force fluids 
b. continue to monitor the vital signs 
c. increase the flow rate of IV fluids
d. stop the transfusion


13. The nurse is caring for a client who has had a chest tube inserted and connected to water seal drainage. The nurse determines the drainage system is functioning correctly when which of the following is observed?
a. continuous bubbling in the water seal chamber
b. fluctuation in the water seal chamber
c. suction tubing attached to a wall unit
d. vesicular breath sounds throughout the lung fields


14. The nurse is caring for a client who has just had a chest tube attached to a water seal drainage system. To ensure that the system is functioning effectively the nurse should:
a. observe for intermittent bubbling in the water seal chamber
b. flush the chest tubes with 30-60 ml of NSS every 4-6 hours
c. maintain the client in an extreme lateral position
d. strip the chest tubes in the direction of the client


15. The nurse enters the room of a client who has a chest tube attached to a water seal drainage system and notices the chest tube is dislodged from the chest. The most appropriate nursing intervention is to:
a. notify the physician
b. insert a new chest tube
c. cover the insertion site with petroleum gauze
d. instruct the client to breathe deeply until help arrives


16. A patient is ordered oxygen via nasal prongs. The nurse administering oxygen via this low-flow system recognizes that this method of delivery:
a. mixes room air with oxygen
b. delivers a precise concentration of oxygen
c. requires humidity during delivery
d. is less traumatic to the respiratory tract


17. An adult is receiving oxygen by nasal prongs. Which statement by the client indicates that the client teaching regarding oxygen therapy has been effective?
a. “I was feeling fine so I removed my nasal prongs.”
b. “I’ve increased my fluids to six glasses of water daily.”
c. “Don’t forget to come back quickly when you get me out of bed; I don’t like to be without my oxygen for too long.”
d. “My family was angry when I told them they could not smoke in my room.”


18. An adult client has a nasogastric tube in place to maintain gastric decompression. Which nursing action will relieve discomfort in the nostril with the NG tube?
a. remove any tape and loosely pin the tube to his gown
b. lubricate the NG tube with viscous xylocaine
c. loop the NG tube to avoid pressure on the nares
d. replace the NG tube with a smaller diameter tube


19. An adult client has just returned to his room following a bowel resection and end-to-end anastomosis. The nurse can expect the drainage from the NG tube in the early post-op period to be:
a. Clear 
b. Mucoid
c. Scant 
d. Discolored


20. The physician inserts a central venous catheter; the nurse should assist the client to assume which of the following positions?
a. supine 
b. trendelenburg’s
c. reverse trendelenburg’s
 d. high fowler’s

21. The major dietary treatment for ascites calls for:
a. high protein 
b. increased potassium
c. restricted fluids
d. restricted sodium


22. The nurse is to give medication to an infant. What is the best way to assess the identity of the infant?
a. ask the mother what the child’s name is
b. look at the sign above the bed that states the client’s name 
c. compare the bed number with the bed number of the care plan
d. compare the ankle band with the name on the care plan


23. The nurse is caring for a client who has been placed in cloth wrist restraints. To ensure the client’s safety, the nurse should:
a. remove the restraints every 2 hours and inspect the wrists
b. wrap each wrist with gauze dressing beneath the restraints
c. keep the head of the bed flat at all times
d. tie the restraints using a square knot


24. The nurse is preparing a client for IVP tomorrow. The client ells the nurse that she gets a rash and becomes short of breath after eating lobster. Given this information, the nurse knows that the client:
a. should be visited by a dietitian while in the hospital
b. is not a candidate for IVP
c. is at risk for an allergic reaction
d. will require an antihistamine before her IVP

25. The nurse is caring for a client who is to have a lumbar puncture. How should the client be positioned during the procedure?
a. prone with head turned to the left
b. side lying in a fetal position
c. sitting at the edge of the bed
d. Trendelenburg position


26. An adult client has a central line placed for IV fluids. When the nurse enters the room the IV bag is dry, the IV line is full of air, and the client is dyspneic. What is the best initial nursing action?
a. notify the physician and administer oxygen via nasal cannula immediately
b. hang another IV bag as soon as possible, then remove the air from the IV line
c. clamp the tubing and place the client on the left side with head down
d. begin CPR and call the code team


27. An adult client is to receive a unit of whole blood. The client’s vital signs before starting the transfusion are BP 120/70, P 80, and T 98.40F. Five minutes after the transfusion was started the vital signs are BP 100/70, P100 and T 99.40F. What should the nurse do initially?
a. slow down the rate of the transfusion, reassess the client in 15 minutes
b. stop the transfusion, keep vein open with normal saline
c. slow down the infusion, notify the physician immediately
d. administer acetaminophen (Tylenol), continue to monitor closely throughout the transfusion


28. The nurse is administering medication in an extended care facility. What is the best way for the nurse to correctly identify the client before administering the medications?
a. check with picture identification on the file
b. check the arm band
c. check the name on the bed
d. check the name on the room door


29. A client is scheduled to undergo an exploratory laparotomy in one hour. The nurse has just received the order to administer his pre-operative medication. What assessment is essential for the nurse before administering the medication?
a. the client’s ability to cough and deep breathe
b. any drug hypersensitivity or allergy
c. the patient's understanding of the surgical procedure
d. whether patient's family is present and supportive


30. An adult client has been on bed rest for several months. Which statement best describes the relationship between complications of prolonged bed rest and nursing interventions to prevent these complications?
a. turning and positioning will help decrease the potential for calcium loss from bones
b. adequate fluid intake is vital to decrease the risk of brittle bones
c. leg exercises are important to decrease the loss of calcium from the bones and the risk of pathological fractures
d. encouraging milk intake will help decrease the loss of calcium from the bones