• Skin Turgor, tongue turgor, mositure & oral cavity, tearing & salivation, appearance of skin & skin temp, edema, body temp, pulse, respirations, bp, neck veins, neuromuscular irritability, behavior sensation fatigue level, comparison of total intake & output of fluids, urine vol & concentration, body weight

Skin Turgor

(elasticity)

• Nursing considerations: Pt's skin over the sternum inner aspect of the thighs, or forehead is pinched.
• Tugor can vary w/ age, nutritional state, ethnicity, complexion.
• Findings in healthy adult: pinched skin STAT falls back to its normal position when released.
• Significant Findings: Fluid vol. deficit- skin flattens more slowly after pinch is released. Severe malnutrtion (infants) can cause depressed turgor even in the absence of fluid depletion.

• Nursing Considerations: Not affected by age. 
• Findings in Healthy Adult: tongue has one longitudinal furrow.
• Significant findings: Fluid vol. deficit-additional longitudinal furrows & tongue is smaller. Na excess causes the tongue to look red & swollen.

• Nursing consderations: dry mouth may be the result of fluid vol. deficit or of mouth breathing.
• Findings in healthy adult: mucous membranes in oral cavity are moist.
• Significant findings: dryness of the membrane where the cheek & gum meet indicates fluid vol. deficit. Dry sticky mucous membranes are noted in Na excess.

• Finding in health adult: tearing & salivation decreases normally w/ age.
• Significant findings: absence of tearing & salivation in a child is a sign of fluid vol deficit.

• Significant Findings: Metabolic acidosis can cause warm, flushed skin (due to peripheral vasodilation)

• Significant Findings: A person w/ a severe fluid vol. deficit may have a pinched & drawn facial expression. A fluid vol. deficit of 10% of body weight causes decreased intraocular pressure, causing the eyes to appear sunken & to feel soft to touch.

• Nursing Considerations: Measurement of an extremity or body pt w/ a mm tape, in the same area each day-more exact method of measurement. Excess of interstitial fluid may accumulate predominatly in lower extremities. Presence of periorbital (ard eyes) edema or pedal edema shoudl prompt one to look for edema in other pts of body.
• Significant Findings: Edema isn't usually apparent in the adult until the retention of 5-10lb of excess fluid occurs. Formation of edema may be localized or generalized. Edema of congestive heart failur, liver, cirrhosis, or nephrotic syndrome is the result of Na retention.

• Nursing Considerations: Fever increases the loss of body fluids.
• Significant Findings: Elevation of body temp in hypernatremia (dehydration) related to lack of available fluid for sweating. Decrease in body temp in fluid vol. defiict, when uncomplicated by infection.

• Findings in healthy adult: Baseline pulse rate, rhythm, & volume.
• Significant Findings: Tachycardia is usually the earliest sign of the decreased vascular vol. associated w/ fluid vol. deficit. Pulse vol. is decreased in fluid vol. deficit & increased in fluid vol. excess.

• Findings in healthy adult: Baseline resp. rate, ryhthm, & qualities.
• Significant Findings: Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing resp alkalosis. Slow, shallow respirations may be a compensatory mechanism for metabolic alkalosis or a primary disorder causing resp acidosis. Moist crackles, in the absence of cardiopulmonary disease, indicate fluid vol excess.

• Nursing Considerations: whenever a fluid imbalance is suspected the pt's bp is checked while pt is lying down, sitting, & standing.
• Findings in Health Adulty: Baseline bp

• Nursing Considerations: The jugular veins provide a built-in manometer for following changes in CVP. To estimate CVP: position pt in a semi-Fowler's position (head of bed elevated to a 30-45 degree angle), keeping the neck straight
• Significant findings: Low CVP indicates: decrease blood vol., drug induced vasodilation. High CVP indicates: increased blood vol., heart failure, vasoconstriction

• Nursing Considerations: When imbalances in cal, mag, & Na are suspected it's important to assess pts for increased or decreased neuromuscular irritability. Test for Chvostek's sign & Trousseau's sign. 

• Nursing Considerations: Because these changes are often vague, they are best evaluated in context w/ specific imbalances. (Brain is fuzzy)

• Output is more important than intake. Output- Shows kidney function, electrolyte, acid-base, fluid vol deficit or excess.
• Significant Findings: when the total intake is substantially less than the total output, the pt is in danger of fluid vol deficit. When the total intake is substantially more than the total output, the pt is in danger of fluid vol. excess.

• Nursing considerations: factors that can alter urinary output must be accounted for: amt of fluid intake, losses from skin, lungs, & GI tract, amt of waste products for excretions, renal concentrating ability, blood vol., hormonal influences.
• Finding in healthy adult: Normal urinary output (30ml) is abt 1mL/kg of body weight per hr. The range of specific gravity is from 1.003-1.035.
• Significant Findings: Low urine vol w/ high specific gravity indicates fluid vol deficit. Low urine vol w/ high specific gravity indicates renal disease. 

• Nursing Considerations: Guidelines for weighing pt: use the same scale each time, measure weight at the same time each day; in the morning before breakfast & after voiding, ensure pt is wearing the same/similar clothing, use bed scale if pt is unable to stand on a small, portable scale.
• Weight significance: 5-10lb loss

Focused Assessment

 Factors to Assess/Questions & Approaches

• Usual patterns of fluid intake: Describe the amt & types of fluids you usually drink in a 24hr period. Any recent changes?
• Usual pattern of fluid elimination: Describe your usual voiding/urination habits. Any recent changes in freq or amt? Is you body losing fluids in any other major way? (vomiting,diarrhea,excessive perspiration,fistula)
• Pt's evaluation of hydration status: Do you think there's an approximate balance b/t your fluid I&O? Have you noticed any signs that your body is experiencing too much or too little hydration (difficulty breathing, edema, dry skin & mucous membranes, thirst)?
• Med/nutrition history: Do you take meds or treatments that might disrupt fluid & electrolyte balance? Have you been trying to lose weight by dieting, using diuretics, laxatives, or diet aids? Have you been following a high protein, low carb diet.
• Fluid, electrolyte, & acid-base imbalances & contributing factors: Are you aware of any other fluid balance problems you may be experiencing? (nature, onset of prob and freq, causes, severity, symptoms, intervention attempted & results.

• Complete Blood Count
• Serum Electrolytes, BUN, Creatinin levels
• Urine pH and Specific Gravity
• ABGs

• Determines the total # of RBCs & values for hemoglobin & hematocrit. 
• Significant values include: Increased hematocrit values-found in severe fluid deficit & shock. Decrease hematocrit values-found w/ acute, massive blood loss, & w/ hemolytic reaction after transfusion of incompatible blood or w/ fluid overload. 

• Determines plasma levels of certain electrolytes such as Na, K, chloride, & bicarbonate ions.
• BUN & creatinine levels can provide info related to fluid status & renal function of the pt.
• Significant Findings: Below normal or above normal levels of Na, K, cal, mag, phosphate, & chloride. Increased BUN; found w/ impaired renal function

• May be obtained by dipstick measurement, using a fresh voided specimen or through lab analysis.

• Lab tests commonly used to determine the adequacy of oxygenation & ventilation, as well as in the assessment & treatment of acid-base imbalance. Obtained through arterial blood sample.
• Partial pressure of CO2 is abbreviated PaCO2; for O2, it's PaO2. When the PaO2 is low, hemoglobin carries less than normal amts of O2; when the PaO2 is high, the hemoglobin carries more O2.
• The PaCO2 is influenced almost entirely by resp activity. When PaCO2 is low, carbonic acid leaves the body in excessive amts; when PaCO2 is high, there are excessive amts of carbonic acid in the body.

Excess Fluid Volume

Related Factors:

• Renal failure
• Decreased cardiac output
• liver disease
• abnormal fluid accumulation
• hormonal problems

Deficient Fluid Volume

Related Factors:

• vomiting
• diarrhea
• abnormal drainage
• excessive use of laxatives
• enemas
• diuretics
• blood loss
• diaphoresis
• burns

• Try to stay away from IVs-mucosa problems
• Involves an above average intake of fluids. Order reads "encourage fluids" & indicates amt of fluid the pt is to have in each 24hr period.
• Explain to pt the rational for the increased fluids & the goal of taking the daily amt of fluid prescirbed. 

• Fluid restrictions-can start IV
• Order reads "restrict fluids" & indicates amt of fluid the pt is to have in each 24hr period.
• Discuss time intervals fluid will served

Medications

Mineral electrolyte preparations:

• Nursing responsibilites: accurately administer the meds, following manufacturer's guidelines.
• Knowing & evaluating the intended therapeutic effect
• Assess for adverse effects
• know risks
• Assess for drug interactions
• Teach pts self-care behaviors

Medications

Diuretics:

• #1 cause in elderly
• Drugs that increase renal excretion of H2O, Na, & other electrolytes.
• Although helpful in treating pts w/ fluid volume excess, they increase the risk for fluid vol deficit & serious electrolyte deficiencies. 
• Careful monitoring (check urine output & serum electrolytes, particularly serum K+level) & education are essential for a pt receiving diuretic therapy.

• Handles fluid disturbances
• Physician or other licensed healthcare professional w/ prescriptive priveleges is responsible for prescribing the kind & amt of solution to be used.
• Nurse must understand the pt's need for IV therapy, the type of solution being used, its desired effect, & untoward reaction that may occur.

Selected IV Solutions

Isotonic Solution:

• Can be located anywhere
• 5% dextrose in H2O (D5W): Shouldn't be used in excessive volumes because it doesn't contain Na; thus the fluid dilutes the amt of Na in the serum. Brain swelling, or hyponatremic encephalopathy, can develop rapidly & cause death unless its promptly recognized & treated.
• Lactated Ringer's Solution: Contains multiple electrolytes in abt the same concentrations as found in plasma. Used in treatment of hypovolemia, burns, & fluid lost as bile or diarrhea. Used in treating mild metabolic acidosis.

Selected IV Solutions

Hypotonic Solutions:

• Located in  larger veins
• A hypotonic solution that provides Na+, Cl-, & free H2O. Na+ & Cl- allows kidneys to select & retain needed amts.
• Fluid out of interstitial spaces (edema)-too much can result in cell death.

Selected IV Solutions

Hypertonic Solutions:

• Used to treat hypovolemia; Used to maintain fluid intake.
• Replaces nutrients & electrolytes.

• Sterile technique must be observed when accessing a vein to void possible catheter-related infection.
• #1 concern is for yourself-risk for HIV, Hepatitis

• For a short duration
• OTC catheters
• placed in peripheral vein

• For long duration
• Are an integral component of pt care in acute, ambulatory, & subacute care setting, as well as in the bone & long term care facilities.
• Provide access for IV fluids, meds, blood products, & TPN solutions to allow a means for hemodynamic monitoring & blood sampling.

• For long duration
• After picc is insterted STAT use xray to make sure its placed in correct location.
• Used to administer IV antibiotics, infusion of parenteral nutrition, chemotherapy, continuous narcotic infusions, vasicants, other meds.
• Turnica-stops mvmt to heart/lungs.

• Determine the most desirable accessible vein.
• Determine accessibility based on pt's condition. Ex. A person w/ burns on both forearms doesn't have vessels available in these areas.
• Don't use veins in surgical areas. Ex. Infusions in the arm shouldn't be given on the same side as recent extensive breast surgery because of vascular disturbances in the area, & a pt w/ a history of axillary node dissection shouldn't have venipunture in the affected arm. Avoid an arm that has a device inserted for dialysis.
• Don't use the antecubital veins if another vein is available.
• Don't use veins in the leg, unless other sites are inaccessible, because of the danger of stagnation of peripheral circulation & possible serious complications.
• Additional potential sites for neonates & children include veins of the head, neck, & lower extremities. Use umbilical cord for neonates.

Complications Associated w/ IV infusions

Infiltration:

• The escape of fluid into the subcutaneous tissue. Dislodged needle. Penetrated vessal wall.
• Swelling, coldness, pain
• Discontinue the infusion if symptoms occur.

Complications Associated w/ IV infusions

• Microorganisms invade the bloodstream through the catheter insertion site. Poor insertion technique. Multilumen catheters. Long term catheter insertion. Frequent dressing changes.
• Red & tender insertion site. Fever, malaise, other vital sign changes.
• Use scrupulous aseptic technique when starting an infusion.

Complications Associated w/ IV infusions

• An inflammation of a vein. 
• Local, acute, tenderness; redness, warmth, & slight edema of the vein above the insertion site.
• Discontinue the infusion STAT.

Complications Associated w/ IV infusions

• A blood clot.
• local, acute tenderness;redness, warmth, & slight edema of the vein above insertion site.
• Stop infusion STAT.

Complications Associated w/ IV infusions

• The body's reaction to a substance that's injected into the circulatory system too rapidly.
• pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, & dyspnea
• Stop infusion STAT.

Complications Associated w/ IV infusions

• The condition caused when too large a volume of fluid infuses into the circulatory system.
• Engorged neck veins, increased bp, & difficulty in breathing (dyspnea)
• Slow rate of infusion or stop STAT.

Complications Associated w/ IV infusions

• Air in the circulatory system. Break in the IV system above the heart level allowing air in the circulatory system as a bolus.
• Resp distress, increased heart rate, cyanosis, decreased bp, change in level of consciousness
• Pinch off catheter or secure system to prevent entry of air or stop infusion STAT.

• The infusion of whole blood or a blood component such as plasma, rbcs, or platelets into the pt's venous circulation.
• Given becuase of rbc loss, such as w/ a major injury or when the body isn't adequately producing cells, such as platelets. \

• Typing: determines blood type
• Cross-mathcing: process of determining compatibility b/t blood specimen

• A, B, AB, O - main blood types
• Antigen-substance that causes the formation of antibodies.
• Antibody-protein substance developed in the body in response to the presence of an antigen that has entered the body.
• Type AB- universal recipients
• Type O- universal donor

• An herited antigen in human blood. One designated D is most important. 
• A person whose blood contains a D antigen is called Rh positive; an Rh negative person lacks D antigen.

• Blood type matches and is free of disease.
• Blood will be tested for HIV, hepatitis B  & C virus, syphilis, west nile virus, & other viruses that can be transmitted to the recepient.
• Some pts who know in advance that they will need blood can donate their own blood for transfusion (autologous transfusion), also called autotransfusion.

Transfusion Reactions

Allergic reaction: allergy to transfused blood

• hives, itching, anaphylaxis
• Stop transfusion STAT & keep vein open w/ normal saline.

Transfusion Reactions

• Fever,& chills, headache, malaise
• Stop transfusion STAT & keep vein open w/ normal saline

Transfusion Reactions

• Immediate onset, facial flushing, fever, chills,headache, low back pain, shock
• Stop infusion STAT & keep vein open w/ normal saline

Transfusion Reactions

• Dyspnea, dry cough, pulmonary edema
• Stop infusion

Transfusion Reactions

• fever, hypertension, dry, flushed skin, abdominal pain
• Stop infusion STAT.