N105: Essentials of Nursing Care - Health Differences

Essentials of Nursing Study Guide

©2017 Achieve Test Prep Page 98 of 160 wrist and metacarpophalangeal joints extended with fingers together caused by hypocalcemia; Chvostek’s sign is twitching of facial muscles also a sign of hypocalcemia; skin and tongue turgor as evidenced by a normal healthy pinched skin immediately returns to its normal position when released (this is not valid in the elderly because skin elasticity decreases with age) • Review laboratory/diagnostic data: Hematocrit increases with dehydration and decreases with severe over-hydration. o Sodium is 135-145 mEq/L o Potassium 3.5-5.0 mEq/L o Chloride is 95-105 mEq/L o Calcium (total) is 4.5-5.5 mEq/L, 8.5-10.5 mg/dl. (ionized) o Magnesium is 1.5-2.5 mEq/L o Phosphate is 1.8-2.6 mEq/L • Urine specific gravity: This is an indicator of urine concentration. The normal range is 1.005 to 1.030. Concentration of solutes increases the specific gravity. Urine pH is relatively acidic, at 6.0. Range of 4.6 – 8.0 is considered normal. BUN is the end product of protein metabolism, the range is 10-20 mg/dl (decreased in malnutrition, liver failure and increased with protein diet, dehydration, starvation, burns, CHF, and MI). • Nursing diagnosis : fluid volume excess related to high sodium intake; fluid volume deficit related to diarrhea; activity intolerance related to potassium loss from diuretic therapy; fluid volume deficit related to alterations in renal functioning associated with aging • Planning: Patient-centered goals (patient will…); decrease intake of foods that are high in sodium; infant’s fontanelle will regain normal contours; patient’s serum potassium level will be within normal limits; patient will drink 4-6 (8) oz. glasses of water per day; incorporate factors influencing the patient’s fluid and electrolyte status; establish a pattern of fluid intake based on an older adult’s preferences and physical needs; replace fluids and electrolytes for a patient with gastrointestinal fluid loss; plan nursing measures to instruct patient regarding sodium content of prepared foods; monitor administration of oral rehydration solutions; administer prescribed potassium as ordered; plan instruction regarding the need for additional fluids • Implementation: promote fluid and electrolyte balance; assist with food and fluid selection; adapt measures to patient’s developmental level; use appropriate nursing measures for deficits; encourage natural fluid replacement; establish daily fluid regime with patient; artificial fluid replacement; assist with parenteral administration of fluids (calculate flow rate, monitor flow rate, add a new IV solution, and monitor infusion site); administration of volume expanders; natural electrolyte replacement and modify dietary intake; artificial electrolyte replacement and administer parenteral/oral potassium chloride; prevent excess fluid and electrolyte loss by administering antiemetics, antipyretics, and antidiarrheal agents; alter room temperature as needed; use appropriate nursing measures for excesses; dietary restriction to limit PO intake to 1000 ml/day; limit sodium intake; administer diuretics, sodium polystyrene sulfonate (Kayexalate), and monitor parenteral therapy for signs of fluid