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An essential nutrient and the most important need after Oxygen. |
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Amount of fluid taken in and the lost is equal.
Body cells requires balnaced electrolytes, fluids, and pH(acids and bases) |
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charged particles capable of conducting electricity |
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Recieve fluids/electrolytes |
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through foods,drinks and IV therapy |
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Fluid requirements for an adult |
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Urine,feces,perspiration,and expiration |
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Vomiting, diarrhea,gastric suctioning, and bleeding |
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Intracellular fluids(ICF) |
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Definition
found within the cells of the body 2/3 of the body fluid |
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Extracellular fluids(ECF) |
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found outside the cells of the body 1/3 of total body. |
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(ECF) found w/in the vascular system |
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(ECF)surrounds the cells and includes lymph |
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(ECF) CSF (cerebrospinal fluid,pleural,peritoneal synovial fluids |
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ECF & ICF major components |
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Definition
Oyxgen from the lungs Dissolved nutrients from GI tract Excretory products of metabolism Charged particles called IONS Pos ions are called cations neg ions are called anions |
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many break up (dissociate) in water |
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Always accompanied by loss of H2O |
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Always accompanied by sodium excretion |
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process by which fluids and electroltyes move through a semi permeable membrane |
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Intermingling of molecules in liquids, gases, and solids by a random movement. |
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found in the ECF Ref range: 135-145 mEq/L for adult |
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found in the ICF Ref range: 3.5-5.0 mEq/L |
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primary regulator of fluid intake |
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Urine Insensible water loss noticeable loss loss through the intestines in feces |
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water loss not usually noticed or measured (breathing,skin) |
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Definition
skin, (severe burns: a condition where a nurse has to be more concerned for fluid deficit);heavy sweating |
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Fluid intake for average adults |
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2200-2700 mL from all sources (drinks,vegetables,fruits,meats,ect.) |
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2500 mL/day in the form of sweat, urine, feces,expired air |
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Dehydration/Fluid volume deficit |
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Fluid intake limited Fluid loss greater than intake |
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Dehydration/Fluid volume deficit causes |
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Definition
Vomiting diarrhea NG suction bleeding excessive sweating excessive urination Minimal po intake |
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dry lips and mucous membranes dry skin & poor turgor Urine output low and dark and concentrated hypotension pulse increases Infants- no tears,sunken eyes and fontanels |
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Fluid excess/Over-hydration |
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Intake exceeds output Common in those with kidney,heart, and liver disease. Excessive IV fluids |
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Fluid excess/Over-hydration(Symptoms) |
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edema/swelling lung congestion elevated bp,pulse,and respiratory rate jugular vein distention urine dilute when kidneys functioning properly |
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Nurses diagnoses(Fluid volume deficit) |
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Definition
r/t chronic illness and malnutrition AMB reports of fatigue,dry skin/mucous membranes and change of mental status |
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Nurses diagnoses(Fluid volume excess) |
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Definition
r/t excess fluid or sodium intake AMB shortness of breath, orthopnea, weight gain and anasarca |
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Definition
No foods or fluids give frequent mouth care
Surgery,tests or illness |
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Encourage Fluids (FF) force fluids) |
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offer fluids frequently maintain adequate intake,to prevent UTI's and prevent dehydration |
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Fluids limited to prescribed amount Kidney,heart or liver disease Remove water pitcher strict i&o divide fluide intake 3 shifts frequent oral care |
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Urine(voided or catheter) out should not be less that 30 ml/hr (normal=30-50ml/hr) Vomitus(emesis) wound drainage NG suction Diarrhea (liquid stool measured) formed stool charted(record consistency,size,and oror) |
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4 oz =120 ml 10oz = 300 ml |
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1 quart = 1000 mls or 1 liter 1 pint = 16 oz or 500 mls 1 cup = 8 oz or 240 mls 1 tblspoon = 1/2 oz or 15 ml 1 tsp = 5 ml |
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primary responsibility of RN Observe and report redness, swelling, pain, bleeding at IV site Limit stress on tubing & assist with ambulation Nursing students DO NOT adjust flow,change pump settings, insert IV, hang IV or fluidss until cleared with clinical instructer. |
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keeping a record of all fluids taken in the body and all fluids lost from the body. |
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fluids taken by mouth popsicles ice cream
Tube feedings & TPN IV Fluids Assess for SOB,coughing,& wheezing strained cereals puddings custard soups liquid drinks etc |
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used to measure fluids for intake or output Other containers graduated include; urinals pilgrim caps specimen cups
bedpans must be emptied into graduate to measure. for accurate output no toilet paper |
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