NR 283 Quiz 2
Name
Chamberlain University
NR-341 Complex Adult Health
Prof. Name
Date
Fluid balance disorders in nursing care are multifaceted and can arise from severe burns, trauma, sepsis, and heart failure. These conditions may disturb fluid and electrolyte homeostasis, posing unique challenges for patient management. When caring for patients with fluid imbalances, nurses must tailor interventions to support cardiac output, fluid retention, or elimination as appropriate. For instance, when a patient experiences hypovolemia and decreased preload, administering 0.9% normal saline as an intravenous bolus can help increase preload and improve cardiac output, as opposed to other interventions like nifedipine or furosemide, which may lower preload. When managing a patient with acute respiratory distress syndrome (ARDS), mechanical ventilation can contribute to fluid retention. This occurs due to reduced renal perfusion, which leads to renin release, and subsequently, increased aldosterone secretion, resulting in fluid retention.
Elderly patients admitted with dehydration present unique challenges in fluid management. One example involves administering sodium-free fluids like D5W to correct hypovolemia; however, this intervention may risk complications such as cerebral swelling. In cases where dehydration leads to hyponatremia or fluid overload, careful monitoring of electrolyte levels is essential.
Fluid movement between body compartments is driven by osmosis and diffusion, regulated by three main hormones: aldosterone, antidiuretic hormone (ADH), and natriuretic peptides. Aldosterone plays a role in sodium retention and potassium excretion, often triggered by severe hypotension or hypovolemia. ADH, produced by the pituitary gland, signals renal cells to reabsorb water, reducing urine output while diluting blood plasma. This hormone’s regulation can be altered in conditions like diabetes insipidus or the syndrome of inappropriate ADH secretion (SIADH). In critically ill patients, dysnatremia is a common issue, with either hyponatremia or hypernatremia potentially arising due to improper fluid management or kidney impairment. To address these imbalances, interventions may include restricting water and sodium intake in hypervolemic hyponatremia or administering isotonic solutions for hypernatremic states.
Risk factors for fluid imbalances include cardiac dysfunction, renal impairment, gastrointestinal losses, and certain medications like diuretics. Managing these factors is essential, as dysregulation can lead to fluid volume deficits or excess.
Effective hemodynamic monitoring is central to managing fluid balance in critically ill patients, especially when treating hypo- or hypervolemia. Nurses must be adept in using devices that measure pulmonary artery wedge pressure (PAWP), central venous pressure (CVP), and arterial blood pressure. PAWP offers insights into left ventricular function and helps gauge fluid volume status, with high PAWP values indicating fluid overload and low values indicating volume depletion. Similarly, CVP values assist in diagnosing hypo- or hypervolemia. Ensuring correct setup, zeroing, and calibration of monitoring equipment is crucial to obtain accurate readings.
For patients requiring invasive monitoring, nurses play an active role in equipment preparation, patient education, and monitoring for complications such as infection, thrombus formation, or neurovascular impairment. Continuous renal replacement therapy (CRRT) may be necessary for critically ill patients with fluid overload or impaired kidney function, providing a steady form of fluid removal that stabilizes hemodynamic parameters without excessive strain. Unlike intermittent hemodialysis (IHD), CRRT minimizes fluid shifts, thus offering a safer option for patients in unstable conditions.
| Condition | Nursing Interventions | Monitoring Parameters |
|---|---|---|
| Hypovolemia | – Administer isotonic fluids (e.g., 0.9% NS) to increase preload. – Monitor urine output and adjust fluid rate as needed. – Assess for signs of dehydration and electrolyte imbalances. | – Urine output ≥ 0.5 ml/kg/hour. – CVP, PAWP, and hemodynamic stability. |
| Hypervolemia | – Restrict fluid intake as indicated. – Use diuretics (e.g., furosemide) for fluid elimination. – Consider CRRT for critically ill patients with fluid overload and unstable hemodynamic status. | – Monitor CVP, PAWP. – Assess for pulmonary congestion, edema. |
| Dysnatremia (Hyponatremia/Hypernatremia) | – Administer sodium replacements or restrict sodium as needed based on type (hypo/hypernatremia). – Monitor electrolyte levels closely. – Adjust fluid intake to prevent further imbalance. | – Serum sodium levels. – CVP, PAWP, and signs of neurological status. |
Nursing care during Continuous Renal Replacement Therapy (CRRT) encompasses a range of critical assessments and interventions aimed at monitoring and maintaining patient stability. Initially, nurses should prepare for CRRT by conducting a baseline assessment, which includes monitoring hourly output, assessing fluid volume status, and adjusting fluid replacement as needed based on hourly fluid balances. Regular neurologic assessments and monitoring of electrolyte and acid-base balance are essential. Additionally, the nurse should evaluate the patient’s temperature, assess for signs of bleeding and infection, monitor coagulation status, and ensure the circuit remains patent.
For patients undergoing hemodynamic monitoring, the transducer must be accurately referenced and zeroed. This involves identifying the phlebostatic axis, positioning the transducer appropriately, opening the reference stopcock to room air, and confirming a zero reading on the monitor. In cases where pulmonary auscultation reveals worsening crackles and dyspnea, or when hemodynamic parameters indicate abnormalities—such as decreased cardiac output or elevated pressures—critical interventions may be necessary. Prioritizing accurate readings, zeroing the transducer, and anticipating medication adjustments or additional interventions like dobutamine may be warranted to stabilize the patient.
Shock is defined as a state of inadequate tissue perfusion resulting in impaired cellular function and potential organ failure. Various forms of shock—cardiogenic, hypovolemic, distributive, and obstructive—can develop based on underlying factors that compromise oxygen delivery. Cardiogenic shock arises from the heart’s inability to pump adequately, often due to conditions such as myocardial infarction or cardiomyopathy. Hypovolemic shock is the most common type and is primarily caused by inadequate fluid volume within the intravascular space. Distributive shock, encompassing septic, anaphylactic, and neurogenic forms, involves systemic vasodilation. Obstructive shock, meanwhile, results from a physical impediment to blood flow, like a pulmonary embolism.
To manage these states, nurses prioritize assessments and interventions specific to each shock type. For example, in cardiogenic shock, cardiac output, stroke volume, and oxygen delivery are critical metrics requiring optimization. Hemodynamic monitoring, medication administration, oxygen therapy, and possibly mechanical assist devices (such as intraaortic balloon pumps or ventricular assist devices) are used to support cardiac function and tissue perfusion. Nurses should be adept at interpreting diagnostic markers like cardiac biomarkers, B-type natriuretic peptide (BNP), and other parameters to guide treatment.
In hypovolemic shock, intravascular volume reduction leads to decreased venous return, reduced stroke volume, and diminished cardiac output, all of which jeopardize adequate tissue perfusion. Absolute hypovolemia results from direct fluid loss, while relative hypovolemia involves fluid shifts from the intravascular to the extravascular compartments. Initial compensatory mechanisms, such as the release of catecholamines, aldosterone, and antidiuretic hormone, help maintain vital organ perfusion. However, substantial fluid loss beyond 30% overwhelms compensatory efforts, leading to hypotension, impaired renal function, and decreased cerebral perfusion.
Early signs of hypovolemic shock include anxiety, tachycardia, delayed capillary refill, and pallor. In managing hypovolemic shock, prompt volume replacement with warmed crystalloid solutions or blood products is essential. In severe cases, medical management may also include vasopressors to maintain hemodynamic stability. Monitoring intake, output, laboratory studies, and hemodynamic parameters is critical in managing hypovolemic shock and ensuring effective intervention.
| CRRT Nursing Care | Shock Types | Medical Interventions for Shock |
|---|---|---|
| – Baseline assessment | Cardiogenic Shock | – Goal: Optimize cardiac output and oxygenation |
| – Monitor hourly CRRT output | – Results from cardiac insufficiency | – Oxygen therapy to achieve PaO₂ > 80 mmHg |
| – Adjust fluid replacement | – Decreased CO, increased PAWP, CVP | – Medications: Nitrates, Diuretics, Beta-blockers |
| – Neurologic, electrolyte assessments | Hypovolemic Shock | – Fluid replacement: 3:1 crystalloid for blood loss |
| – Infection and coagulation monitoring | – Caused by intravascular volume loss | – Hemodynamic support with dopamine |
| – Ensure circuit patency | – Commonly from hemorrhage, burns | – Continuous monitoring of VS and lab values |
| – Temperature and bleeding checks | Distributive Shock | Device Interventions |
| – Results from systemic vasodilation | – Intraaortic Balloon Pump to decrease cardiac workload | |
| Hemodynamic Monitoring | – Includes septic, anaphylactic types | – Extracorporeal Life Support for severe cases |
| – Locate and zero transducer | Obstructive Shock | |
| – Positioning at phlebostatic axis | – Caused by blood flow obstruction | |
| – Zero monitor for accuracy | – E.g., pulmonary embolism |
Blood Loss and Shock Types
When blood loss reaches a critical level of 1500 ml, immediate administration of packed red cells, along with fresh frozen plasma and platelets, is essential to restore clotting factors. Maintaining arterial oxygen saturation is crucial, often achieved through supplemental oxygen or mechanical ventilation. For unstable patients, positioning in the supine position can assist in stabilizing vital functions.
In cases of distributive shock, widespread vasodilation and increased capillary permeability lead to pooling of blood within the vessels, causing tissue hypoperfusion and impaired cellular metabolism. Distributive shock encompasses three primary types: neurogenic, septic, and anaphylactic.
Neurogenic Shock
Neurogenic shock typically occurs within 30 minutes following a spinal cord injury, especially in the cervical or high thoracic region, and can persist for up to six weeks. This type of shock results from a significant loss of sympathetic nervous system vasoconstrictor tone, leading to extensive vasodilation. Key indicators include hypotension (due to vasodilation), bradycardia (from unopposed parasympathetic tone), and hypothermia due to hypothalamic dysfunction affecting temperature regulation.
Septic Shock
Septic shock arises from an overwhelming inflammatory response, commonly triggered by gram-positive or negative bacterial infections, leading to systemic inflammatory response syndrome (SIRS) and subsequent shock. Common symptoms include tachypnea, tachycardia, and hypotension. Respiratory failure is frequent, initially presenting as respiratory alkalosis due to compensatory hyperventilation, eventually progressing to respiratory acidosis. Other signs include variable temperature and skin changes, progressing from warm and flushed to cool and mottled.
Anaphylactic Shock
This life-threatening hypersensitivity reaction occurs in response to an external agent, causing sudden and severe vasodilation, release of vasoactive mediators, and increased capillary permeability. This rapid response leads to relative hypovolemia, diminished cardiac output, and respiratory distress marked by symptoms like laryngeal edema, bronchospasm, tachycardia, dyspnea, and chest pain.
Effective management of distributive shock varies by type. For neurogenic shock, treatment includes stabilizing the spine and using vasopressors to maintain blood pressure. Septic shock management focuses on IV fluid resuscitation, vasopressors, antibiotics, and glucose control. For anaphylactic shock, maintaining an open airway is paramount, with medications like epinephrine, IV fluids, and antihistamines used to counteract the reaction.
Obstructive shock results from physical obstruction in blood flow, commonly due to conditions like cardiac tamponade, tension pneumothorax, or pulmonary embolism. Symptoms include decreased cardiac output and increased afterload. Management focuses on relieving the obstruction through interventions like mechanical decompression, anticoagulant therapy, or surgery, depending on the cause.
Acute kidney injury (AKI) denotes a sudden decline in kidney function, often associated with life-threatening conditions such as shock or heart failure. Prerenal, intrarenal, and postrenal causes vary from decreased blood flow and glomerular perfusion to direct tissue damage from nephrotoxins or physical obstructions. Nursing care aims to monitor and address complications like fluid imbalance, metabolic acidosis, and electrolyte disturbances to stabilize kidney function.
| Type of Shock | Key Characteristics | Management Approach |
|---|---|---|
| Neurogenic Shock | Hypotension, bradycardia, hypothermia due to loss of sympathetic tone following spinal cord injury | Stabilize spine, vasopressors for BP, atropine for bradycardia |
| Septic Shock | Tachypnea, tachycardia, hypotension; causes respiratory failure, hyperventilation, skin changes from warm to cool | IV fluid replacement, vasopressors, antibiotics, glucose control, hemodynamic monitoring |
| Anaphylactic Shock | Respiratory distress (laryngeal edema, bronchospasm), tachycardia, dizziness, chest pain, pruritus, urticaria | Airway management, epinephrine, IV fluids, antihistamines, corticosteroids |
| Obstructive Shock | Decreased cardiac output, jugular vein distention, caused by physical obstructions like pulmonary embolism | Relieve obstruction (mechanical decompression, anticoagulants, surgical intervention) |
| Acute Kidney Injury (AKI) | Impaired kidney function with elevated serum creatinine, BUN, hyperkalemia, risk of progression to chronic kidney disease | Manage fluid, electrolyte balance, monitor for signs of complications such as metabolic acidosis and hyperkalemia |
| Complications of AKI | Includes fluid volume overload, metabolic acidosis, sodium imbalance, and increased risk of infections | Fluid replacement, monitoring for metabolic acidosis, emergency treatment for hyperkalemia, infection prevention |
As nitrogenous waste products build up in the brain, various neurologic changes can occur. Initial symptoms may include fatigue and difficulty concentrating. As the condition progresses, more severe manifestations such as seizures and coma may develop.
The primary goals in managing AKI are eliminating the underlying cause, managing symptoms, and preventing complications.
Dialysis is essential for removing waste products and correcting fluid and electrolyte imbalances. There are two primary types:
Peritoneal Dialysis: Uses the peritoneal membrane as a semipermeable barrier. Although suitable for AKI, hemodialysis is more common.
Hemodialysis: Uses an artificial membrane in contact with the blood. Indications for hemodialysis include a glomerular filtration rate (GFR) below 15 mL/min and complications like encephalopathy and hyperkalemia.
CRRT is used to manage fluid overload and hemodynamic instability in critically ill patients. Unlike intermittent hemodialysis, CRRT offers continuous, gentle removal of fluids and waste, improving hemodynamic stability and reducing the risk of cerebral edema. CRRT is primarily used when other methods are insufficient, and its duration can extend up to 30-40 days, with the hemofilter changed every 24-48 hours (Granado & Mehta, 2016).
DDS may occur during initial dialysis sessions due to rapid fluid shifts, causing cerebral edema and neurologic symptoms such as headache, confusion, and muscle cramps. Treatment involves discontinuing dialysis and providing supportive care, including airway management and osmotic diuretics.
In AKI, nutritional support aims to maintain caloric intake and minimize protein breakdown. Patients are advised to consume 30-35 kcal/kg of body weight, prioritize calories from carbohydrates and fats, and restrict sodium intake to prevent edema. Enteral nutrition is preferred, with parenteral nutrition used only if gastrointestinal function is impaired.
Effective nursing assessment and intervention are crucial in managing AKI. Key responsibilities include:
Assembly Health and Senior Services Committee Statement to Assembly, No. 4098 State of New Jersey. Njleg.state.nj.us. (2011). Retrieved from https://www.njleg.state.nj.us/2010/Bills/A4500/4098_S1.PDF.
Durable Powers of Attorney for Health Care. Lawhelp.org. (2016). Retrieved from https://www.lawhelp.org/dc/resource/frequently-asked-questions-about-durable-power.
New Jersey Board of Nursing: Law and Public Safety. Njconsumeraffairs.gov. (2020). Retrieved from https://www.njconsumeraffairs.gov/regulations/Chapter-37-New-Jersey-Board-ofNursing.pdf.
American Association of Critical-Care Nurses. (2020). Critical care nursing care guidelines. AACN Publications.
Johnson, K., & Foster, L. (2019). Essentials of shock management in nursing practice. Elsevier.
Roberts, R., & Weber, T. (2021). Continuous renal replacement therapy and hemodynamic support in intensive care. Springer.
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