Unit 10 Fluid Balance

Key terms Dehydration Edema Graduate Intake output 2

Fluid Balance Water is needed to live. Death can result from too much or too little water. Water is ingested through fluids and foods. Water is lost through urine, feces, and vomit. It is also lost through the skin (perspiration) and the lungs (exhalation.) Fluid balance is needed for health. The amount of fluid taken in (intake) and the amount of fluid lost (output) must be equal. When fluid intake exceeds fluid output body tissues swell with water (edema). Edema is common in people with heart and kidney diseases. Dehydration is a decrease in the amount of water in body tissues. Fluid output exceeds intake. 3

Normal Fluid Requirements An adult needs 1500 mL (milliliters) of water daily to survive. About 2000 to 2500 ml are needed for normal fluid balance. The water requirements increases with hot weather, exercise, fever, illness, and excess fluid losses. 4

Special Fluid Orders The doctor may order the amount of fluid a person can have during a 24-hour period. This is done to maintain fluid balance. Encourage fluids- the person drinks an increased amount of fluid. The person is given a variety of fluids allowed on the diet. Restrict fluids-fluids are limited to a certain amount. They are offered in small amounts and in small containers. Nothing by mouth (NPO)- the person cannot eat or drink anything. Is ordered before and after surgery, before some tests and to treat certain illnesses. A sign is posted above the bed. Thickened liquids- all fluids are thickened, including water. The thickness depends on the person’s ability to swallow. 5

Intake and Output Records The doctor or nurse may order intake and output (I&O) measurements. They are used to evaluate fluid balance and kidney function. They help in planning medical treatment. They also are kept when the person has special fluid orders. All fluids taken by mouth are measured and recorded. So are foods that melt at room temperature. The nurse measures and records intravenous (IV) fluids and tube feedings. Output includes urine, vomitus, diarrhea, and wound drainage. 6

Measuring intake & Output Intake and output are measured in milliliters (mL). 1 ounce (oz) equals 30 mL 1 pints is about 500 mL 1 quart is about 1000 mL A measuring container for fluid is called a graduate. It is used to measure left-over fluids, urine, vomitus, and drainage from suction. Like a measuring cup, the graduate is marked in ounces and milliliters. Hold the measuring device at eye level to read the amount. An I&O record is kept at the bedside. The totals are recorded in the person’s chart and shared at the end-of- shift report. 7

Your role The purpose of measuring I&O and how to help are explained to the person. The urinal, commode, bedpan, or specimen pan is used for voiding. Remind the person not to void in the toilet. Also remind the person not to put toilet issue into the receptacle. 9

Examples of Fluids Water Milk Coffee Tea Juices Soups Soft drinks Ice cream Sherbet Custard Pudding Gelatin popsicles 10

Performance Skill #14: Calculate Intake and Output Wrote down the intake and output amounts in the units used to measure the intake and output quantities (i.e. cc=cubic centimeters, ml=milliliters, oz=ounces) Converted the measured unit into the units to be recorded on resident intake and output chart Calculated all the measured quantities listed as resident intake to obtain a total amount of intake for the time period Added all the measured quantities listed as resident output to obtain a total amount of output for the time period Recorded the total intake and output to be compared to the recorded intake and output calculation of the evaluator Slid e 11

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Unit 10 Collecting and Testing Specimens 13

Key Terms Glucosuria Glycosuria Hematoma Hematuria Hemoptysis Ketone Melena Sputum 14

Specimens Ordered by doctors, specimens (samples) are collected and tested to prevent, detect, and treat disease. Most specimens are tested in the laboratory. All specimens sent to the laboratory require requisition slips which has the person’s identifying information and the test ordered. Some tests are done at the bedside. 15

Urine Specimens The random urine specimen The random urine specimen is collected for a routine urinalysis (UA). No special measures are needed. It is collected any time during a 24-hour period. Many people can collect the specimen themselves. Weak and very ill persons need help. 16

Midstream specimen The midstream specimen (clean-voided specimen or clean-catch specimen). The perineal area is cleaned before collecting the specimen. This reduces the number of microbes in the urethral area. The person starts to void into a device. Then the person stops the urine stream, and a sterile specimen container is positioned. The person voids into the container until the specimen is obtained. Stopping the urine stream is hard for many people. You may need to position and hold the specimen container in place after the person starts to void. 18

24-hour urine specimen All urine voided during a 24-hour period is collected. Urine is chilled on ice or refrigerated during this time. This prevents the growth of microbes. For some tests, a preservative is added to the collection container. The person voids to begin the test with an empty bladder. Discard this voiding. Save all voidings for the next 24 hours. The test is restarted if: A voiding was not saved Toilet tissue was discarded into the specimen The specimen contains stools 20

Collecting a Urine specimen from an infant or child Sometimes specimens are needed from infants and children who are not toilet-trained. A collection bag (wee bag) is applied over the urethra. A parent or another staff member assists if the child is upset. Voiding on request is hard for toilet-trained toddlers and young children. Potty chairs and specimens pans are useful. Remember to use terms the child understands. Potty, tinkle, pee pee are examples. The nurse may ask you to give the child water or other fluids when a urine specimen is needed. Usually the child needs to void about 30 minutes after drinking fluids. 21

Testing Urine The doctor orders type and frequency of urine tests. Random urine specimens are needed. The nurse may ask you to do these simple urine tests. Testing for pH- urine pH measures if the urine is acidic or alkaline Testing for glucose and ketones- in diabetes, the pancreas does not secrete enough insulin. The body needs insulin to use sugar for energy. If not used, sugar builds up in the blood. Some sugar appears in the urine. Glucosuria/glycosuria means sugar in the urine. Ketones are substances that appear in urine from the rapid breakdown of fat for energy. The body uses fat for energy if it cannot use sugar. Tests for glucose and ketones are usually done 4 times a day (QID)- 30 minutes before each meal and at bedtime. The doctor uses the test to make drug and diet decisions. Testing for blood- Injury and disease can cause hematuria (blood in the urine) sometimes blood is seen in the urine. At other times it is unseen (occult). 23

Reagent strips Dipsticks are used to test urine. The strips have sections that change color when they react with urine. To use a reagent strip: Do not touch the test area on the strip. Dip the strip into urine. Compare the strip with the color chart on the bottle 24

Straining urine A stone (calculus) can develop in the kidney, ureter, or bladder. Stones (calculi) vary in size. They can be small as grains of sand, pearl-size or larger. Stones causing severe pain and urinary system damage may require removal by medical or surgical procedures. Some stones are passed through urine. So all of the person’s urine is strained. Passed stones are sent to the laboratory. The person drinks 8 to 12 glasses of water a day to help pass the stone. Expect the person to void in large amounts. 25

Stool Specimens Stools are checked and studied for blood, fat, microbes, worms, and other abnormal contents. Ulcers, colon cancer, and hemorrhoids are common causes of bleeding. Often blood is seen if bleeding is low in the bowels. Stools are black and tarry from bleeding in the stomach or upper gastrointestinal tract. Melana is black, tarry stool. Sometimes bleeding occurs in very small amounts. Then stools are tested for occult blood. Occult means “hidden” or “not seen”. The test is done to screen for colon cancer and other digestive disorders. The stool specimen must not be contaminated with urine. The person uses one device for voiding and another for BM. Some tests require a warm stool. The specimen is taken at once to the laboratory or storage area. 27

The specimen pan is placed at the back of the toilet for a stool specimen. A tongue blade is used to transfer a small amount of stool from the bedpan to the specimen container. 28

Sputum Specimens Respiratory disorders cause the lungs, bronchi, and trachea to secrete mucus. Mucus from the respiratory system is called sputum when expectorated (expelled) through the mouth. Sputum is not saliva. Saliva (spit) is a thin, clear liquid produced by the salivary glands in the mouth. Sputum specimens are studied for blood, microbes, and abnormal cells. The person coughs up sputum from the bronchi and trachea. This is often painful and hard to do. It is easier to collect a specimen in the morning. Secretions collect in the trachea and bronchi during sleep. They are coughed up on awakening. 29

Blood glucose testing Blood glucose testing is used for persons with diabetes. The doctor uses the results to regulate the person’s drugs and diet. Capillary blood is obtained through a skin puncture. The fingertip is the most common site for skin punctures. You will learn to use your agency’s device. Always follow the manufacturer’s instructions. 30