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BODY FLUIDS- as primary body fluid, water is most important nutrient of life - humans can survive for only a few days without water 1. FUNCTIONS OF WATER • provide medium for transporting nutrients to cells, wastes from cells, and substances such as hormones, enzymes, blood platelets, and red and white blood cells • facilitate cellular metabolism an d proper cellular chemical functioning • act as solvent for electrolytes and nonelectrolytes • help maintain normal body temperature • facilitate digestion and promote elimination • act as tissue lubricant BODY FLUID COMPARTMENTS a. Intracellular fluid (ICF) - within cells
b. Extracellular fluid (ECF) - all fluid outside cells, including intravascular (plasma – liquid component of blood) and interstitial (fluid that surrounds tissue cells and includes lymph) fluids total body water – total amt of water in body expressed as % of body weight VARIATIONS IN FLUID CONTENT - in a healthy person, total body water constitutes about 50 – 60% of body’s weight, depending on age, lean body mass, and sex - total body water differs by sex and person’s amt of fat cells - fat cells contain little water while lean tissue is rich in water - women tend to have proportionally more body fat than men, they also have less body fluid than men - decreasing % body fluid in older people is related to increase in fat cells B. ELECTROLYTES electrolyte – substance capable of breaking into electrically charged ions when dissolved in a solution cations – ions that develop a positive charge develop a negative charge anions – ions that 3.
1. SODIUm (NA+) chief electrolyte of ECF that moves easily between intravascular and interstitial spaces and moves across cell membranes by active transport - influential in many chemical reactions in body, particularly nervous and muscle tissue cells - controls and regulates volume of body fluids; maintains water balance throughout the body - primary regulator of ECF volume and influences ICF - participates in generation and transmission of nerve impulses - essential electrolyte in sodium-potassium pump - normal extracellular concentration: 135 – 145 mEq/L 2. POTASSIUM (K+) – major cation of ICF working in reciprocal fashion with sodium (excessive intake of sodium results in excretion of potassium, vice versa) - chief regulator of cellular enzyme activity and cellular water content - plays vital role in such processes as transmission of electric impulses, particularly nerve, heart, skeletal, intestinal, and lung tissue; protein and carbohydrate metabolism, and cellular bldg. - adequate qty. usually in well-balanced diet - food sources include bananas, peaches, kiwi, figs, dates, apricots, oranges, prunes, melons, raisins, broccoli, potatoes, meat and dairy products - excreted primarily by kidneys, however, there are large amts in GI secretions and some in perspiration and saliva - normal range for serum: 3.5 – 5 mEq/L 3. CALCIUM (CA+) – most abundant electrolyte, with up to 99% of total found in iodized form of bones and teeth - close link between concentrations of calcium and phosphorus - necessary for nerve impulse transmission and blood clotting - catalyst for muscle contraction - needed for vitamin B12 absorption and its use by body cells - acts as catalyst for most cell chemical activities - necessary for strong bones and teeth - determines thickness and strength of cell membranes - adult avg. daily requirement about 1 g, higher amts. according to body wt. required for children and pregnant and lactating women - 1,500 mg/day recommended consumption for older adults, particularly postmenopausal women and men older than 65 - sources include milk, cheese, and dried beans, some present in meats and vegetables
- excreted in urine, feces, bile, digestive secretions, and perspiration 4. MAGNESIUM (MG2+) – most cation found within body cells – heart, bone, nerve, and muscle tissues - 2nd most important cation in ICF - important for metabolism of carbohydrates and proteins - important for many vital reactions involving enzymes - necessary for protein and DNA synthesis, DNA and RNA transcription, and translation of RNA - maintains normal intracellular levels of potassium - helps maintain electrical activity in nervous tissue and muscle membranes - adult daily avg. requirement about 18 – 30 mEq, with children requiring larger amts. - found in most foods, but especially in vegetables, nuts, fish, whole grains, peas and beans 5. CHLORIDE (CI-) – chief extracellular anion, found in blood, interstitial fluid, and lymph and in minute amts. in ICF - acts with sodium to maintain osmotic pressure in blood - plays a role in body’s acid-base balance - has important buffering action when oxygen and carbon dioxide exchange in red blood cells - essential for production of hydrochloric acid in gastric juices - found in foods high in sodium, dairy products, and meat - deficit leads to potassium deficit, and vice versa - normal serum levels: 95 – 105 mEq/L 6. body - found in both ECF and ICF - essential for acid-base balance; bicarbonate and carbonic acid constitute body’s primary buffer system - losses possible via diarrhea, diuretics, and early renal insufficiency - excess possible via overingestion of acid neutralizers, such as sodium bicarbonate - normal levels range between 25 – 29 mEq/L PHOSPHATE (PO4-) - major anion in body cells - buffer anion in both ICF and ECF - helps maintain body’s acid-base balance - involved in important chemical reactions in body (necessary for many B vitamins to be effective, helps promote nerve and muscle action, plays a role in carbohydrate metabolism) 7. BICARBONATE (HCO3-) – anion that is major chemical base buffer within
- important for cell division and transmission of hereditary traits - avg. daily requirements similar to calcium - found in most foods but especially in beef, pork, and dried peas and beans - inversely proportionate to calcium - - increase in one results in decrease of the other - normal range: 2.5 – 4.5 mEq/L C. FLUID
ELECTROLYTE MOVEMENT - ECF provides nourishment to each body cell and receives cell’s waste - these exchanges are essential to life
products 1. OSMOSIS – through semipermeable membranes, water (pure solvent) is able to be transported through cell walls - major method of transporting body fluids - through osmosis, water passes from an area of lesser solute concentration to an area of greater solute concentration until equilibrium is established - the greater the concentration of the two solutions, the greater the osmotic pressure or drawing power of water osmolarity – concentration of particles in a solution, or its pulling, power isotonic – solution that has about the same concentration of particles (osmolarity) as plasma - remains in intravascular compartment w/out any net flow across semipermeable membrane hypertonic – solution has greater osmolarity than plasma - water moves out of cells and is drawn into intravascular compartment, causing cells to shrink hypotonic – solution has less osmolarity than plasma - solution in intravascular space moves out and into intracellular fluid, causing cells to swell and possibly burst 2. DIFFUSION – tendency of solutes to move freely throughout a solute; “coasting downhill” - moves from area of higher concentration to an area of lower concentration until equilibrium is established - gases move by diffusion - oxygen and carbon dioxide exchange in the lung’s alveoli and capillaries by diffusion
3. ACTIVE TRANSPORT – process that requires energy for movement of substances through a cell membrane from an area of lesser solute concentration to an area of higher concentration - adenosine triphosphate makes it possible for certain substances to acquire energy needed - energy requirements for active transport are affected by characteristics of cell membrane, specific enzymes, and concentrations of ions - “pumping uphill” - substances include amino acids, glucose (in certain places only - kidneys, intestines), and ions of sodium, chloride, potassium, hydrogen, phosphate, calcium, and magnesium 4. FILTRATION – passage of fluid through permeable membrane from area of high pressure to lower colloid osmotic pressure (oncotic pressure) certain substances, such as plasma proteins, which have high molecular weights on permeable membranes in the body hydrostatic pressure – force exerted by fluid against container wall - blood hydrostatic pressure is the pressure of plasma and blood cells in the capillaries - depends primarily on arterial blood pressure on arteriolar side of capillaries, and on venous blood pressure on venular side of capillaries - filtration pressure is the difference between colloid osmotic pressure and blood hydrostatic pressure - these pressures are important in understanding how fluid leaves arterioles, enters interstitial compartment, and eventually returns to venules - positive pressure in arterioles - - helping to force or filter fluids into interstitial space - negative pressure in venules - - helping fluid enter venules D. FLUID BALANCE - desirable amt of fluid intake and loss in adults ranges from 1500 – 3500 mL each 24 hrs., with most people averaging 2500 mL/day - individual’s health state as well as balance between actual intake and loss must be considered - intake should normally be approx. balanced by output or fluid loss - may not always occur in a single 24-hr. period but should be achieved within 2 – 3 days 1. FLUID SOURCES
Ingested Liquids – makes up largest amt of water intake - primarily regulated by thirst mechanism - stimulated by intracellular dehydration and decreased blood volume b. Water in Food – 2nd largest source of water - depends on diet
c. Water from Metabolic Oxidation – occurs during metabolism of food substances, specifically, carbohydrates, fats, and proteins - source varies among different types of nutrients 2. FLUID LOSSES – through kidneys as urine, intestinal tract in feces, and skin as perspiration (sensible losses) - insensible losses include ex. of invisible amt of water lost from skin constantly through evaporation and from the lungs exhaled as breaths - losses vary according to person and circumstances - any deviations from normal ranges for a balanced water intake and output should alert nurse to potential imbalances 3. HOMEOSTATIC MECHANISMS – almost every organ and system in the body helps fluid homeostasis function automatically and effectively: • kidneys (master chemists) selectively retain electrolytes and water and excrete wastes and excesses • cardiovascular system is responsible for pumping and carrying nutrients and water • lungs regulate oxygen and carbon dioxide levels - - carbon dioxide is especially crucial in maintaining acid-base balance • adrenal glands secrete aldosterone which helps body conserve sodium, helps save chloride and water, and causes potassium to be excreted • thyroxine (from thyroid gland) increases blood flow leading to increased renal circulation, resulting in increased glomerular filtration and urinary output • parathyroid glands secrete parathyroid hormone, regulating level of calcium in ECF • GI tract absorbs water and nutrients • nervous system (acting as switchboard to inhibit and stimulate mechanisms) regulates sodium and water intake and excretion
ACID-BASE BALANCE - body fluids must maintain acid-base balance to sustain health and life - acidity or alkalinity of solution is determined by concentration of hydrogen ions (H+) acid – substance containing hydrogen ions that can be liberated or released - strong acid dissociates (separates) completely and releases all hydrogen ions - weak acid releases only a small number of hydrogen ions base (alkali) – substance that can accept or trap hydrogen ions - strong base binds/accepts H+ easily - weak base doesn’t accept H+ easily pH – unit of measure used to describe acid-base balance - expression of hydrogen ion concentration and resulting acidity or alkalinity of a substance - scale ranges from 1 to 14 - neutral solution measures 7 (ex. pure water) - as hydrogen ions increase the solution becomes more acid, pH is less than 7 - as hydrogen ions decrease the solution becomes more alkaline, pH is greater than 7 - normal blood plasma is slightly alkaline and has a normal pH range of 7.35 – 7.45 - when blood plasma pH exceeds normal range in either direction, signs and symptoms of illness appear - if deviation goes unabated, death results acidosis – condition characterized by excess hydrogen ions in ECF in which pH falls below 7.35 alkalosis – lack of hydrogen ions and pH exceeds 7.45 1. system CARBONIC ACID-SODIUM BICARBONATE BUFFER SYSTEM – most important buffer
- buffers either act like a base and bind or soak up free hydrogen ions or act like an acid and release hydrogen ions when too few are present in a solution - normal ECF has a ratio of 20 parts bicarbonate to 1 part carbonic acid - exact quantities are unimportant as long as they remain a 20:1 ratio 2. PHOSPHATE BUFFER SYSTEM – active in intracellular fluids - converts alkaline sodium phosphate (weak base) to acid in the kidneys
3. PROTEIN BUFFER SYSTEM – mixture of plasma proteins and globin portion of hemoglobin in red blood cells - tend to minimize changes in pH and serve as excellent buffering agents over a wide range of pH values F. DISTURBANCES IN FLUID, ELECTROLYTE, AND ACID-BASE BALANCE 1. FLUID IMBALANCES – occur when body’s compensatory mechanisms are unable to maintain homeostatic state - involve either volume or distribution of water or electrolytes Fluid Volume Deficit - result from loss of body fluids, especially if fluid intake is simultaneously decreased - 5% wt loss is considered pronounced deficit - 8% wt loss or more is considered severe - 15% wt loss is usually life-threatening hypovolemia – deficit caused by deficiency in amt of both water and electrolytes in ECF when water and electrolyte proportions remain near normal - both osmotic and hydrostatic pressure changes force interstitial fluid into intravascular space - interstitial space is depleted, fluid becomes hypertonic, cellular fluid is drawn into interstitial space, leaving cells without adequate fluid to function properly - young children, elderly, and people who are ill are especially at risk dehydration – decreased volume of water, but water is not decreased without electrolyte changes also hydration – union of a substance with water - used to indicate normal water volume in the body 3rd space fluid shift – distributional shift of body fluids into potential body spaces such as pleural, peritoneal, pericardial, or joint cavities; bowel; or interstitial space - once trapped, fluid is not easily exchanged with ECF, deficit occurs - fluid is trapped but not lost - - essentially unavailable for use - may occur as a result of severe burn, bowel obstruction, or pancreatitis a.
- decreased body wt does not occur, nor can fluid loss be measured - treatment is directed toward correction of cause Fluid Volume Excess hypervolemia – excessive retention of water and sodium in ECF in near-normal proportions resulting in fluid volume excess overhydration – above-normal amts of water in extracellular spaces - common causes include malfunction of kidneys, causing inability to excrete excesses, and failure of heart to function as a pump, resulting in accumulation of fluid in lungs and dependent parts of the body - when water is retained, so is sodium edema – excessive ECF accumulated in tissue spaces - because of increased extracellular osmotic pressure, fluid is pulled from cells to equalize tonicity - by the time intracellular and extracellular spaces are isotonic, an excess of both water and sodium is in ECF - observed around eyes, fingers, ankles, and sacral space and later in or around body organs - may result in wt gain in excess of 5%; excess fluid remains in intravascular space – concentration of solids in blood decreases Grading Scale: volume 30% above norm fairly normal contours 3+ = deep pit; remains several seconds after pressing; skin swelling obvious by general inspection 4+ = deep pit; remains for prolonged time after pressing, possibly minutes; frank swelling Brawny Edema = fluid can no longer be displaced secondary to excessive 1+ = slight indentation; normal contours; fluid b.
2+ = deeper pit after pressing; lasts longer than 1+;
interstitial fluid accumulation; no pitting; tissue palpates as firm or hard; skin surface shiny, warm, moist interstitial-to-plasma shift (hypervolemia) – movement of fluid from space surrounding cells to the blood - compensatory response to volume or osmotic pressure changes of intravascular fluid ELECTROLYTE IMBALANCES – commonly involve deficit or excess of electrolyte a. Hyponatremia – sodium deficit in ECF caused by loss of sodium or gain of water - osmotic pressure changes result in ECF moving into cells causing prints from examiner’s fingers to remain on pt’s skin over the sternum when pressure is applied Hypernatremia – surplus of sodium in ECF that can result from excess water loss or an overall excess of sodium Hypokalemia – potassium deficit in ECF - extracellular potassium level falls, potassium moves from cell creating intracellular potassium deficiency - sodium and hydrogen ions are retained to maintain isotonic fluids - influences normal cellular functioning, pH of ECF, and functions of most body systems - skeletal muscles are generally 1st to demonstrate signs/symptoms - typical signs include muscle weakness and leg cramps Hyperkalemia – excess of potassium in ECF - can be hazardous - - transmission of stimuli through heart muscle is slowed or prevented, and cardiac arrest eventually occurs if not corrected Hypocalcemia – calcium deficit in ECF - if prolonged, calcium is taken from bones, resulting in osteomalacia, characterized by soft and pliable bones - common signs include numbness and tingling of fingers, muscle cramps, and tetany c. b. 2.
Hypercalcemia – excess of calcium of ECF - emergency situation leading to cardiac arrest d. Hypomagnesemia – magnesium deficit where potassium level also drops because the kidneys tend to excrete more potassium when magnesium supplies are poor - hypomagnesemia and hypokalemia often occur together Hypermagnesemia – magnesium excess that can occur in endstage renal failure when kidneys fail to excrete magnesium and excessive amts are administered therapeutically e. Hypophosphatemia – below-normal serum concentration of inorganic phosphorus - many factors may lower serum levels while total-body phosphorus stores are normal Hyperphosphatemia – above-normal serum concentrations of inorganic phosphorus ACID-BASE IMBALANCE - arterial blood gases (ABGs) are common lab test used in assessment acid-base imbalance - venous blood results are only specific for particular extremity or area where blood is drawn and do not provide information on how well lungs are oxygenating blood - pH of plasma indicates balance or impending acidosis or alkalosis - carbon dioxide (PaCO2) is influenced almost entirely by respiratory activity - when low, carbonic acid leaves body in excessive amts - when high, there are excessive amts of carbonic acid in body - imbalances occur when carbonic acid or bicarbonate levels become disproportionate a. of carbon dioxide - lungs are source of problem and are unable to participate in compensation - high PaCO2 because of alveolar hypoventilation b. Respiratory Alkalosis – primary deficit of carbonic acid in ECF Respiratory Acidosis – primary excess of carbonic acid in ECF - any decrease in alveolar ventilation that results in retention 3.
- result of increased alveolar ventilation and consequent decrease in carbon dioxide - increase in respiratory rate and depth causes loss because carbon dioxide is excreted faster than normal - deficit of carbon dioxide depresses or ceases respirations - lungs are source of problem and are unable to participate in compensation - low PaCO2 because of alveolar hyperventilation c. bicarbonate - lungs attempt to increase carbon dioxide excretion by increasing rate and depth of respirations - kidneys attempt to compensate by retaining bicarbonate and excreting move H+ - if attempts are unsuccessful, body may lose consciousness and death can occur d. or retention - body attempts to compensate by retaining carbon dioxide - respirations become slow and shallow with periods of no breathing at all - kidneys excrete potassium and sodium with excessive bicarbonate and retain H+ in carbonic acid Metabolic Alkalosis – primary excess of bicarbonate in ECF - result of excessive acid losses or increased base ingestion Metabolic Acidosis – proportionate deficit of bicarbonate in ECF - result of increase in acid components or excessive loss of
- imbalances can seriously compromise the patient’s health status and may prove life-threatening - nursing assessment is directed toward: • identifying patients at high risk for fluid, electrolyte, and acid-base imbalance • determining that a specific imbalance is present and identifying the nature of the imbalance along with severity, etiology, and defining characteristics • determining effectiveness of plan of care A. COMPARISON OF INTAKE AND OUTPUT - intake should include all fluids taken into the body volume deficit - when intake is substantially less than output
- output should include urine, vomitus, diarrhea, drainage (fistulas, suction, lesions), perspiration - prolonged hyperventilation should be noted
volume excess – when intake is substantially more than output B. URINE VOLUME AND CONCENTRATION - factors that can alter urinary output must be accounted for: • amt of fluid intake • losses from skin, lungs, and GI tract • amt of waste products for excretions • renal concentrating ability • blood volume • hormonal influences - low urine volume with high specific gravity = volume deficit - low urine volume with low specific gravity = renal disease - high urine volume = volume excess
BODY WEIGHT - believed to be more accurate indicator of fluid gained and lost - use same scale ea. time at the same time ea. day (in morning, before breakfast, after voiding) wearing the same or similar dry clothing - use a bed scale if patient is unable to stand - rapid variations in wt. reflect changes in body fluid volume - 2% loss of total body wt (TBW) = mild volume deficit - 2% gain of TBW = mild volume excess - 5% loss of TBW = moderate volume deficit - 5% gain of TBW = moderate volume excess - 8% loss of TBW = severe volume deficit - 8% gain of TBW = severe volume excess D. TONGUE TURGOR - skin over sternum, inner aspect of thighs, or forehead is pinched; with children over the abdominal are and on medial aspect of thighs - with volume deficit skin flattens more slowly after pinch and may remain elevated for many seconds - can vary with age, nutritional state, and even race and complexion - severe malnutrition can cause depressed skin turgor - tongue turgor is not affected appreciably by age and is useful assessment for all age groups - with volume deficit, additional longitudinal furrows and tongue is smaller - sodium excess causes tongue to look red and swollen
DEGREE OF MOISTURE IN ORAL CAVITY - dry mouth may be result of volume deficit or mouth breathing - dryness of membrane = volume deficit - dry sticky mucous membranes = sodium excess
TEARING AND SALIVATION - decrease normally with age - absence in a child = volume deficit - obvious with 5% loss of TBW APPEARANCE AND TEMPERATURE OF SKIN - metabolic acidosis can cause warm, flushed skin
FACIAL APPEARANCE - severe volume deficit = pinched and drawn facial expression - volume deficit of 10% = decreased intraocular pressure, eyes appear sunken and feel soft to touch I. EDEMA - measurement of extremity or body part with millimeter tape is more exact method of measurement - edema not usually apparent until retention of 5 – 10 lbs of excess - excess of interstitial fluid accumulating predominantly in lower extremities of ambulatory pts. and presacral region of bed-ridden pts - pitting edema not evident until at least 10% increase in wt - may be localized (thrombophlebitis) or generalized (heart failure, cirrhosis) - presence of periorbital edema or pedal edema should prompt investigation in other body parts J. VITAL SIGNS 1. BODY TEMPERATURE – fever increases loss of fluids; important for early detection and interventions - elevations probably related to lack of available fluid for sweating - decrease temperature with volume deficit uncomplicated by infection - elevation between 101 – 103 increases fluid requirements by 500 mL/day - above 103 increases it by 1000 mL/day 2. PULSE – tachycardia is the earliest sign of decreased vascular volume associated with volume deficit - irregular pulse with potassium imbalances and magnesium deficit - pulse volume is decreased in volume deficit and increased in volume excess 3. RESPIRATIONS – deep, rapid respirations may be compensatory for metabolic acidosis or disorder causing respiratory alkalosis - slow, shallow respirations may be compensatory for metabolic alkalosis or disorder causing respiratory acidosis - moist crackles = volume excess
BLOOD PRESSURE – check while pt is lying down, sitting and standing - a systolic fall greater than 15 mm Hg from lying to sitting or standing position = volume deficit K. NECK VEINS AND CENTRAL VENOUS PRESSURE (CVP) – position pt in semi-Fowler’s position (head 30 – 40° angle) with neck straight and constricting clothing removed - provide adequate lighting and measure levels of distention on neck or above manubrium - low CVP may indicate a) decreased blood volume, b) drug-induced vasodilation - high CVP may indicate a) increased blood volume, b) heart failure, c) vasoconstriction - more accurate measurements by hemodynamic monitoring L. NEUROMUSCULAR IRRITABILITY - to test for Chvostek’s sign, facial nerve should be percussed anterior to ear lobe - to test for Trousseau’s sign, blood pressure cuff is inflated for 3 minutes - deep tendon reflex is elicited and may be hyperactive with hypocalcemia, hypomagnesemia, hypernatremia, and alkalosis - muscle being tested should be slightly stretched and patient relaxed - deep tendon reflex may be hypoactive with Hypercalcemia, hypermagnesemia, hypokalemia, and acidosis - reflex graded as: 0 = no response +1 = somewhat diminished but present +2 = normal +3 = brisker than avg.; possibly indicative of disease +4 = hyperactive
PLANNING / NURSING DIAGNOSIS
EXCESS FLUID VOLUME - may result from greatly increased intake or decreased excretion
DEFICIENT FLUID VOLUME - may result from decreased intake, increased excretion, fluid shifts, and special needs in strenuous exercise, extreme heat or dryness, and conditions that increase metabolic rate RISK
IMBALANCED FLUID VOLUME
- maintain approximate balance between intake and output - maintain urine specific gravity within normal range - practice self-care behaviors to promote fluid, electrolyte, and acid-base balance
- maintain adequate intake - respond appropriately to signals of impending imbalance - when imbalance exists: • relate relief of symptoms after implementations and treatment • exhibit signs and symptoms of restored balance or homeostasis • identify signs and symptoms of recurrence of imbalance
- interventions include dietary modifications, modification of intake, medication admin., IV therapy, blood and blood products replacement, and TPN A. PREVENTING FLUID IMBALANCES - adequate intake and well-balance, nutritious diet with appropriate adjustments are essential - general measures to help prevent fluid imbalances: • be familiar with events that can lead to fluid imbalances, and observe pt carefully - loss of fluid because of illness can cause serious and lifethreatening problems • note pt’s present intake, learn previous eating/drinking patterns • note whether pt experiences excessive thirst or little or no thirst • be aware of excessive losses of fluids, attempt to prevent • consider ways medical regimen may lead to imbalances • learn whether pt has been “treating” him/herself that may threaten fluid balance (enemas, laxatives, antacids, OTC drugs that promote urination) • consider conditions with destructive effects as threats to balance (immobilization, trauma, burns, surgical procedures, exposure to toxic agents) • teach pts to observe for imbalances and report them promptly (rapid wt gains/losses, swollen fingers, feet, and ankles, puffy eyelids, muscle weakness, chg in skin sensations, scanty or profuse urine) • be aware of normal physiologic chgs associated with aging (dehydration) B. DEVELOPING DIETARY PLAN - initiate teaching that involves both pt and person preparing meals - provide pt with written list for reference - evaluate pt’s understanding of teachings (describe 24-hr diet plan)
1. Modifying Fluid Intake – increase, decrease, or modify in terms of types ingested - identify appropriate fluid modification - determine whether pt understands rationale, is motivated to follow modification, and is
capable of adhering to the plan - develop and implement plan of care based on preceding information
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