Mastering Fluids and Electrolytes: Key Concepts for Nursing
School
Louisiana State University, Eunice**We aren't endorsed by this school
Course
NURS 1230
Subject
Nursing
Date
Dec 11, 2024
Pages
57
Uploaded by ChancellorKuduPerson1237
FLUIDS & ELECTROLYTESDIURETICSNURS1232LSU - EuniceM. Foreman (Some slides from N 1132 and N 1230 lectures)Lehne 11thEd Ch 44 and 45, Giddens Concepts 8 & 17A&P CoursesReview all information in lecture classes (N 1130, N1132, N 1230)1
FLUIDS AND ELECTROLYTES - Lecture Content Outline•AGENTS AFFECTING VOLUME & ION CONTENT•1) Fluid Volume & Osmolality•A) Fluid deficit & Fluid excess•B) Volume contraction & expansion•C) Edema and 3rdspacing•2) ELECTROLYTE IMBALANCES –Know lab values (ranges vary with institution and references, use lab normal at your facility)Sodium (Na), Potassium (K), Calcium (Ca), Magnesium (Mg),Chloride (Cl) and Phosphate (PO4)•3) ACID BASE DISTURBANCES•4) DIURETIC AGENTS•Osmotic•Loop•Thiazides•Potassium sparing2
Colloids•Albumin, Blood products
Parenteral Solutions-Isotonic Fluids Isotonic SolutionsUseSpecial ConsiderationsDextrose 5% in water; D5W0.9% sodium chloride; NS Lactated Ringer’s; LRoFluid loss and dehydrationoShock oBlood transfusionsoResuscitationoFluid challengesoHypercalcemiaoDehydrationoBurnsoLower GI tract fluid lossoAcute blood loss-Solution is isotonic initially; becomes hypotonic when dextrose is metabolized. -Cautions: May cause▪Hyperglycemia with resuscitation▪Fluid overload in renal and cardiac disease -Since this replaces extracellular fluid, don’t use in patients with CHF, edema, or hypernatremia; can lead to overload. - Closely monitor the patient for signs of fluid overload-Contains potassium; don’t use with renal failure; can cause hyperkalemia.-Don’t use in liver disease because the patient can’t metabolize lactate; functional liver converts it to bicarbonate; don’t give if pH > 7.54
Parenteral Solutions-Hypotonic Fluids Hypotonic Solutions UseSpecial Considerations0.45% sodium chloride, ½ NSoWater replacementoHypertonic dehydration-Can cause a sudden fluid shift from blood vessels into cells. Resulting in cardiovascular collapse from intravascular fluid depletion and increased ICP from fluid shift into brain cells.-Contraindications: Increased ICP, from cerebrovascular accident, head trauma, or neurosurgery, and patients at risk for third-space fluid shifts.5
Parenteral Solutions-Hypertonic Fluids Hypertonic SolutionsUses Special Considerations3% NS, 5% NSDextrose 5% in ½ NS; (D5 ½ NS) Dextrose 5% in NS; (D5 NS)Dextrose 10% in NS; (D10W)oHypotonic overhydration -Don’t give to a patient with impaired heart or kidney function-his system can’t handle the extra fluid-Monitor serum glucose levels closely. 6
ELECTROLYTE IMBALANCES•Nurses monitor laboratory values to identify any electrolyte imbalances.•Electrolytes are minerals (sometimes called salts) that are present in all body fluids. •Laboratory tests can reflect electrolyte concentrations in Plasma, but not directly within cells.•Electrolytes regulate fluid balance and hormone production, strengthen skeletal structures, and act as catalysts in nerve response, muscle contraction, and the metabolism of nutrients.•When dissolved in water or another solvent, electrolytes separate into ions and then conduct either a positive (cations: sodium, potassium, calcium, magnesium) or negative (anions: phosphate, sulfate, chloride, bicarbonate) electrical current.•Electrolytes are distributed between intracellular fluid (ICF) and extracellular fluid (ECF) compartments.7
ELECTROLYTE IMBALANCES•Major electrolytes in the body include sodium, potassium, calcium,magnesium, phosphorus, and chloride.•We will be discussing these: KNOW NORMALS/ABNORMALS•Sodium imbalance•Potassium imbalance•Calcium imbalance•Magnesium imbalanceWhat about chloride and phosphate?•Chloride = 98 - 106mEq/L•Assists sodium in maintaining serum osmolality, blood volume, blood pressure, and pH of body fluids (acid/base balance).•Most of the chloride in your body comes from the “salt” you eat.•Sodium& chloride changes in direct proportion to one another.•Phosphate = 3.0-4.5 mg/dL•has an “inverse relationship” with Calcium•Phosphate up, calcium down; Phosphate down, calcium up•1:2 ratio P –C •Essential for bony tissue, nerve and muscle function, Vit-D absorption, metabolizes glucose and lipids for energy 8
SODIUM IMBALANCES•Ranges: 135 –145 mEq/L•When would you administer hypotonic solutions?•Hypernatremia•Hyponatremia•When would you administer hypertonic solutions?•Hypernatremia•Hyponatremia•Usually in combination NaCl. 9
Potassium Imbalances –cont.•Regulation of Potassium Levels: •Ranges: 3.5 –5.0 mEq/L•Primarily by the kidneys•Renal excretion is increased by aldosterone (adrenal steroid that promotes conservation of sodium while increasing potassium loss)•Insulin has a profound effect on potassium level; in high doses insulin stimulates potassium uptake by cells10
Potassium Imbalances –cont.•HYPOKALEMIA:•< 3.5 mEq/L•Results from an increase loss of potassium from the body•Movement of potassium into the cells•Potassium stores are depleted in 2-3 days without replacement11
Potassium Imbalances –cont.•Oral potassium chloridePROTOTYPE•PROTOTYPE - K-Dur•mild = PO dosages range from 16-24mEq/day•Deficiency = PO dosage range 40-100mEq/day•Sustained-release version has fewer GI effects (do not crush)•Difficulty swallowing capsules, liquid doesn’t taste good, problem with pt adherence•Side effects of meds: abdominal discomfort, nausea and vomiting, diarrheaTake with meals or a full glass of waterUse of spironolactone to decrease excretion of potassium12
Potassium Imbalances –cont.•HYPOKALEMIA –Nursing Implications (continued):•IV potassium chloride (KCl) : severe or cannot take PO•Must be diluted in IV bag and infused slowly; no faster than 10-20 mEq/hr with continuous monitoring (NEVER IV BOLUS AND NEVER IVPB)•Never add to an existing IV bag --- why?•Rapid infusion results in cardiac death!•Contraindications to potassium use•Avoid in patients who are predisposed to hyperkalemia•Severe renal impairment, use of potassium-sparing diuretics, hypoaldosteronismPrincipal complication of hypokalemia is hyperkalemia13
Potassium Imbalances –cont.•HYPERKALEMIA:•> 5.0 mEq/L•Results from an increased intake of potassiumrarely occurs with oral administration•Movement of potassium out of the cells•Inadequate renal excretionPrincipal complication of hypokalemia is hyperkalemia14
Potassium Imbalances –cont.•HYPERKALEMIA –•ECG changes - Potentially life-threatening due to risk ofcardiac arrhythmias and cardiac arrest(mildly elevated 5-7 = V-fib, peaked T-waves, widened QRS(severely elevated 8-9 = cardiac arrestNOTE: That is really high! I’ve seen problems at 6.5-7)•HYPERKALEMIA –Nursing Implications:•Monitor vitals, ECG•Decrease potassium intake•Stop potassium-sparing diuretics•Withhold oral doses of potassium; •Place on potassium-restricted diet•Stop IV infusion of K•Dialysis, if needed•Administer loop diuretics, such as Lasix, if adequate kidney function•Sodium polystyrene sulfonate (Kayexalate) given PO or enema•Sodium bicarb, calcium chloride, insulin15
Calcium Imbalances –cont.•Ranges: 9 –10.5 mg/dL•HYPOCALCEMIA –Nursing Implications:•Monitor vitals, ECG•Foods high in calcium –dairy products and dark green vegetables•Administer oral or IV supplements (Calcium gluconate, Calcium chloride, Magnesium, Vitamin D•Seizure precautions, emergency equipment16
Calcium Imbalances –cont.•HYPERCALCEMIA:•> 10.5 mg/dL•> 13 mg/dL is severe, coma likely•HYPERCALCEMIA –Nursing Implications:•Monitor vitals, ECG•Monitor LOC•Increase clients activity level•Encourage fluids to promote urinary excretion•Encourage fiber•Administer NS, loop diuretics, corticosteroids, potassium salts•Assess for blood clots17
MAGNESIUM IMBALANCES•What is it for:•Most magnesium is found in the bones;smaller amounts within the body cells,and a very small amount in ECF.Ranges: 1.8 –2.6 mEq/L•Closely related: calcium, phosphorus and magnesium18
Magnesium Imbalances –cont.•HYPOMAGNESMIA <1.8 mEq/L•Nursing Implications:•Monitor vitals, ECG•Assess DTR’s•Administer oral or IV magnesium sulfate •Oral mag can cause diarrhea and thus increase mag depletion•PO mag oxide tablets 400-800mg daily•IV route is preferred because IM can cause pain and tissue damage•Discontinue mag-losing medications•Seizure precautionsContraindicated in clients who have AV block, rectal bleed, N/V, abdominal pain19
Magnesium Imbalances –cont.•HYPERMAGNESMIA –> 2.1 mEq/L•Nursing Implications:•Stop Mg containing supplements, antacids or laxatives (Why?)•Monitor vitals, ECG•Assess DTR’s•Monitor LOC•Monitor serum electrolytes•Administer loop diuretics andmagnesium free IV fluids,if adequate kidney function•Have injectable form of calcium gluconateavailable to treat toxicity!•Therapeutic Uses:•Used to stop preterm labor (off label or not at all? no)•as an anticonvulsant for eclampsia (OB)20
General Nursing Implicationsfor Fluid & Electrolyte Imbalances•Assess fluid balance (daily weight, I&O, spec gravity)•Assess neurologic status (LOC)•Evaluate motor and sensory function (DTR’s)•Monitor vital signs (esp. those affected by electrolytes)•Compare EKG changes and monitor serum electrolyte levels•Assess nutritional status (incl serum albumin)•Assess medical history (renal & endocrine)•Assess medication history (diuretics, antacids,Laxatives, salt substitutes, OTC meds,)21
4 Types of Acid-Base Disturbances•Respiratory alkalosis•Respiratory acidosis•Metabolic alkalosis•Metabolic acidosis22
Respiratory Alkalosis•ABG = resp alkalosis low PCO2 high pH•Treatment•Mild: none needed•More severe: rebreathe his or her CO2-laden expired breath (paper bag over nose & mouth)23
Respiratory Acidosis•Treatment•Correction of the underlying cause•Infusion of sodium bicarbonateif severe24
Metabolic Alkalosis•Treatment•Infusing a solution of sodium chloride plus potassium chloride25
Metabolic Acidosis•Treatment•Correction of the underlying cause of acidosis•If severe, alkalinizing salt (eg: sodium bicarbonate po or IV)26
Diuretics•Diuretics impact fluids and electrolytes•A&P of Urinary system•Need to know how diuretics affect fluid compartments in the body•What happens when client develops edema? In lower extremities? •Where else may a person have edema? Why?•What is the major electrolyte that may increase fluid in the body?27
Renal A&P, structure, function, •A & P of Kidney•Basic functional unit of the kidney•Renal tubules•Filtration mechanism of kidney•Movement of electrolytes through kidney28
DIURETICSDrugs that increase urinary output •Major applications:•Treatment of hypertension•Excretion of edematous fluid related toheart failure and kidney and liver disease•Prevention of kidney failure•Classification of medications used:•High-ceiling “LOOP” diuretics•Thiazide diuretics & “the like”•Potassium-sparing diuretics•Osmotic diuretics29
Introduction to DiureticsThree basic functions of diuretics:•1) Cleansing of extracellular fluid (ECF) and maintenance of ECF volume and composition•2) Maintenance of acid-base balance•3) Excretion of metabolic wastes and foreign substancesOf these three, maintenance of ECF volume and composition is the one that diuretics affect most..30
Mechanism of ActionHow diuretics work:•Mechanism of action is blockage of sodium and chloride reabsorption, thus preventing the passive reabsorption of water, and promoting the excretion of both. •Site of action –proximal tubule produces greatest diuresis•Diuretic drugs that act early in the nephron will block the greatest amount of solute reabsorption, and thus produce the greatestdiuresis.•Conversely, diuretics that act at distal sites have very little reabsorption available to block, thus produce the leastdiuresis.31
Adverse impact•Adverse impact on extracellular fluid:•May cause hypovolemia (from excessive fluid loss)•Acid-base imbalance•Altered electrolyte levels32
Classification of DiureticsFOUR CATEGORIES:•1) Osmotic diuretics•Mannitol (Osmotrol)•2) High-ceiling (Loop) diuretics •Furosemide (Lasix) •Others: Toresmide (Demedex), Bumetanide (Bumex) ethacrynic acid “water pill” (Edecrin)•3) Thiazides and related diuretics•Hydrochlorothiazide (HydroDIURIL), and “thiazide-like” •4) Potassium-sparing diuretics •Aldosterone antagonists•Spironolactone (Aldactone)•Nonaldosterone antagonists•Triamterene (Dyrenium), Amiloride (Midamox) Fifth Group:•Carbonic anhydrase inhibitors (not discussed here)33
Osmotic Diuretic•Mannitol (Osmotrol) PROTOTYPE (only one available in US)•Method of action:•Promotes diuresis by creating osmotic force within the lumen of the nephron at the proximal convoluted tubule, thus inhibits passive reabsorption of water.•Has no effect on excretion of potassium and other electrolytes.•Pharmacokinetics•Drug must be given parenterally/IV•Onset 30-60 minutes; duration 6-8 hours•Therapeutic uses•Can preserve urine flow, thus used prophylaxis in renal failure; administered for the oliguriaphase of kidney injury•Reduction of intracranial and intraocular pressure; osmotic force draws edematous fluid back into the bloodstream•Promotes sodium retention of water excretion in clients who have hyponatremia and fluid volume excess34
Mannitol (Osmitrol) - continued•Adverse effects•Edema; ie pulmonary congestion or CHF can develop•Rebound - increased intracranial pressure•Fluid and electrolyte imbalance, metabolic acidosis•Preparations/Dosing administration:•Continuous IV; amount varies depending on indication•Renal failure –set rate to elicit urine flow of 30-50mL/hr•Requires special needles and filters•Nursing Implications:•Monitor daily weight, I&O, edema•Monitor headache, nausea, vomiting, LOC•Monitor lithium levels, serum electrolytes, ECG•Contraindicated in clients who have active intracranial bleed, anuria, severe pulmonary edema, severe dehydration, and renal failure35
•Stop here•Go to slides 54-57•Assignment 2 information•Assignment 4 information•Assignment 3 TBA36
High-Ceiling (Loop) DiureticsPROTOTYPE- Furosemide (Lasix) most frequently prescribed loopdiuretic!(suffix = -ides)bumetanide (Bumex), furosemide (Lasix), toresmide (Demadex)•Mechanism of action•Acts on ascending loop of Henle to block reabsorption of sodium, chloride, potassium, calcium, magnesium, and prevents reabsorption of water•This drug can promote diuresis even when renal blood flow and GFR is low•Pharmacokinetics•Rapid onset (PO 60 min, lasts 8 hrs; IV 5 min, lasts 2 hrs)•IM/IV•Therapeutic uses•Used in patients who require rapid diuresis!•Pulmonary edema associated with CHF•Edematous states - daily fluid management •Hypertension - volume management37
Furosemide (Lasix) - continued•Adverse effects•Can produce F&E imbalances: excessive loss of sodium (hyponatremia), loss of chloride (hypochloremia), and water loss (dehydration)•Dehydration promotes hypotension, thrombosis, and embolism•Hypotension•Loss of volume•Relaxation of venous smooth muscle•Hypokalemia•Potassium wasting drug; If serum potassium level falls below 3.5mEq/L, dysrhythmias, sometimes fatal, may result•Ototoxicity - tinnitus (rare, unless combined with other ototoxic drugs)•Other adverse effects:•Hyperglycemia•Hyperuricemia•Use in pregnancy•Negative impact on lipids, calcium, and magnesium38
Furosemide (Lasix) - continued•Nursing Implications:•Monitor VS, B/P, urine output, & weight•Assess edema, lung sounds•Monitor electrolytes (Na, K, chloride), calcium, magnesium, blood glucose•Monitor ECG•Foods rich in potassium: dried fruits, nuts, spinach, potatoes, bananas and citrus fruits•Administer potassium supplements, as ordered•Avoid dosing late in the day/eveningusual dosing time 0800 & 1400 •S/S dehydration, hypotension, thrombosis or embolism•Report electrolyte disturbances, tinnitus or hearing loss•Observe for s/s of low mag and low calcium•When used with other antihypertensive meds, can have additive hypotensive effect•Contraindicated in clients who have anuria (no urine output)39
Other High-ceiling (Loop) Diuretics•Ethacrynic acid (Edecrin)•Torsemide (Demadex)•Bumetanide (Bumex)•All can cause similar adverse reactions as furosemide (Lasix)•Ototoxicity, hypovolemia, hypotension, hypokalemia, hypomagnesaemia, hyperuricemia, hyperglycemia, and disruption of lipid metabolism40
Thiazide Diuretics•PROTOTYPE - HCTZ - Hydrochlorothiazide (HydroDIURIL/Microzide) Most widely used diuretic•Others:•Chlorothiazide (Diuril)•Methyclothiazide (Enduron)•Thiazide-like:•Chlorthalidone (Thalitone)•Metolazone (Zaroxolyn)•Indapamide (Lozide)41
Mechanism of Action•Blocks reabsorption of sodium and chloride in the early segment of the distal convoluted tubule, and prevents the reabsorption of water at this site•Increased flow of urine due to retention of sodium and chloride in the nephron•Ability to promote diuresis is dependent on adequate kidney function; thus are ineffective when GFR is low (<15-20mL/min)42
Pharmacokinetics•Pharmacokinetics:•Onset within 2 hours; peaks in 4–6 hours and may persist up to 12 hours•Maximum diuresis is considerably lower than that produced by loop diuretics•NOT effective when urine flow is scant (unlike loop diuretics)43
Hydrochlorothiazide –cont.•Therapeutic uses•Essential hypertension, and in combination with other antihypertensive agents for B/P control •Edema of mild-moderate, HF, and liver and kidney disease•Reduces urine productivity in clients with diabetes insipidus •Promotes reabsorption of calcium, thus reduces risk for postmenopausal osteoporosis•SIADH-Syndrome of Inappropriate ADH- too much ADH (Antidiuretic hormone)44
Adverse effects•Nearly identical to loop diuretics,except thiazides are NOT ototoxic, and they are NOT effective when urine flow is scant•Hypokalemiais most common•Elevate levels of uric acid and glucose•Drug Interactions & Nursing Implications•Nearly identical to loop diuretics!!•How supplied/preparations•Available alone or in fixed dose combination with other meds•Chlorothiazide is administered orally & IV; all others are given orally45
Thiazide-Like (benzothiadiazide)•Metolazone (Zaroxolyn)- a quinazoline•Used synergistically with loop diuretics•In CHF, removes fluid, reduces blood pressure•Used in renal insufficiency with less toxicity to kidneys; 10 x more potent than HCTZ•Sulfonamide derivative (Allergy to sulfonamides)•Site of action - distal convoluted tubule where they inhibit the sodium-chloride symporter.•Half life –14-40 hours, may be dosed every 2-3 days, not daily•Primary site of action-cortical diluting segment of the ascending limb of the loop of Henle.•This can result in hypokalemia, hypochloremia and mild metabolic alkalosis•75% protein bound, 46
Potassium-Sparing Diuretics2 Subcategories are:•1) Aldosterone antagonist•PROTOTYPE - Spironolactone (Aldactone)•2) Nonaldosterone antagonists•Triamterene (Dyrenium)•Amiloride (Midamor)•Useful responses•Modest increase in urine production•Substantial decrease in potassium excretion•Rarely used alone for therapy; often used to counteract potassium loss caused by thiazide or loop diuretics47
Spironolactone (Aldactone)•Mechanism of action•Blocks the action of aldosterone (sodium and water retention) in the distal nephron/mineralocorticoid receptors•Retention of potassium and increased excretion of sodium and water•Effects are delayed up to 48 hrs; by blocking aldosterone's action, spironolactone blocks the synthesis of new proteins, but does not stop existing transport proteins from doing their job. Therefore, effects are not visible until existing protein complete their normal life cycle, a process which takes 1-2 days.•Remember: the degree of diuresis a drug produces is directly proportional to the amount of sodium reuptake it blocks! 48
Spironolactone (Aldactone) - continued•Therapeutic uses•Hypertension and edema; usually in combination with a thiazide or loop diuretic•Heart failure (decreases mortality in severe heart failure)•Other uses:•Primary hyperaldosteronism (decreases K+ excretion)•Premenstrual syndrome•Polycystic ovary syndrome•Acne in young women49
Adverse effects•HYPERKALEMIA –can lead to fatal dysrhythmias with serum levels > 5mEq/L (above 6 mEq/L)•Metabolic acidosis•Endocrine effects - a steroid derivative similar to that of steroid hormones (progesterone, estradiol, testosterone)•Benign and malignant tumors (risk in humans is unknown)50
Spironolactone (Aldactone) - continued•How supplied/preparations:•Oral –take with or without meals (if GI upset occurs)•Nursing Implications:•Use caution when combining potassium-sparing diuretics with one another or with potassium supplements, and in patients taking ACE inhibitor, ARB, or direct renin inhibitors due to increase risk for hyperkalemia•Do not administer to clients who have hyperkalemia, are taking potassium supplement or another potassium-sparing diuretic, or have severe kidney failure or anuria•Monitor VS, weight, electrolytes, edema, changes in HR or rhythm, etc.•Monitor for metabolic acidosis, such as drowsiness and restlessnessInstruct clients to report cramps, diarrhea, thirst, changes in menstruation, hirsutism, deepened voice, gynecomastia51
Study Guide for Exam 2 F&E•Know your normal/abnormal lab values .•Know Isotonic, Hypotonic, and Hypertonic solutions and when they would be used. (Study with N 1230 lecture content)•Acid-Base imbalances: Metabolic acidosis and alkalosis, Respiratory acidosis and alkalosis (Slides only)•Electrolyte imbalances: Na, Cl, K, Ca, Mg, and phosphate (along with lecture N 1230)(For N 1232: FOCUS ON MEDICATIONS TO ALTER IMBALANCES)52
Diuretics Prototypes (See list in MyCourses)•Medications: Diuretics:•Learn classifications and prototype drugs, Where they act, drug action and nursing management•Focus on administration of drugs, nursing management, effects and adverse effects•REMEMBER: Study N 1230 with N 1232. The two courses are very coordinated and the content is congruent. This message is essential to your success this semester.•REMEMBER: Review N 1130 and 1132 content, and Calculations53
Assign 2 Due 3/4/24 at 11 am before class•Create 3 exam questions (1 must be NGN) related to any topic from Exam 2 content•You may use any of the following topics:•Fluids imbalances•Electrolytes imbalances•Diuretics (Prototypes)You may use PowerPoint information or Lehne textbook information from chapters covered in class or Gidden Concept #8. No Other Sources. No Copied Questions from study guides.54
Assign 2 Con’t•Directions: Write three questions: 2 multiple choice and 1 NGN question format•A) Question must contain stem with clearly stated question, one correct answer marked, and three incorrect answers. It must contain a rationale for correct and incorrect responses, and a source of information including page number or slide.•B) Next Generation (NGN) NCLEX style question must contain a brief scenario, a question, and multiple responses. Indicate which responses are correct and which are incorrect. Write rationale for each correct and incorrect response. Include source of information and page number or slide. 55
Assign 4 Due 4/29 at 9 am before class•OB Case Study and Concept Map (INDEPENDENT WORK)•Directions: (Concept map page size 8 ½ x 11 up to no larger than 11x17 paper, NO POSTERS)1. Createa case study scenario related to pregnancy, L&D, postpartum, or neonate. May include diabetes in pregnancy, hypertension in pregnancy, surgery, or any other complication or potential complication, or a normal situation. You should use a situation from OB clinical withoutidentifiers as to patient. If not, you may use a personal OB or neonatal situation - yourself or a family member, no identifiers. Describe the situation in detail, medications, complications, etc. 2. Createa concept map related to the case study you developed. Must contain A, B, and CA) Page 1: Include a one page introduction of your patient, problem, normal and abnormal signs, symptoms, data, or observations. In other words, describe the situation you have created.B) Page 2: Concept Map. The center of your concept map (8 ½ x 11 up to 11 x 17) must have a briefdescription of the situation. Select or create a template to use, or use one from first semester.56
Assign 4 con’tC) Concept map mustcontain all/most the following:•1. Social Determinants of Health/Environmental/Cultural/Genetic factors influencing the situation•2. Nursing Assessments as indicated/Cues identifying need for assessments•3. Labs and other collaborative orders as indicated by case study•4. Medications if needed to manage the condition in case study•5. Dietary management related to case study•6. Actual or Anticipated evaluation criteria/resolution of problem or situation57