fluid and electrolytes made insanely easy.pdf.pdf

7/22/2019 Fluid and Electrolytes Made Insanely Easy.pdf.pdf

1/20

Fluid and Electrolytes Made INSANELY Easy!Loretta Manning, MSN, RN, GNPPresident, I CAN Publishing, Inc.

Fluid and ElectrolytesMade

EasyNSNA, November 10, 2012

Loretta Manning, MSN, RN, GNP

President, I CAN Publishing, Inc.

Regional Director, Sylvia Rayfield & Associates

Without electrolytes, our bodies

would be like a ship without light,resulting in a crash!

Without electrolytes, our bodies

would be like a ship without

light, resulting in a crash!

The most important thing

in nursing is not so much

to obtain more and

more facts, but to

TRANSFORM how we

THINKabout them!Lorett a Mannin g, MSN, RN, GNP

Make mistakesAsk dumb questionsCollaborateHave fun1

MACH

1

2012 I Can Publishing, Inc.

Whos Here? Red= Freshman and trying to figure out

just how to spell fluid and electrolytes.

Yellow= Sophomore but still feel insecure

with fluid and electrolytes.

Blue= Junior and starting to feel l ike I am

just trying to remember F&E.

Green=Senior and feel like I have so

much information in my brain that it is hard

to remember all of this! I keep wondering

when all of this is going to come together!

What concerns meis not the way things

are, but rather the way

people think things are.

Epictetus, Phi losopher


2/20

Trivialize

Tedious

Terrorize

Learning is DirectlyProportional to the

Amount of FUN

You have.

REMEMBER!!! Its

not what you

KNOW, but what

you REMEMBERthat counts!

Grid puzzleLittle figures1. 2. 3.

4. 5. 6.

7. 8. 9.

Grid solutionCUSHY CARL

1994 I CAN


3/20

Balancing Act for the Brain and

Kidneys:Kidneys

2012 I CAN Publishing, Inc.

What is the priority plan for a client with

Cushings syndrome?

1. Prevent skin breakdown.2. Prevent dehydration.

3. Teach client about symptoms of

hypoglycemia.

4. Prevent fluid overload.

FLUID SHIFTS

Mary had a little lamb and everywhere Mary went the

lamb was sure to go.

1994 I CAN

9 BRAIN RULES FOR THRIVING

VERSUS JUST SURVIVING

Exercise

Attention

Memory (repeat to remember)

Memory (remember to repeat)

Sleep

Stressed brains dont learn the same

Sensory

Vision trumps all other senses

Wiring

What I hear, I forget;

What I see, I remember.

What I do, I understand.

Confusius, 451 B.C.

FLUID & ELECTROLYTE

IMBALANCE


4/20

2008 ICAN Publishing Inc.

S ystem Specific Physiology, Assessments,Labs / Diagnostic ProceduresA nalysis of Assessments, Nursing Diagnoses/Concepts

F irst-prioritize Interventions / PharmacologyE xpected outcomesT o Reduce Potential RISKS

room assignments, recognize limitations ofstaff, restraints, risk for falls, infection,

identification, skin breakdown, scope ofpractice for delegation,know Standards ofPractice, safe equipment)Y (Why?) Ask questions when you dont know(Accuracy / Appropriateness of orders)!

Structure for Fluid & Electrolytes !

Loss of 2% body weight, an increase

of ADH and a thirsty feeling areregulating fluid balance!


Fluid & Electrolytes(Sung to the tune of Jingle Bells

Verse 1

Sodium, sodium is foun d outs ide the cel l s

Low leve ls come f rom pooping, puking, peeing! !

Verse 2

Sodium, sodium is foun d outs ide the cel l s

High levels come from too much salt and not drinking!

Verse 3

Potassium, potassium is fou nd inside the cel ls

Low levels come fro m Lasix and laxat ives.

Verse 4Pot assium, pot assium is fo und inside t he cel ls

High levels come from some meds and renal failure!

Verse 5

Electrolytes, electrolytes l ike sodium and potassium

Dont have to be that hard when you sing our song!

ACTIVITY

Osmosis fluid moves

lower to higher

Diffusion higher to

lower

Which of these would be an example of

osmosis?

1. Water moves from an area of lower to

higher particle concentration.

2. Water moves from an area of higher to

lower particle concentration.

3. Fluid remains within the cell.

4. Fluid moves outside the cell due to

changes in protein.


5/20

Which of these would be an example of

diffusion?

1. Water moves from an area of lower to

higher particle concentration.

2. Water moves from an area of higher to

lower particle concentration.

3. Fluid remains within the cell.

4. Fluid moves outside the cell due to

changes in protein.

SAFETY::

System Specific PhysiologyFLUID VOLUME EXCESS: HYPERVOLEMIA

ECF volume due to:

Heart or renal failure, cirrhosis

Na, excess IV fluids

aldosterone secretion

albumin,

Syndrome of Inappropriate Antidiuretic

Hormone (SIADH)

SAFETY:

System Specific Assessment:

Labs & Diagnostic Procedures

FVE (hypervolemia) (Decreased values)

Hct

Serum Osmolality

Serum Sodium (NA)

BUN

SAFETY:

System Specific Assessment

Fluid Volume EXCESSSigns and Symptoms of Hypervolemia: in volume


pulse

temperatureblood pressurein edemain ascitesin crackles in lungs

swelling neck (jugular vein distention)

in confusion, headache and seizures

SAFETY:

Analysis of Assessments /

Nursing Diagnosis / Concepts

Fluid Volume Excess

SAFETY: RESTRICT

FIRST - Priority Nursing Interventions

Reduce IV flow rate

Evaluate breath sounds and ABGs

Semi-Fowlers position

Treat with oxygen and diuretics as ordered

Reduce fluid and sodium intake

I & O and weight

Circulation, color, and presence of edema

Turn and position at least every 2 hrs


6/20

SAFETY

Expected Outcomes System Specific

COMPARISONof initial assessment to expected

outcome evaluation

System Specific

Assessment FVE

pulse

B/P

weight

edema

ascites

crackles in lungs

dyspnea

confusion

Expected OutcomeFluid Balance

Pulse within client norm -

B/P within client norm

Weight within client norm

edema

ascites

crackles in lungs

dyspnea

confusion

SAFETY

Expected Outcomes System Specific

COMPARISONof initial assessment to

expected outcome evaluation

System SpecificAssessment FVE Labs

Hct

Serum Osmolarity

Serum Sodium (NA)

BUN

Expected OutcomeFluid Balance of Labs

to normal range

Hct

Serum Osmolarity

Serum Sodium (NA)

BUN

SAFETY:

(Connect ing NCLEX to Concept)

To Reduce Potential Risks

Room assignments, recognize limitations of

staff, restraint safety

I nfection, Identification, Identify TRENDS orChanges in Clinical Condition

Skin breakdown, Safe equipment, Scope ofPractice for delegation

Know Standards of Practice, know how todocument / report errors

Which clinical finding indicates the client

is experiencing potential fluid volume

excess?

a.B/P change from 108/78 to 140/90

b.Decreased crackles in lower lung fields

c.Pulse increased from 72/min to 80/min

d.Weight from 150 lbs to 142 lbs

Which nursing action would be appropriate

for a client with orthopnea, dyspnea, and

bibasilar crackles?

1. Elevate legs to promote venous return.

2. Elevate the head of the bed, decrease the IV

fluids, and notify the provider of care.

3. Orient the client to time, place, and situation.

4. Prevent complications of immobility.

SAFETY:

Why? Is there anything you

want to ask?

(Accuracy / appropriateness of orders)


7/20

Which order should be questioned for a

client presenting with with orthopnea,

dyspnea, BP150/92 with adventitious

breath sounds in bilateral lower lung

fields?

a. Administer furosemide (Lasix) as ordered.

b. Daily weight every AM.

c. Increase IV fluids for 2 hours.

d. Position client in semi-Fowlers position.

Brain conducting Posteriorpituitary gland

Posterior

Pituitary Gland


1994 I CAN PUBLISHING, INC.

SOGGY SIDS-I-A-D-H

(Syndrome of Inappropriate Antidiuretic Hormone)Lyrics (Sing to tune: BINGO) Darlene A. Franklin, RN MSN

Chorus

S-I-A-D-H, S-I-A-D-H, S-I-A-D-H,

This hormone stops the PeePee.Verse 1

Brain tumors, trauma, and bad bugs

A complication might be


This hormone stops the PeePee.Verse 2

Low output, sodium; gained weight

And high S. gravity (specific gravity)


This hormone stops the PeePee.

Verse 3

But, Diabetes InsipidusThe opposite youll see

Pee, PeeGive IVs

Pee PeeGive IVsPee, PeeGive IVs

Vas-o-pressin they need!Verse 4

High output, sodium; pounds lost,

And low S. gravity (specific gravity)

Pee, PeeGive IVs

Pee PeeGive IVs

Pee, PeeGive IVs

Vas-o-pressin they need!

htt p:/ / www.marvistavet.com/ assets/ images/dog

_IV. gif

What would be the highest priority of care for a

client with syndrome of inappropriate anti-

diuretic hormone (SIADH)?

1. Instruct the UAP to encourage the client todrink fluids.

2. Advise client to report large amounts of urineoutput.

3. Evaluate for signs and symptoms ofdehydration.

4. Instruct the LPN to report a weight gain of 2.5pounds.
http://www.marvistavet.com/assets/images/dog_IV.gifhttp://www.marvistavet.com/assets/images/dog_IV.gifhttp://www.marvistavet.com/assets/images/dog_IV.gifhttp://www.marvistavet.com/assets/images/dog_IV.gifhttp://www.marvistavet.com/assets/images/dog_IV.gifhttp://www.marvistavet.com/assets/images/dog_IV.gif


8/20

CALLING THE SHOTS IN ACID VS. BASE

1994 I CAN

SAFETY::System Specific PhysiologyFLUID VOLUME DEFICIT: Dehydration-Big TimeDeficit = ShockLoss of fluids from anywhere: vomiting,

diarrhea, hemorrhage, thoracentesis,paracentesis, diabetes insipidus.

Third spacingWhen fluid is in a placethat does you no good.

SAFETY:


Fluid Volume DEFICIT

Decrease in weight

Decreased skin turgor

Dry mucous membranes

Decreased urine output

Decrease in Blood Pressure

Decrease in warmth to extremities

Decrease fluid to pump so pulse isDecrease strength in pulse (weak)

SAFETY:


Labs & Diagnostic Procedures

Dehydration (increased values)

Hct (more that 3x Hgb)

BUN > 20

Specific Gravity > 1.030 (except

diabetes insipidus

Osmolality > 295mOsm/kg water

Serum Na > 145 mEq/L

SAFETY:



Fluid Volume Deficit

SAFETY: FLUIDS

FIRST - Priority Nursing

Interventions

Fluid (po), Isotonic fluids, Blood

Level of consciousness, look at weight

Urine < 30 ml / hr report or trending

IV fluids as ordered, I & O

Document vital signs and watch trends

(hypotension and weak pulses)

Shock position (back with legs ); skin


9/20

What would be the priority nursing

intervention for a client with a B/P change

from 140/88 to 86/62?

a. Put client in supine position with legs

elevated.

b. Notify provider of care.

c. Put client in Fowlers position.

d. Evaluate characteristics of mucous

membranes.

Expected OutcomesCOMPARISONof initial assessment to expected outcome

evaluation

System SpecificAssessment of FVD

Decrease in weight

Decrease in BP

Decrease fluid = pulse

Dry mucous membranes

Decreased urine output

Decrease in warmth toextremities

Expected Outcome

Evaluation of clients

response

Weight - clients norm

BP- clients norm

Pulse within clients norm

Moist mucous membranes

Urine output 30 cc/hr

Extremities warm to touch

Expected OutcomesLABSCOMPARISON of initial assessment to expected outcome

evaluation

System Specific

Assessment of FVD Labs

Hct (more that 3x Hgb)

BUN > 20

Specific Gravity >

1.030

Osmolality >

295mOsm/kg water Serum Na > 145

mEq/L

Expected Outcome

Evaluation of clients Labs

to normal range

Hct (3x Hgb)

BUN 10 -20

Specific Gravity 1.005

1.030

Osmolarity 285 -

295mOsm/kg water Serum Na 135145mEq/L

Which assessment best indicates proper

rehydration?

1. 400 cc of po intake.

2. Heart rate of 105 beats per min.

3. Respiratory rate of 32 per min.

4. Urine output of 100 cc per hour.

SAFETY:



Room assignments, recognize limitations

of staff, restraint safety

Infection, Identification, Identify TRENDS

or Changes in Clinical Condition

Skin breakdown, Safe equipment, Scope

of Practice for delegation

K now Standards of Practice, know how

to document / report errors

Which system specific assessment

findings would the client present with

who has been vomiting for 24 hours

indicating a need for furtherintervention?

a.B/P increase from 110/70 to 130/80.

b.Urine output decrease from 95cc/hr to

75cc/hr.

c.BUN -15.

d.Pulse increased from 68/min to 118/min.


10/20

SAFETY:


want to ask?


Which of these orders would be most

important for the nurse to question for a client

who is in hypovolemic shock?

1. Administer dopamine and digitalis.

2. Infuse 0.9 Normal Saline 500 cc bolus.

3. Administer a blood transfusion as ordered.

4. Foley catheter to a straight drain.

Brain conducting Posterior

pituitary gland

Posterior

Pituitary Gland


DIABETES INSIPIDUS

Dry

I + O, daily weight

Low specific gravity

U rinates lots

Treat = pituitary hormone

r Ehydrate 1994 Adapted fromCreative Educators

No Water, No Salt

NO WATER, NO SALT


SAFETY::

System Specific Physiology

Sodium Deficit (Hyponatremia)

Na < 135 mEq / L

Electrolyte imbalance that may result indisturbances involving these systems:

Neurological

Cardiac

Endocrine

From: GI sct., Diarrhea, inadequate salt

intake, diuretics, vomiting, Fluid shift from ICF to

ECF


11/20

SAFETY:

System Specific AssessmentSodium Deficit (Hyponatremia)

Na < 135 mEq / L

B/P

Muscle Strength

Deep Muscle Reflexes (DTR)

Pulse (bounding)

Apprehension

Confusion & lethargy

Seizures

Serum Sodium (NA)

Serum Osmolality

Specific Gravity


12/20

SAFETY:



R oom assignments, recognize limitations of

staff, restraint safety

I nfection, Identification, Identify TRENDS or

Changes in Clinical Condition

S kin breakdown, Safe equipment, Scope of

Practice for delegation

Know Standards of Practice, know how to

document / report errors

The priority nursing intervention with a

client with a serum sodium level

128mEq/L?

a. Have suction at the bedside

b. Encourage water intake to 2000cc/day

c. Question order for IV for Normal Saline

d. Restrict cheese and condiments

SAFETY:


want to ask?


A client with a sodium level of 133 mEq / L has

an order to push po fluids. What would be the

priority of care?

1. Review the plan with the UAP.

2. Develop a plan for UAP to give 60 cc / hr.

3. Notify the provider of care and verify order.

4. Review the importance of recording weight

every 48 hours.

Balancing Act for the Brain andKidneys:

Kidneys


ANEMIC ADAM

1994 I CAN

Why am I so

BRONZE?

SALT


13/20

SAFETY::


Sodium Excesst (Hypernatremia)

Na > 135 mEq / L

Electrolyte imbalance that may result indisturbances involving these systems:

Neurological

Cardiac

Endocrine


HYPERNATREMIA

LODES OF EXTRA SODIUM

L ow H2O int ake

Osmot ic DiureticsDiabetes Insipidus

Excessive H2O loss

Sodium int ake t oo much

from meds and meals

SAFETY:


Sodium Excess (Hypernatremia)

Na > 135 mEq / L

Pulse

Muscle irritability & twitching

Deep Muscle Reflexes (DTR)

Thirst (may be depressed in elderly)

Restlessness progressing to confusion


Decreased urine out put , DRY

mouth

Rest less ( irritable);

progressing t o

confusion

I ncreased fluid retent ion

Edema (peripheral andpitting)

Deep muscle ref lexes

HYPERNATREMIAYou feel DRIED out from too MUCH sodium!

SAFETY:


Labs & Diagnostic ProceduresSodium Excess (Hypernatremia)

Na > 135 mEq / L

Labs (Increased values)

Serum Sodium (NA)

Serum Osmolality

SAFETY:



Sodium Excess (Hypernatremia)

Na > 135 mEq / L

Electrolyte ImbalanceSodium Excess


14/20

SAFETY: SODIUM

FIRST - Priority Nursing InterventionsHYPERNATREMIA

(Na) > 135 mEq / L

Sodium intake

Oral hygiene

Diuretic (I.e., Loop Diuretics)

Increase water intake, I&O

Use hypotonic or isotonic fluids

Monitor for inadequate renal output

SAFETY

Expected Outcomes

COMPARISONof initial assessment to expected outcome evaluation

System SpecificAssessment of SodiumExcess (Hypernatremia)

Deep Muscle Reflexes

(DTR)

Pulse

Thirst

Muscle irritability & twitching

Expected OutcomeEvaluation of ClientsResponse

Within clients norm Deep Muscle Reflexes

(DTR)

Pulse

Thirst

No Muscle irritability &

twitching

SAFETY

Expected Outcomes



Sodium Excess Labs

Serum Na > 145mEq/L

Osmolality > 300mOsm/L

Expected Outcome

Evaluation of clients Labs

to normal range

Serum Na (135-145mEq/L)

Osmolality

(270-300mOsm/L)

SAFETY:



R Room assignments, recognize

limitations of staff, restraint safety

I Infection, Identification, Identify TRENDS


S Skin breakdown, Safe equipment

Scope of Practice for delegation

K Know Standards of Practice, know how todocument / report errors

Which of these assessment findings would be

most important to report to the provider for a

client with a serum sodium 147 mEq/L?

a. Dry mucous membranes.

b. Complaints of being thirsty.

c. Urine output drop from 80 cc/hr to 45 cc/hr.

d. Skin warm to touch.

Which nursing intervention would be

most appropriate to delegate to the UAP

(unlicensed personnel or CNA) for a

client with a serum sodium of 148mEq/L?

a.Restrict PO water intake

b.Evaluate effectiveness of diuretic

c.Provide oral hygiene every 2-4 hours

d.Provide a snack of crackers and

cheese


15/20

SAFETY:


want to ask?


Which of these orders should the nurse question?

1. Administer IV fluids 0.9 % Sodium Chloride

as ordered.

2. Place suction at the bedside.

3. Monitor I&O.

4. Limit water intake.

Balancing Act for the Brain and

Kidneys:

Kidneys


CUSHY CARL

1994 I CAN

SAFETY::


Potassium Deficit (Hypokalemia)(K+) < 3.5mEq / L

Electrolyte imbalance that may result in disturbances involving

these systems:

GI Losses: vomiting, nasal gastric suctioning, diarrhea, laxative

use

Renal loses: diuretics (Lasix), use of corticoids steroids

Skin loses: diaphoresis and wounds

Insufficient potassium: dietary or prolonged non-electrolyte IV

solutions ie. D5W

Intracellular shift: Tissue repair (burns, starvation, trauma)

* Older adults risk because of laxatives & diuretics

SAFETY:System Specific AssessmentPotassium Deficit(Hypokalemia)

(K+) < 3.5 mEq / L

Hypoactive reflexes

Muscle cramping

Weak & irregular Pulse

EKG changes: Inverted T waves

Bowel sounds (hypoactive),

constipation


16/20


C onstipation, ibowelsoundsR eflexes iArrhythmias, inverted T waves

Muscle cramps

Pulseirregular and weak

SAFETY: CRAMPSystem Specific AssessmentPotassium Deficit(Hypokalemia)

(K+) < 3.5 mEq / L

SAFETY:


Labs & Diagnostic ProceduresPotassium Deficit (Hypokalemia)

(K+) < 3.5mEq / L

Serum Potassium < 3.5mEq/L

Arterial Blood Gases

Metabolic alkalosis: pH > 7.45

EKG changes: Inverted T waves, V-Tach

depressed ST segment

SAFETY:



Potassium Deficit (Hypokalemia)

(K+) < 3.5 mEq / L

Electrolyte Imbalance: Potassium deficit

SAFETY: POTASSIUM

FIRST - Priority Nursing InterventionsHYPOKALEMIA

(K+) < 3.5 mEq / L


Potatoes, avacados, broccoli, etc, (K+)

Oral potassiom suppliments (with diuretics)

T waves depressed (flattened)monitor

Arrhythmiasmonitor

Shallow ineffective respirationsmonitor

Sounds of breathing diminishedmonitor

IV supplement in NEVER an IV push!!!

Urine outputmonitor (must b e 0.5 mL/kg per h r)Muscle cramping, motility (GI) i

SAFETY

Expected Outcomes


System SpecificAssessment of Potassium

Deficit (Hypokalemia)

Hypoactive reflexes

Muscle cramping

Weak & irregular Pulse

EKG changes: Inverted T

waves

Bowel sounds (hypoactive)

Expected OutcomeEvaluation of Clients

ResponseWithin clients norm

Normal Muscle Reflexes

No muscle cramping

Pulse within clients norm

No EKG changes

Bowel sounds within clients

normal

SAFETY:



R Room assignments, recognize

limitations of staff, restraint safety

I Infection, Identification, Identify TRENDS


S Skin breakdown, Safe equipment

Scope of Practice for delegation

K Know Standards of Practice, know how to

document / report errors


17/20

Which documentation indicates the nurse

understands how to provide safe care for a client

with a serum potassium of 3.3 mEq/L?

a. Potassium Chloride administered IV push.

b. Oral potassium supplement held due to level.

c. Discussed eating oranges, broccoli, bananas.

d. Administered Lasix as ordered.

SAFETY:


want to ask?


A client is scheduled for a cardiac catheterization at 0900.

On admission 3 days ago lab work was: K 3.1 mEq/L and

Na 147 mEq/L. She is currently complaining of muscle

cramps and weakness. Which nursing intervention is a

priority at this time?

a. Hold 0700 dose of spironolactone (Aldactone).

b. Call the provider to recommend a stat K level.

c. Recommend eating a banana for breakfast.

d. Observe EKG for spiked T waves.

HYPERKALEMIA

(K+) > 5.0 mEq / L

Stop infusion of IV

potassium, Salt

substitutes avoid

Tall T waves (peaked)

Orders: Kayexalate or dextrose withregular insulin

Provide potassium restricted foods,Potassium-losing diuretics (Lasix)

Which of these medications should be

questioned for a client with a potassium level

5.2mEq/L?

a. Furosemide (Lasix).

b. Hdrochlorothiazide (HCTZ).

c. Kayexalate.

d. Lisinopril (Prinivil).

HYPOCALCEMIA

CA - 8.5-11 mg/dL

Risk factors:P Parathyroid (hypo)

E End-stage renal disease

T Thyroidectomy

S Steroids


18/20

HYPOCALCEMIA: Assessments

Trousseaus sign (hand/finger

spasms)

Watch for arrhythmias( pulse, ST - ECG

I ncrease in bowel sounds

diarrhea

Tetany

Chvosteks sign (facial twitching)

Hypotension, Hyperactive DTR

NURSING CARE

Seizure precautionsAdminister calcium supplements

Foods high in calcium,(I.e. dairy, green)

Emergency equipment on standby

The client is admitted with hypoparathyroidism.

What is mot important to have at the bedside for

this client?

a. Cardiac monitor

b. IV Pump

c. Heating Pad

d. Tracheostomy set

Which foods would the nurse encourage

the client with hypoparathyroidism to eat?

a. High calcium

b. High potassium

c. Low sodium

d. Low potassium

The nurse is preparing to discharge a client who

has a calcium level of 9 mg / dL, but had been

admitted with a low calcium level. Which

statement indicates a need for additional

teaching?

a. I will call my provider if I have any twitching.

b. I will take my calcium every AM.

c. I will avoid broccoli, spinach, and milk.

d. I will take my vitamin D with my calcium.

HYPERCALCEMIA

CA . >11 mg/dL

Risk Factors:Immobility

Malignant tumors

Hyperparathyroidism

Thiazide diuretics

Excess calcium or vitamin D supplements


19/20

HYPERCALCEMIA:

Assessments

Constipation

Flank pain (Calcium in urine )

Deep bone pain

reflexes

HYPERCALCEMIA:

Assessments

Constipation

Flank pain (Calcium in urine )

Deep bone pain

reflexes

Nursing Care:

The 4 Fs)

Fluids

Fiber

Fluids (IV) that are ordered

Furosemide

What is most important to include in a teaching

plan for an elderly client with

hyperparathyroidism?

a. To decrease physical activity.

b. To increase fluid intake.

c. To stop taking furosemide (Lasix).

d. To report any twitching of the fingers.

SAFETYKEY TO SUCCESS

R REVIEW, REFLECTE ENGAGE WHILE STUDYING

L LEARN TO PRIORITIZE AND THINK!

A APPLICATION

X X OUT NEGATIVE THINKING!


20/20

Fluid and ElectrolytesMade

EasyYou CAN do it!!!

We wish you much SUCCESS

The secret of joy in

work is contained in

one word-EXCELLENCE.

To know how to do

something well is to

enjoy it.

Pearl Buck

fluid and electrolytes made insanely easy.pdf.pdf

Documents