2.3 Nutrition, Fluid Balance, Electrolytes, Acid Base Imbalance Flashcards
Describe the nutritional assessments that identify the need for nutritional supplements
Anthropometric measurements: Height Weight Body Mass Index: -ideal 18.5-24.5 -healthy -overweight 25-30 -obese 30+
Explain the significance of the abnormal findings for TOTAL PROTEIN
If your total protein level is low, you may have a liver or kidney problem, or it may be that protein isn’t being digested or absorbed properly. A high total protein level could indicate dehydration or a certain type of cancer, such as multiple myeloma, that causes protein to accumulate abnormally
Explain the significance of the abnormal findings for ALBUMIN
Lower-than-normal level of serum albumin may be a sign of:
Kidney diseases
Liver disease (for example, hepatitis, or cirrhosis that may cause ascites)
Increased blood albumin may be due to:
Dehydration
High protein diet
Having a tourniquet on for a long time when giving a blood sample
Explain the significance of the abnormal findings for GLOBULIN
Low globulin levels can be a sign of liver or kidney disease.
High levels may indicate infection, inflammatory disease or immune disorders. However, abnormal results may be due to certain medications, dehydration, or other factors
Explain the significance of the abnormal findings for A/G RATIO
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Identify assessment findings used to determine the route of nutritional supplementation
Enteral Nutrition:
Used with patient’s who have a functional GI tract
Cancer, critical illness, neurological/muscular disorders, GI disorders, resp failure with prolonged intubation, inadequate oral intake.
Parenteral Nutrition:
Used with patient’s who has a non-functional GI tract
GI surgery, obstruction, extended bowel rest
Identify changes in bowel sounds that are expected with the stressed patient and nursing implications of changes in peristalsis
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Describe the procedure for changing a CVC dressing
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Describe the rationale for parenteral administration of lipids and nursing implications related to lipid administration
Fat emulsion (lipids) may be added Provides essential fatty acids and additional calories Monitor for fat overload syndrome -fever -elevated tri -clotting problems -multisystem failure
Identify solutions that may only be administered via central vein
TPN
Explain the guidelines for administration of parenteral fluids
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Compare the rational for the use of the major types of parenteral solutions and discuss the rate of administering fluids.
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Describe how to determine the caloric value of intravenous solutions
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Identify the significance of abnormal findings for the following components of the Comprehensive Profile lab test including nursing responsibilities
ALKALINE PHOSPHATASE
Alkaline Phosphatase:
Nursing:
Identify the significance of abnormal findings for the following components of the Comprehensive Profile lab test including nursing responsibilities
AST (SGOT)
AST (AGOT):
Nursing:
Identify the significance of abnormal findings for the following components of the Comprehensive Profile lab test including nursing responsibilities
BILIRUBINE, TOTAL
Total Bilirubin:
Nursing:
Identify the significance of abnormal findings for the following components of the Comprehensive Profile lab test including nursing responsibilities
BUN
BUN 5-20 mg/dl:
Indication of renal failure/insufficiency/injury
Low= malnourished, low in protein
High= dehydration
Nursing
Identify the significance of abnormal findings for the following components of the Comprehensive Profile lab test including nursing responsibilities
CREATININE
Creatinine 0.6-1.2 mg/dl:
Indication of renal failure/insufficiency/injury
Low= malnourished, low in protein
High= renal function
Nursing:
Identify the significance of abnormal findings for the following components of the Comprehensive Profile lab test including nursing responsibilities
GLUCOSE
Glucose 60-100 mg/dl:
Direct measurement of glucose, evaluation of DM pt’s
Low= starvation, hypothyroidism, hypopituitarism
High= DM, diuretic therapy, chronic renal failure
Nursing:
Identify the significance of abnormal findings for the following components of the Comprehensive Profile lab test including nursing responsibilities POTASSIUM (K) SODIUM (NA) CHLORIDE CALCIUM
**SEE LEARNING PACKET PG 48-53
Identify the significance of abnormal findings for the following components of the Comprehensive Profile lab test including nursing responsibilities
TOTAL PROTEIN
Total Protein:
Measures total protein in blood including albumin and globulin
Keeps fluid within the vascular spaces due to osmotic pressure.
Low protein: fluid leaks out of vascular spaces into interstitial spaces causing edema.
Nursing:
Identify components of the “basic kidney profile” and explain the significance of abnormal findings for each of the components
Basic Kidney Profile:
Your kidney numbers include 2 tests: ACR (Albumin to Creatinine Ratio) and GFR (glomerular filtration rate). GFR is a measure of kidney function and is performed through a blood test. Your GFR will determine what stage of kidney disease you have
Review foods and substances high in sodium
Foods high in sodium:
Smoked, cured, salted or canned meat, fish or poultry including bacon, cold cuts, ham, frankfurters, sausage, sardines, caviar and anchovies.
Frozen breaded meats and dinners, such as burritos and pizza.
Canned entrees, such as ravioli, spam and chili.
Salted nuts.
Beans canned with salt added
Review foods and substances high in potassium
Foods high in potassium: Leafy greens, beans, nuts, dairy foods, and starchy vegetables like winter squash are rich sources. Dried fruits (raisins, apricots) Beans, lentils. Potatoes. Winter squash (acorn, butternut) Spinach, broccoli. Beet greens. Avocado. Bananas.
Review s/s and treatment for HYPO/HYPERNATREMIA HYPO/HYPERKALEMIA HYPO/HYPERCHLOREMIA HYPO/HYPERCALCEMIA HYPO/HYPER MAGNESIA
**SEE LEARNING PACKET PG 48-53
What should be taught to patients regarding electrolyte disturbances
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IV solutions and rates are appropriate. If not, identify the appropriate solution and rate.
Mrs. Golden, age 65, has a history of severe CHF and was admitted for treatment of
sepsis and dehydration. Her BP is 70/40; pulse 110, weak and thready. He orders
0.45% saline at 75 ml/hr
Mrs. Golden: 0.45 saline is a hypotonic solution and is not appropriate for this patient. The patient needs total volume replacement, which would require an isotonic solution instead. She needs volume resuscitation due to the sepsis and dehydration with low BP and tachycardia, but you would need to monitor closely as she is at risk for fluid volume overload if her heart function is poor. LR would not be the isotonic fluid of choice due to her potential for compromised liver (can’t metabolize the lactate) and kidney function (can’t have the K+ in the solution). You could expect 0.9 normal saline for the IV solution for this patient
IV solutions and rates are appropriate. If not, identify the appropriate solution and rate
Mrs. Kelly is a 35-year-old patient who recently underwent abdominal surgery. Her N.G.
is draining 1500 ml per shift, and her serum pH is 7.60. The Dr. order is Ringers Lactate
@ 150 ml/hr
Mrs. Kelly: Ringers Lactate at 150ml/hr is not appropriate for this patient. The lactate in the IV solution will cause further alkalosis because the liver converts lactate to bicarbonate. This patient needs a hypertonic IV solution in order to shift fluid out of the cells and into the ECF. She would likely need K+ replacement due to the large amount of drainage from the NG. You could expect D5.45 normal saline +KCL for this patient
IV solutions and rates are appropriate. If not, identify the appropriate solution and rate
Mr. Donatelli, age 40, is a hypertensive patient who has been on thiazide diuretic therapy.
His skin and mucous membranes are dry, and he complains of a headache. His BP is
200/120. The order is for 5% dextrose in 0.45 Saline at
25 ml/hr
Mr. Donatelli: D5.45 normal saline is not appropriate for this patient as it is a hypertonic IV solution which would cause cellular dehydration and further increase BP. This patient needs a hypotonic solution to carefully correct the cellular dehydration caused by the diuretic, as well as replacement of K+. You could expect 0.45 normal saline +KCL for this patient and the rate would be increased above 25ml/h
IV solutions and rates are appropriate. If not, identify the appropriate solution and rate
Mr. Jefferson is a 55-year-old patient in ESRD who is admitted with nausea and vomiting.
The order is 1000 ml D5 in Ringers Lactate every eight hours
Mr. Jefferson: D5LR is a hypertonic IV solution and is not appropriate for this patient. A patient with end-stage renal disease cannot handle this solution that would dehydrate the cells, and it would provide electrolytes (from the LR) and the kidneys could not handle more K+ in particular. The patient has nausea and vomiting and needs isotonic fluid replacement. You could expect 0.9 normal saline for this patient at a decreased rate.
Review the body’s bicarbonate: carbonic acid (HCO3:H2CO3), buffering mechanism
Buffers are substances that prevent major changes in pH by removing or releasing hydrogen irons
When excess acid is present in body fluid, buffers BIND with hydrogen ions to minimize the change in pH
If body fluids become too basic/alkaline buffers RELEASE hydrogen ions restoring the pH
Bicarbonate is a weak base: when an acid combines with bicarbonate, the pH changes only slightly
Carbonic acid is a weak acid: when a base is added to the system, it combines with carbonic acid and pH remains within range
Discuss the normal ratio between bicarbonate and carbonic acid
Normal ratio 20-1:
20 parts bicarbonate
1 part carbonic acid
If this ratio is maintained the pH remain within the 7.35-7.45 range
Identify the 3 compensatory mechanisms in an acid-base disturbance
Kidneys and lungs
Compare and contrast the cause, s/s, and nursing implications for
Acidosis: metabolic and respiratory
Acidosis Metabolic
Causes:
Overproduction of H+ from ketoacidosis from DKA, starvation or alcoholism; lactic acidosis; severe infection
Excessive ingestion of H+ from ASA toxicity, NS resuscitation
Inadequate renal function
Abnormal alkali losses from diarrhea, prolonged vomiting, ileostomy, intestinal fistulas or suctioning
Compensatory Mechanism:
Lungs increase respiratory rate and depth
NI:
Treat underlying cause
NaHCO3 IV
Lactated Ringers
Safety measure r/t decreased LOC
Monitor I/O, VS, potassium telemetry
Acidosis Respiratory
Causes:
Reduced surface area of lung from reduces gas exchange, PE, CHF, pneumonia, atelectasis, lung cancer, COPD
Obstruction of airways from COPD, bronchitis, asthma
Anything that decrease respiratory effort, respiratory center depression, drugs, tumors, immobility, reduced LoC, neuromuscular disease (MS, MD)
Compensatory Mechanism:
Kidneys excrete H+ and save HCO3
NI:
Treat underlying cause
Extreme caution with sedative/opiates
Improve ventilation: turn, cough and deep breathing, inspirex, elevate HOB, ventilator/airway management
Safety measures t/t decreased LOC
Compare and contrast the cause, s/s, and nursing implications for
Alkalosis: metabolic and respiratory
Alkalosis Metabolic Causes: Excessive loss of H+ from vomiting, gastric suctioning, potassium loss, fistulas, diuretics Excessive ingestion HCO3, antacids, NaHCO3 Compensatory Mechanism: Lungs decrease respiratory rate and depth NI: Treat underlying cause Treat hypochloremia/hypokalemia Ca gluconate Seizure precautions Monitor VS, telemetry, I/O, K, Cl, Ca
Alkalosis Respiratory Causes: Overstimulation of respiratory center from fever, early ASA toxicity, CNS disease or intracranial surgery/tumors Hyperventilation from anxiety, pain, aggressive vent settings Compensatory Mechanism: Kidneys excrete HCO3 and save H+ NI: Treat underlying cause Rebreather mask Coach breathing Treat hypochloremia/hypokalemia Seizure precautions
Define and give the normal ranges for the following:
a. pH -
b. pO2 -
c. pCO2 -
d. HCO3 -
e. O2 saturation -
a. pH - 7.35-7.45
b. pO2 - 80-100 (<80 hypoxemia)
c. pCO2 (respiratory) - 45-35
d. HCO3 (bicarb) - 22-26
e. O2 saturation - 96-100%
Enteral Therapy NASOGASTRIC and OROGASTRIC tube types:
Nasogastric (Levine, Salem)
Stomach tubes used to decompress or remove stomach contents. Used short-term for feedings…
they become stiff in the presence of HCl acid
HOB at 30 degrees
Increased aspiration risk
Enteral Therapy WEIGHTED Tubes types:
Weighted Tubes (Keofeed, Cortrak) Smaller tube (5, 8, 10 Fr) inserted thru the nose into the stomach that migrates into the jejunum due to peristalsis Decrease aspiration risk Med and feedings
Enteral Therapy GASTROSTOMY tube types:
Gastrostomy (PEG), surgically placed.
Allows use of gut as holding pouch. High fat foods leave stomach slowly causing patient to feel
full longer. Discourages eating of table food.
**know which tube your patient has
Enteral Therapy JEJUNOSTOMY tube type:
Jejunostomy (K-Tube)
Small tube (looks like IV tubing) surgically placed into the small bowel. Tube within a tube. Too
much pressure used for clearing will cause entire tube to collapse
**know which tube your patient has
Small intestine is an alkaline environment. What do you NOT put down a J-tube or K-tube?
Potassium: causes diarrhea, gas and irritation
Cranberry juice (other citrus juices): irritate the mucosa
Question an antacid order for J or K tube
The above can be administered via G or NG tubes with stomach placement
Causes of diarrhea with tube feedings?
Feeding that is too fast, too much or too strong
Antibiotics given within 2 wks are the greatest offender
Other med: K+, antacids, digitalis preparations
Milk products
Stress
Surgical interventions
Contaminated products/unclean equipment
Nursing interventions for tube feeding
- Accurate I/O
- Daily weight until stable, then 3x / wk.
- Accu check q 6 hrs.
- Assess bowel sounds, nares, stools q shift
- Change bag and tubing q 24 hrs.
- Check placement before each feeding and q shift
- Check residual before each feeding and every shift and follow doctors’ orders and/or policy if large amount obtained.
- Flush with 20ml warm water before and after all meds.
- Stop feeding ½ hr. before meals.
- Stop feeding if patient vomits.
- Communicate with the dietician on how a patient is tolerating feedings, adjustment in rates or formula.
Nutritional components
Basal Metabolic Rate: energy needed at rest for life sustaining, breathing, temp control, body circulation, energy need to do general things
Resting energy expenditure: resting metabolic rate, consumed over 24 hour period, routine maintenance
Vitamins and Minerals: essential for metabolism
Water: 60-70% of body weight, ***30mL/kg of water intake 24 hour
Fats: calorie dense nutrients, good and bad
Carbohydrates: main source of energy
Calories: energy we get from food, 2000-3000 men, 1600-2400 women
Proteins: energy, 1 protein=4 kcal, blood clotting, fluid regulation, acid/base, regulating proteins. Albumin is protein.
***0.8g/kg of protein for healthy individual
Identify the significance of abnormal findings for the following components of the Comprehensive Profile lab test including nursing responsibilities
SERUM ALBUMIN
Serum Albumin 3.2-4.5g/dl:
Primary protein in blood
High= dehydration
Low= malnutrition, <2.8g/dl
Identify the significance of abnormal findings for the following components of the Comprehensive Profile lab test including nursing responsibilities
PRE-ALBUMIN
Pre-albumin 15-36mg/dl:
Precursor to albumin, a transport protein
Shorter 1/2 life than albumin
More accurate indication of malnutrition for acutely ill patients and liver function
High= nephrotic syndrome
Low= malnutrition, liver damage
Identify the significance of abnormal findings for the following components of the Comprehensive Profile lab test including nursing responsibilities
TRANSFERRIN
Transferrin:
A protein that transports dietary iron from the gut to storage cells in body
Iron dextran infusions may be used if low
Low= anemia, B12 def, malnutrition
Identify the significance of abnormal findings for the following components of the Comprehensive Profile lab test including nursing responsibilities
HEMAGLOBIN
Hemoglobin:
Protein that carried O2 bound to RBC
Low (no bleeding)= malnutrition
Low (bleeding)= anemia, bleeding, transfusion?
Complications of Malnutrition
Cardiovascular: leaky capillary membranes= edema= low cardiac output
Endocrine: intolerance to heat and cold
Gastrointestinal: anorexia, vomiting, diarrhea, malabsorption, impaired protein synthesis
Immunologic: infection risk, skin breakdown, poor wound healing, dry flaky skin
Integumentary: reduced muscle mass, activity intolerance, weak, fall risk
Musculoskeletal: weakness
Neurologic: confusion
Psych-social: substance abuse
Respiratory: general weakness which limit lung compacity, pneumonia
Hepatic: not absorbing protein, impaired liver
Risks associated with ENTERAL FEEDING
Complications?
Nursing implications?
Aspiration: HOB at 30 degrees, stop tube feeding before turning or lowering HOB, check for aspiration/residual
Fluid and electrolyte imbalance: risk for potassium/sodium/chloride/calcium abnormalities, watch lab values, dehydration, fluid overload, I/O
GI intolerance: stress causes sympathetic nervous system which decrease peristalsis, N/V, bloating, bowel assessment, diarrhea, often on PPI to reduce acid in gut. Feeding starts slow
Hyperglycemia: high blood sugars, required BS checks regularly
Refeeding syndrome: life threatening, check electrolytes (must be in balance), reduced phosphorus= acute respiratory failure, reduced magnesium= neuromuscular symptoms, reduced potassium= cardiac muscle fatality
Parenteral nutrition: feeding by IV
When oral nutrition or enteral nutrition is not enough to meet nutritional needs
When the gut requires complete rest
Intravenous administration of amino acids, vitamins, minerals, electrolytes, dextrose
May add fat emulsion (lipids): provides essential fatty acids and addition calories, monitor for fat overload syndrome= fever, increase triglycerides, clotting problems, multisystem failure
Specific orders are placed based on individual needs
Order is place by provider
Routes:
Peripheral Parenteral Nutrition
Total Parenteral Nutrition
Routes of Parenteral Nutrition
Peripheral Parenteral Nutrition (PPN): Typically short term Peripheral IV Lower in dextrose concentration (<10%) May be able to handle some oral/enteral nutrition
Total Parenteral Nutrition (TPN):
Long term use
Central line access due to dextrose level
Higher dextrose content which is hypertonic solution
Requires close monitoring of fluid balance and serum electrolytes
Risk associated wit Parental Nutrition
Infection: infection at site, sterile dressing. High levels of dextrose is grounds for bacterial growth.
Fluid/Electrolytes Imbalance: monitor labs, I/O, weight
Hyperglycemia: increased risk r/t dextrose, do not abruptly stopped PPN or TPN
Psych-social: reduced oral stimulation, mouth care, eating/drinking is social event
Central Intravenous Therapy general info
Vascular access devices that are placed into the central circulation
PICC Line: placed by specialty nurse, usually in the basilic vein runs up to heart, tip of catheter rests inferior/superior vena cava and right atrium. Long term, lots of volume can be pumped into patient. TPN administration
Midline: usually in basilic vein, tip of catheter stops mid way up vein. NOT A CENTRAL LINE, PPN only
Central Venous Catheters (CVC) general info
Non-tunneled catheter: place in internal jugular
Tunneled catheter: placed subclavian
TPN feeding
X-ray to verify placement
Placed by provider
Can use femoral CVC but higher risk of infection
Port-a-Cath (port)
Port-a-Cath (port): 1+ years Sterile technique Implanted Tip of catheter is in superior vena cava
Nursing Implications for Central Line Care
Risks associated with insertion: Pneumothorax Air embolism Central line assoc. bloodstream infection Thrombophlebitis DVT
General care: Sterile dressing Trained staff to access Blood draws Maintenance of unused ports
Air embolism
Air embolism: Very rare S/S: SOB Chest pain Low BP High HR Reduced LOC Stroke like symptoms
Intervention:
Place on left lateral decubitus position, possibly with slight Trendelenberg unless contraindicated. The rationale for this position is to trap the air in the left ventricle until it can be reabsorbed, and prevent it from traveling to the lungs
Intracellular Fluid, Interstitial Fluid and Plasma info and what is in it
Intracellular Fluid (ICF): This is the fluid inside of the cell Containing: K+ Mg+ PO4 (phosphorus) Glucose Oxygen
Extracellular fluid:
This is the fluid that fluid outside of cell which includes:
Plasma:
This is the fluid in the vascular spaces (arteries, veins, capillaries)
Interstitial Fluid (IF): Fluid that floats around between all the cells
Containing:
Na+
Cl
HCO3 (bicarb)
Plasma:
This is the fluid in the vascular spaces (arteries, veins, capillaries)
Hydrostatic pressure?
Hydrostatic pressure:
The force of intravascular fluid pushing outward moving fluid from capillaries into the interstitial space
-strongest at arterial end
-CHF causes increased hydrostatic pressure
-traumatic injuries cause vasodilation and increase capillary permeability
Oncotic Pressure?
Oncotic pressure:
Inward pulling force caused by blood proteins (albumin) to move fluid from the interstitial space back into the capillaries
-strongest at the venous end
-albumin is water magnet (little to no albumin in the vascular space means H2O moves into the interstitial spaces and leads to edema)
-decreased plasma protein and serum albumin means decreased oncotic pressure
Lymphatic system regarding extra fluid
The lymphatic system is the back up if extra fluid leaks out of the capillaries. The extra fluid should shift into the lymphatic system and returned to the heart for re-circulation. Lymphatic obstruction will lead to decreased absorption of fluid causing edema.
Osmolality
Osmoles/Weight
Osmolality = Osmoles/Weight
Dependent on Na+ concentration
Normal Na+ 135-145
Normal serum osmolality 280-300 mOsm/kg H20
Osmo value is approx. double your Na+ so if Na+ is low your osmolality will be low. And the revers affect
Fluid Shifting: Osmolarity
ISOTONIC SOLUTION
Isotonic Solution:
Solution that has the same solute concentration as another solution. There is no net movement of water particles and the overall concentration on both sides of the cell membrane remain constant
Equal in, equal out
Inside cell: 20% solute concentration (80% water)
Outside cell: 20% solute concentration (80% water)
Fluid Shifting: Osmolarity
HYPERTONIC SOLUTION AND ASSESSMENT
Hypertonic Solution:
Solution that has a HIGHER solute concentration than another solution. Water particles will move out of the cell causing crenation (shriveling, notched)
Inside cell: 20% solute concentration (80% water)
Outside cell: 40% solute concentration (W60% water)
Water moves out of the cell
**Water follows salt= dehydration of the cell
**Water follows Na+ because Na+ stays where it is. Reminder, K+ slightly permeable across membranes and will move unlike Na+
Hypertonic solutions assessments: Cardiac function Renal function Pulmonary edema Fluid overload Heart failure I/O Labs Weights
Fluid Shifting: Osmolarity
HYPOTONIC SOLUTION AND ASSESSMENT
Hypotonic Solution:
Solution that has a LOWER solute concentration than another solution. Water particles will move into the cell, causing the cell to expand and eventually lyse (breakdown).
Inside cell: 20% solute concentration (80% water)
Outside cell: 10% solute concentration (90% water)
**Water follows salt= expanding the cell
**Water follows Na+ because Na+ stays where it is. Reminder, K+ slightly permeable across membranes and will move unlike Na+
Intravenous Solutions
ISOTONIC
Isotonic:
0.9% NaCl (NS)
Lactated Ringer’s
D5W (5% dextrose in water)
**Isotonic in the bag but turns to hypotonic in the patient due to metabolizing the dextrose
Intravenous Solutions
HYPOTONIC
Hypotonic:
0.45% NaCl (1/2 NS)
Pulls water INTO cell= volume replacement
Used on patient’s who are dehydrated
Caution with patient’s
- HF
- cardiovascular issues
- ICP
- edema
Intravenous Solutions
HYPERTONIC
Hypertonic:
Pulls fluid OUT of cell
Must have proper kidney and heart function
D5NS (5% dextrose in 0.9% NS): patient’s with SIADH, cerebral edema, increased ICP
D5.45NaCl (5% dextrose in 0.45% NaCl): patient’s with DKA, often used post-op
D5LR (5% dextrose in lactated ringer’s):
3% saline
Fluid and Electrolytes Pearls
Telemetry is always used
K+ and Mg+ are buddies, they often go together and Ca+ tags along
Na+ and H2O are buddies, water follows sodium
Never give K+ IV push, must be on pump
High K+ = acidosis
Low K+ = alkalosis
Ca+ and Mg+ think muscles, skeletal and heart
Ca+ and Mg+ act like sedatives, sedated if you have too much and opposite if you don’t have enough
Na+ affects brain with imbalances, CNS changes
Na+ should be correctly slowly, otherwise cerebral edema can occur
High K+, are kidneys working? Or is it medication
Ca+ and Phos have an inverse relationship
ADH released = AD H2O to the body, retained fluid, not excreted through urine.
Low Ca+ means look at the albumin
