2.3 Nutrition, Fluid Imbalance, Shifts, Liver Failure Flashcards
Explain factors that impact fluid balance
Fluid intake, distribution and output
Anti-diuretic Hormone (ADH released from posterior pituitary gland)- vasopressin. (ADH - add water to our body)
Renin-angiotensin-aldosterone system (RAAS)- maintains fluid balance and blood pressure by retaining Na+ and H2O
Natriuretic Peptides (opposite effect of aldosterone)- hormone that promotes Na+ excretion and increases urine output
- Atrial: atrial muscles release this hormone (ANP)
- Brain: ventricular muscles (in heart) release this hormone (BNP). Secreted by increased BP and blood volume
Review signs & symptoms, causes and nursing implications of
ISOTONIC volume imbalances
− fluid volume excess
− fluid volume deficit
Isotonic
Fluid volume excess:
Volume Imbalance
Extracellular Fluid Volume Excess
Serum Osmolality is NORMAL
Fluid movement: Extracellular becomes overloaded (3rd spacing)
Vascular and interstitial spaces are both affected
S/S: Weight gain Increased BP Dependent edema Pulmonary congestion JVD Ascites
Causes:
Fluid overload from excess NaCl IV fluids
Heart/kidney and/or liver failure
Traumatic injury or burn (later fluid shift)
NI:
Na+ restriction
Diuretics
Fluid Deficit:
Volume imbalance
Extracellular fluid volume deficit
Serum Osmolality is NORMAL
Fluid movement:
Extracellular becomes hypovolemic (dehydrated)
Vascular and interstitial spaces are both affected
S/S: Weight loss, dry skin/mucous membranes Oliguria Increased urine specific gravity Nausea, weakness Postural hypotension May lead to hypovolemic shock and cardiovascular collapse
Causes:
Dehydration from fluid loss (diarrhea, wound drainage, diaphoresis, hemorrhage) or lack of intake
Traumatic injury or burn (initial fluid shift)
NI:
Isotonic IV fluids
Blood transfusion if hemorrhage
Review signs & symptoms, causes and nursing implications of
OSMOLAR imbalances
− hypotonic
− hypertonic
Osmolar Imbalance
Hypotonic:
Osmolar imbalance
Intracellular fluid volume excess
Serum osmolality <280
Fluid movement into the cells, cells become fluid overloaded
S/S: Sudden weight gain N/V Convulsions/seizures Behavior changes Increased ICP
Causes: Water intoxication (PO intake, excessive tap water enemas IV fluids) Na+ deficit (salt wasting kidney disease, SIADH)
NI:
Restrict oral fluids, strict I/O, monitor labs, neuro checks
Hypertonic IV fluids
Diuretics
Hypertonic:
Osmolar imbalance
Intracellular fluid volume deficit
Serum osmolality >300
Fluid movement out of cells, cell becomes dehydrated
S/S: Thirst Oliguria Increased urine specific gravity Weight loss, dry skin/mucous membranes Twitching/convulsions Flushing/hyperthermia Increase H&H
NI:
Oral re-hydration
Hypotonic IV fluids
Compare and contrast HHS (hyperosmolar hyperglycemic syndrome) and DKA (diabetic
ketoacidosis).
Diabetes Ketoacidosis (DKA)
Type 1 diabetes
Intracellular fluid volume deficit
Causes:
Insulin deficiency
Infection, illness, stressors
Non-compliance with insulin needs
S/S: Blood sugar >250 N/V, ab pain, dehydration Electrolyte abnormalities Metabolic acidosis from ketones Kussmaul resp CNS depression, coma, death
TX: Aggressive fluid replacement Regular IV insulin Add D5 when blood sugar <250 Monitor K+ can go up or down
NI: Monitor labs Strict I/O, daily weights Assess LOC/neuros Admin IV fluids and insulin as ordered Monitor telemetry Teaching
Hyperosmolar Hyperglycemic Syndrome (HHS)
Type 2 diabests
Intracellular fluid volume deficit
Causes:
Production of some insulin
Older population with co-morbidities more common
S/S: Blood sugar >600 Little to no ketones Increase urine output, thirst Neuro impairment Decreased GFR and acute kidney injury
TX: Treat underlying problem Regular IV insulin Correct fluid and electrolyte abnormal Life threatening if not treated
NI: Monitor labs Strict I/O, daily weights Assess LOC/neuros Admin IV fluids and insulin as ordered Monitor telemetry Teaching
Compare and contrast diabetes insipidus and SIADH (syndrome of inappropriate anti-diuretic
hormone secretion).
Diabetes Insipidus (DI)
ADH deficit
Hypertonic Fluid volume deficit (cell dehydrated)
Causes:
Neurogenic: hypothalamus and posterior pituitary
Nephrogenic: renal tubules not sensitive to ADH
S/S: Polyuria (up to 12L/day) Polydipsia Increased serum osmolality, increased serum Na+ Decreased urine specific gravity
TX:
Replace fluids
Vasopressin IV
DDAVP, intranasal
NI: Strict I/O Daily weights Seizure precautions Admin meds Monitor labs
Syndrome of Inappropriate ADH (SIADH)
ADH excess
Fluid volume excess
Causes:
Malignant tumors, ectopic, production of ADH
Head injury, stroke, lung disease
Drugs: SSRI’s, barbiturates, anesthetics
S/S: Decrease urine output Polydipsia Decreased serum osmolality and serum Na+ Mental status changes, cerebral edema
TX: Fluid striction Hypertonic saline (3-5%) Diuretics Demeclocycline (antibiotic that suppresses ADH)
NI:
Strict I/O
Daily weights
Neuro checks
Compare and contrast thyroid storm (crisis) and myxedema coma
Thyroid Storm
Life threatening, hyperthyroidism
Causes: Hyperthyroidism with stressor Untreated Grave's disease Trauma to thyroid DKA, infection, illness, stressors Meds: aspirin, iodine
S/S: Fever, flushed skin Increased HR and BP= stress on heart Increased RR= risk for resp failure Restless, confused, seizers, Coma Diarrhea
TX: Antithyroid meds: PTU or methimazole Beta blockers Steroids Cooling blanket Fluid replacement
NI: Admin meds/fluids as ordered Monitor vitals Protect/support ventilation Provide low stimulation
Myxedema Coma
Life threatening
Hypothyroidism
Causes: Elderly women with hypothyroidism Infection/Illness/stressors Meds: lithium, sedatives Thyroidectomy
S/S: Decreased HR and BP= possible death Decreased resp drive= resp failure Decreased Na+ Decreased blood sugar
TX: Thyroid replacement: IV Synthroid Glucose Steroids Warming blanket Increase vascular volume
NI: Admin meds/fluids as ordered Monitor vitals Protect/support ventilation NO sedatives
Compare and contrast the following types of cirrhosis:
a. Alcoholic
b. Post necrotic
c. Biliary
d. Cardiac
Alcoholic Cirrhosis: Most common form Directly related to alcohol consumption Fatty liver Alcoholic hepatitis Liver shrinks, becomes hard and nodular Malnutrition common Poor metabolism of ETOH
Post-hepatic (necrotic) Cirrhosis: Results of chronic Hep B or C (C most common), autoimmune hepatis or non-alcoholic fatty liver Immune response Liver shrinks, becomes hard and nodular Obesity is a contributing factor
Biliary Cirrhosis:
Obstruction of bile flow in the liver or biliary system
Retained bile destroys cells
Inflammation
Elevated bilirubin levels
Progressive liver failure
Caused by tumors, gallstones, chronic pancreatitis
Cardiac Cirrhosis:
Rare
Caused by long term, severe right heart failure
Overload of fluid backs up into the liver leading to damage
Late dietary protein
Identify diagnostic tests used for cirrhosis
LABS and DIAGNOSTIC
Lab results in cirrhosis:
Liver function studies= Increased ALT, AST, ALP (highest in Hep C)
CBC with platelets= Decreased
RBC, Hgb/Hct, platelets
Coagulation= Increased PT, inhibited clotting factor, low vit K
Serum electrolytes= Decreased Na+, K+, PO4, Mg+ (risk for altered renal function and malnutrition)
Bilirubin= Increased direct and indirect
Serum albumin= Decreased
Serum ammonia= Increased (liver can not convert ammonia to urea in order to excrete by kidneys)
US: evaluates size and detects ascites and liver nodules
EGD: esophagogastroduodenoscopy is upper GI scope to look for varices and bleeding in cirrhosis, patient is typically sedated
Liver biopsy: liver tissue obtained to test for cancer cells, cysts and cirrhosis
Describe the procedure for a liver biopsy and the nursing responsibilities associated with this
Liver Biopsy
Ultrasound guided needle into liver tissue (right upper quad) and is considered a minor surgical procedure. Liver is tested for cancer cells, cysts and cirrhosis
Risk: hemorrhage r/t deficient Vit K
NI:
Hold anticoagulants
Patient void prior
Admin Vit K if ordered
Patient hold their breath before need insertion
Hold pressure to the site
Position the patient on their right side for 1-2 hours, bed rest for 8 hours
Teach NO coughing, lifting or straining for 2 weeks
Monitor VS
Watch for peritonitis
Describe use of CIWA protocol in the management of alcohol withdrawal.
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Complications of liver failure related to etiology, signs and symptoms, treatment, and nursing implications.
ASCITES
Ascites:
Accumulation of plasma rich fluid in peritoneal cavity
Albumin is a water magnet and is synthesized in liver, albumin helps to maintain osmotic pressure
Causes: portal hypertension is primary cause
Decreased serum proteins and increased aldosterone cause fluid to accumulate because of Na+ and H2O retention
Decreased albumin and decreased oncotic pressure in the vascular space causes extracellular fluid shifting= ascites
Lymphatic congestion from increased plasma and lymphatic pressures causes leaking of fluid into the peritoneal cavity
Dilutional hyponatremia due to H2O retention
Hepatorenal impairment due to poor kidney perfusion causing azotemia (increased nitrogen compounds such as urea and creatinine) and oliguria (decreased urine out put that causes worsening edema)
Leads to ab distention causing discomfort, can lead to altered breathing
Assessment/NI:
Daily weights (1 L of fluid = 1 kg of weight)
Monitor vitals, lungs, cardiac rhythm, electrolytes (Na+, K+, Mg+)
Monitor neuro status: hyponatremia s/s: confusion, lethargy
Measure ab girth daily
Nutritional status
Glucose
Admin meds
Describe the use of the following drugs in liver failure:
a. octreotide
b. lactulose
c. spironolactone
d. furosemide
e. propranolol
f. proton pump inhibitor
Octreotide:
Lactulose:
Spironolactone: potassium sparing diuretic, decreases aldosterone levels
**Spironolactone and Furosemide can be given together, check I/O closely and lytes closely
Furosemide: Loop diuretic, promote excretions of potassium, retain sodium
Propranolol:
Proton pump inhibitor:
Albumin: for severe hypoalbuminemia
Oxazepam: only benzodiazepine not metabolized in liver
Compare and Contrast the etiology of the following abnormal assessment findings:
a. asterixis
b. fetor hepaticus
c. spider angioma
d. caput medusae
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Discuss why narcotics, sedatives and tranquilizers are contraindicated in patients with liver disease.
Medications to avoid: Narcotics Sedatives Tranquilizers Acetaminophen
These medications are metabolized by the liver and can become toxic due to liver failure
**Lorazepam (Ativan) is often ordered for alcohol withdrawal, safest for withdrawal but know the level of liver failure
Describe dietary modifications indicated in liver failure
Diet: Na+ restriction Fluid restriction Vit B-treat anemia Fat soluble vitamins (Vit K is essential for production of clotting factors) High carb and high calories Low fat Protein, depend on failure level **follow dietician
