Ch. 39 Disorders of Fluid & Electrolyte Balance Flashcards
1
Q
Sodium nl range
A
135-145 mEq/L
2
Q
Potassium nl range
A
3.5-5.0 mEq/L
3
Q
Calcium nl range
A
9-11 mg/dL
4
Q
Magnesium nl range
A
1.5-2.5 mEq/L
5
Q
Phosphate nl range
A
2.5-4.5 mg/dL
6
Q
Chloride nl range
A
96-106 mEq/L
7
Q
pH nl range
A
7.35-7.45 (no units)
8
Q
Carbon dioxide
A
35-45 mmHg
9
Q
Bicarbonate
A
22-26 mEq/L
10
Q
Oxygen
A
80-100 mmHg
11
Q
In the lungs there is __ __ __, which is water lost through __.
A
insensible water loss; breathing
12
Q
If someone has a rapid respiratory rate, they can loose a lot of ___ ___.
A
insensible water
13
Q
Homeostasis is a __ __ or __ environment in the body maintained by various __ __.
A
relatively stable; constant; control mechanisms
14
Q
Extracellular fluid
A
body fluid outside the cells
15
Q
Intracellular fluid
A
body fluid inside the cells
16
Q
The fluid of the body is secreted in specialized compartments like: (3)
A
- ) Joints
- ) Intestinal Lumen
- ) Cerebral Ventricles
17
Q
Fxns of body fluid: (5)
A
- ) surrounds and permeates the cell
- ) lubricant and solvent for metabolic chemical reactions
- ) transports oxygen, nutrients, chemical messengers and waste products to destinations
- ) regulates body temperature
- ) medium for food digestion
18
Q
The total body water in a person is __ -__% their body weight
A
40-60%
19
Q
__% of an adult’s body weight is water
A
60%
20
Q
__% of an infant’s body weight is water
A
70%
21
Q
Women who generally have more adipose tissue, have a __ __ of water in their body than males
A
lower proportion
22
Q
The obese and elderly have a _ __ of water in their body
A
lower proportion
23
Q
In a newborn, about __% of the body fluid is in the extracellular fluid
In a toddler it is __%
A
50%
30%
24
Q
The extracellular fluid accounts for __ of the body’s fluids. It is responsible for __ and __ __ to and __ __ from the cells.
A
1/3
transporting; carrying nutrients; waste products
25
Intravascular
| what does it include?
fluid within the blood vessels
| electrolytes, plasma, and albumin
26
```
Interstitial
location of most __ __.
Little to no __,
Rich in __, __, and __.
Low in __, __, and __ __.
```
```
between cells
extracellular fluid
protein
sodium, chloride, and bicarbonate
potassium, magnesium, and phosphate ions
```
27
```
Transcellular
Examples : Brain & Spinal Cord =
Lungs =
Heart=
GI tract =
```
```
contained in specialized body cavities
cerebral spinal fluid
pleural fluid
pericardial fluid
(peritoneal fluid?) diarrhea/vomiting
```
28
Intracellular make up __ of total body fluids
It contains: (4)
The electrolytes that it contains include: (3)
There is low __ and __ levels.
2/3 of total body fluids ;
solutes, oxygen, electrolytes, and glucose;
K, Mg, Phosphorous ;
Na; Cl
29
Intracellular fluid provides the medium for __ __ of the __ to take place
metabolic processes
| cell
30
Fluid homeostasis contains for 4 subprocesses:
intake, absorption, distribution, excretion
31
Intake: mostly through __ and __. (__L)
| Other examples include: __ of liquids through __, __ __ (___L), and __.
eating; drinking; 2.2; infusion; IV; cellular metabolism (0.3L), accidental
32
Absorption: occurs through the __ __.
| Abnormal absorption occurs when there is __ __ in water or through __ in __ __.
GI tract
prolonged submersion
lungs; near drowning
33
Distribution involves __ __ and __ other compartments and is a result of __ __.
transfer to ; from; concentration gradients
34
Excretion: lost through __ and __ . Also __ __ __ through __ and __.
Excretion occurs through __, __, and __.
urine/ feces
insensible water loss; sweat; breathing
bowels, lungs, skin
35
The __ __ is the primary barrier for movement of solutes through the body
cell membrane
36
__ allow water and small water soluble substances to pass
Pores
37
Active tranport is the movement of molecules through the cell membrane from an area of __ to __ concentration
low to high
38
Active transport is usually associated with accumulating high amounts of substances that the cell needs such as __, __ and __ __.
Active transport uses __.
Examples of active transport:
ions, glucose, amino acids
ATP
uptake of glucose in the intestines
uptake of mineral ions in the hair root in plants
39
Passive transport is the movement of substances across the __ __
Does it require energy?
The rate depends on the ___ of the cell membrane
cell membrane
NO
permeability
40
4 main examples of passive transport include:
Diffusion
Facilitated Diffusion
Filtration
Osmosis
41
Facilitated Diffusion uses ___ ___ embedded within the cell membrane
transport proteins
42
During filtration, fluid moves from __ __ __ to __ __ __.
high hydrostatic pressure ; lower hydrostatic pressure
43
Hydrostatic pressure is the pressure created by the __ __ __.
Examples include:
weight of fluids
increased pressure of arteries forces fluid into capillary walls and into interstitial spaces
44
Osmosis is the water movement across the cell membrane from __ solute concentration to __ concentration
low; higher
45
If RBC is placed in a dilute hypotonic solution what kind of osmotic pressure is this?
Water may __ the cell causing it to __ and __.
low osmotic pressure
enter; swell; malfunction
46
Osmolarity =
osmolar concentration in 1 Liter of solution when describing fluids outside the body
Moles of some particle/ 1 L of solution
47
Osmolality =
osmolar concentration in 1 KG of solvent for describing fluids inside the body
48
1 L of water weighs __ KG
1
49
Think of osmolality and osmolarity as meaning ___
CONCENTRATION
50
Hydrostatic pressure is the __ force and osmotic pressure is the __ force in fluid movement
push ;
pull
51
At the arterial end of the capillary the blood hydrostatic pressure __ the interstitial hydrostatic pressure and the __ __ __ of the blood. Therefore fluid is __ __ of the capillary into the interstitial compartment
exceeds; plasma colloid pressure
pushed out
52
At the venous end of the capillary the blood hydrostatic pressure is __ and the __ __ is higher therefore fluid is pulled back in to the capillary.
decreased
osmotic pressure
53
Lymphatic capillaries __ __ __
return excess fluid
54
Regulation of water balance: Internal control mechanisms include:
1.)
2.)
3.)
4.)
are responsible for __ and __ of fluid balance
1. ) thirst
2. ) RAAS system
3. ) ADH
4. ) diuretics
distribution; maintenance
55
The __ , __, and __ __ are responsible for regulating water balance
hypothalamus
pituitary
adrenal cortex
56
Hypothalamus is responsible for __.
This arises from __ __ or increase in __ like __. There are also ___ in the hypothalamus that regulate fluid so if water volume falls below certain threshold or __ become too high, the brain signals thirst.
thirst
lower fluids; osmolites; salt
osmoreceptors ; osmolites
57
Posterior pituitary release __, which regulates __ __ by the __.
ADH ; water retention; kidneys
58
Adrenal cortex: responsible for releasing __ and __ to regulate both __ and __.
glucocorticoids
mineralocorticoids
water; electrolytes
59
ADH is also referred to as __
vasopressin
60
ADH is synthesized in the __ and stored in the __ __. When there's a fluid volume deficit or increased __ __, the __ sense this and stimulates __ and ___. __ acts on the renal and __ __ ___ in the kidneys and makes them __ __ to water, so water is ___ instead of __ in the urine. The reverse is also true. When fluid is in excess (hypervolemia) and there is a decrease in plasma osmolality , ___ sense this and __ is suppressed allowing for urinary excretion of water.
hypothalamus; posterior pituitary
plasma osmolality; osmo-receptors; third; ADH;
ADH; distal collecting tubules; more permeable; reabsorbed; excreted; osmoreceptors; ADH
61
ADH only affects __ __.
water reabsorption
62
__ and __ secreted by adrenal cortex help regulate __ and __.
Glucocorticoids; minerlaocorticoids; water; electrolytes
63
Glucocorticoids like __ primarily have an __-______ effect and increase __ __ levels
cortisol; anti-inflammatory; serum glucose
64
Mineralcorticoids like __ enhance __ __ and __ __.
aldosterone; sodium retention and potassium excretion
65
The adrenal cortex regulation is also known as the:
Renin Angiotensin Aldosterone System (RAAS)
66
When decreased renal perfusion such as with ___ or __, the release of __ from the kidneys causes the conversion of ___ (from the __) to ____ _.
hypotension; hypovolemia; renin; angiotensinogen; liver; angiotensin 1
67
Angiotensin 1 is converted to __ _ by way of the enzymes called __ __ __ (___) which is found in the __.
Angiotensin II
Angiotensin converting enzyme (ACE)
Lungs
68
Angiotensin II is a ____, which results in __ __ __.
vasoconstrictor; increased blood pressure
69
Angiotensin II stimulates the release of __ from the __ __, which causes the tubules of the kidneys to increase the reabsorption of __ and__ in the blood and excrete __. This increases the fluid volume in the body which also increases __ __.
aldosterone; adrenal cortex
sodium; water; potassium; blood pressure
70
GI regulates water balance with __, __, and __.
intake, absorption, excretion
71
Kidneys regulate water balance with __ and __.
ADH; aldosterone
72
Heart plays role with production of __ and __
ANP = atrionaturetic peptide and BNP (beta naturitic peptide)
73
ANP secreted by heart cels act as a powerful ___.
vasodilator
74
BNP is secreted by __ of the heart in response to ___ ___ of the heart muscles such as when the heart is ____ due to ___ ____ overload
ventricles
excessive stretching
enlarged ; fluid volume
75
BNP decreases __ __ __ and __ __ __.
systemic vascular resistance; central venous pressure
76
BNP and ANP antagonize the ___ and __ blood volume and __ systemic blood pressure in after load
RAAS; decrease; lower
77
Electrolytes are __ __ dissolved in __.
ionized salts; water
78
Isotonic solution is if cell placed in solution has the __ osmolality as __ __. Neither __ nor __
Example: __
same; intracellular fluid; shrink; swell
normal saline
79
Hypotonic solution: when the cell is placed in a hypotonic solution, which has a __ osmolality than the __ __ they __ as water moves __ the cell.
Example: __ __ __
lower
intracellular fluid
swell
into
half normal saline
80
Hypertonic solution: when cell in hypertonic solution, which as a __ osmolality than __ __
they __ as water is pulled __ of the cell
For example: __% ___
greater
intracellular fluid
shrink; out
3% saline
81
Intake occurs normally through __ and __ __ but also: (4)
food; fluid intake
1. ) oral medications
2. ) IV or blood infusions
3. ) body tubes
4. ) near drowning (salt water)
82
Absorption is the key to maintain __. Depends on __ , which can be electrolyte __ or __.
balance
| diuretics; sparing; wasting
83
Absorption is essential for electrolyte to be used metabolically; this depends on :
(4)
1. Concentrations
2. Binding Proteins
3. pH of intestine
4. Medications (diuretics that spare or waste electrolytes)
84
Distribution is primarily influenced by __ including (5):
hormones
1. Epinephrine
2. Insulin
3. Parathyroid hormone
4. Medications
5. May be rapid
85
Excretion: can be lost through __, ___ and __ (__)
Patient with high K can be given medications to __ __ __ in feces
Abnormal losses include patient having a __ with a lot of __.
urine; feces, sweat (sodium)
increase K excretion
drain; output
86
Why are infants at high risk for fluid and electrolyte imbalances? (3)
1. immature kidneys
2. rapid respiration (insensible water loss)
3. more surface area than adults so they loose fluid very rapidly
87
What are elderly at high risk for fluid and electrolyte imbalance?
Elderly population have __ and __ changes to the __.
Structural changes lead to __ __ __ and __ in __ ( __ __ _ __)
hormonal; structural; kidney
decreased renal flow; decrease; GFR (filtering rate of kidneys)
88
The elderly have a decrease in __ ___. They also lose their ability to __ their urine and __ water.
creatinine clearance; concentrate; conserve
89
The elderly have a decrease in __ and __. They also have an increase in __, loss of __ tissue and __ of the skin, which causes more water __ through the skin
renin; aldosterone; ADH; subcutaneous; thinning; loss
90
Female bodies contain more __ tissue
| More __ = __ fluid
fatty
| fat; fluid
91
__ and __ also have low proportion of water, so they are more likely to be adversely affected by fluid and electrolyte imbalance
elderly; obese
92
Hypovolemia =
extracellular fluid volume deficit
93
Hypovolemia loss is a/an ___ loss. This means that the __ fluid and the __ within the cell are the same thus there is no change in __.
isotonic; extracellular; concentration; osmolality
94
With hypovolemia, it is characterized by __ depletion and thus differs from dehydration, which is defined as excessive loss of __ __.
Na; body water
95
Causes of hypovolemia: (Big Picture) (2)
1. Decreased Intake
| 2. Increased Loss
96
Causes of Hypovolemia -> Decreased Intake
| -> (2)
1. Someone who is nauseous/anorexic might not drink enough fluids
2. Someone who has the inability to drink (lethargy/coma) will also have decreased intake
97
Causes of Hypovolemia -> Increased loss -> (7)
1. Trauma that involves hemorrhage
2. Blood Donations
3. Burns- loss of plasma that can lead to hypovolemia
4. High urine output (polyuria, diuretics to treat HTN, dialysis d/t chronic kidney disease)
5. High GI output - someone with diarrhea, vomiting
6. Nasal Gastric Tube for suctioning (for someone with bowel obstruction)
7. Fluid Shift (third spacing, shock, diaphoresis)
98
Diuretics not only promote fluid loss, but also __ __ or __. These meds are used for: (2)
electrolyte reabsorption; loss
1. Treating patients for HTN
2. Treating patients for Heart Failure
99
Loop diuretics such as __ diurese (or __ __) by inhibiting __ and __ reabsorption from the __ of __ in the kidneys. The also inhibit __ and __ reabsorption
Lasix; remove fluid; Na; Cl; Loop; Henle; magnesium; calcium
100
Thiazine diuretics like __ diurese by inhibiting __ and __ reabsorption from the __ __ __ in the kidneys; they also increase __ __ at the distal tubule.
HCTZ ; Na; Cl; distal convoluted tubules ; calcium reabsorption
101
Potassium-sparing diuretics like __ are competitive antagonists for __. Stimulation of the __/__ exchange in the __ __ of the kidneys does not occur. Because of this, patients on aldactone lose a lot of fluid but retain or reabsorb __ as well as prevents reabsorption of __.
Aldactone; aldosterone
Na/K; collection tubules
K; Na
102
Clinical manifestations of hypovolemia might not be present until ~ __ to __% of volume is lost
10-20%
103
Hypovolemia can be recognized by ___. This is b/c when the body loses a lot of fluid, the heart is trying to compensate for the decreased cardiac output by __ __.
tachycardia
working harder
104
Someone who has lost a lot of blood or fluid could also have a __ __ __.
lower blood pressure
105
The absence of perfusion can be assessed by skin signs such as __ __ __. If it's the case of a lot of blood loss, this person will also be __. Other sx that you might see in someone who is hypovolemic could be:
1. )
2. )
poor skin turgor
pale
1.) lightheadedness
2.) dizziness/feeling faint
106
B/c a person who is hypovolemic have low blood volume, the kidneys are not adequately perfused so they have a __ __ __ which is called __.
low urine output; oliguria
107
If someone is hypovolemic b/c of blood loss, we can look at labs which show that there is a low __ consisting of a __ __ and __ ___. The patient may also feel __ and __ __.
RBC; low hemoglobin; low hematocrit; nauseated; very thirsty
108
Another clinical manifestation of hypovolemia is __ __ __
One liter of fluid weighs __ __. So if a person loses __ __ or __ __ in a 24-hour period, that means they have excreted one liter of fluid or lost it through another abnormal route such as __ or __ from a __.
substantial weight loss
one kg
2.2 lbs
suctioning; drains; wound
109
Third spacing = fluid shifting from the __ __ to the __ __ . This occurs patients with __ __ , __ or __ __ in the __ __.
intravascular space; interstitial space
| liver failure; ascites; increased fluid; peritoneal space
110
We treat hypovolemia by correcting the __ __
If it's decreased intake in __ __, we can replace both water and electrolytes with __ fluid such as:
(2)
underlying cause
PO fluid; isotonic ;
Normal Saline
Lactated Ringer's
111
If the hypovolemia is a result of hemorrhage, we can give __ __ like __ __.
blood products; packed RBCs
112
The important thing for us to remember is to monitor our patient's __ and __ as we measure their __ __
intake; output; daily weight
113
Patients with hypovolemia are known to have ___, or decreased urine output. As we are replacing fluids, we want to make sure they have an adequate urine output. We also want to make sure that they are not __ __. It is important to __ __ __.
oliguria; retaining fluids; weigh them daily
114
Maintain safety. Someone who is hypovolemic may be __ or __ so we have to put them on __ __ if they have a change in __ __.
lightheaded; confused; fall precautions; neural status
115
Someone who is hypovolemic will have a __ __ __ and __ __ __.
decreased skin turgor; dry mucous membranes
116
Dehydration is the
insufficient body fluid resulting from inadequate intake, excessive loss of fluids, a combination of both, or fluid shift between compartments
117
In dehydration, loss is more common and affects the __ compartment first
extracellular
118
Water can shift ___ the extracellular compartments. For example: If fluid is lost from the __ __ b/c of vomiting, water shifts from the __ ___ in to the __ __ to replace the loss of __. If the deficit continues, eventually fluid is lost from the __ impairing __ __.
within; digestive tract; vascular compartment ; digestive tract ; secretions; cells; cell functions
119
Dehydration: Mild deficit:
a decrease of 2% in body weight
120
Dehydration: Moderate deficit:
5% weight loss
121
Dehydration: Severe deficit:
8% of > weight loss
122
Clinical Manifestations: Initially, dehydration involves a decrease in __ and __ __. These losses may produce direct effects such as:
(9)
interstitial; intravascular fluids
1. Dry mucous membranes in the mouth
2. decreased skin turgor or elasticity
3. Low BP
4. Weak Pulse
5. Feeling Fatigue
6. Increased HCT (hematocrit) indicating a higher proportion of RBCs compared to the amount of water in the blood
7. prolonged capillary refill time
8. decreased or absent tears
9. depressed fontanel for neonates/infants
123
As brain cells continuously lose water and friction, what occurs? (3)
1. Decreased mental function
2. confusion
3. Loss of consciousness
124
In dehydration, he body attempts to compensate for fluid loss by:
1. increasing thirst
2. increasing HR
3. constricting the cutaneous blood vessels which leads to pale and cool skin
4. the body produces less urine, less concentrated urine increasing the specific gravity as a result of renal vasoconstriction
5. increase secretions of ADH and aldosterone
125
Alcohol consumption is important to ask when asking questions about PO intake b/c alcohol causes __ __ __.
increased fluid loss
126
On physical examination, we will see __ __ __ in the mouth and decreased __ __. Looking at the lab analysis for someone who is dehydrated, we want to check their __ as well as their __ ( __ __ __) and __. The __ and __ really gives us a view into how their kidneys are working. We can also look at __ __ __ , which will be elevated as urine is concentrated and has low water.
dry mucous membranes; skin turgor; electrolytes; BUN; blood urea nitrogen; creatinine;
BUN; creatinine; urine specific gravity
127
BUN : the __ produces urea as a waste product of the digestion of protein. BUN is an indication of renal health.
Normal ranges:
liver;
1.8-7.1 mmol/L
128
The main causes of an increase in BUN are: (7)
1. High protein diet
2. Decrease in Glomerular Filtration Rate (GFR) suggestive of renal failure
3. Decrease in blood volume (hypovolemia)
4. Congestive heart failure (CHF)
5. Gastrointestinal hemorrhage
6. Fever
7. Increased catabolism
129
Creatinine: Serum creatinine is an important indicator of renal health b/c it is an easily measured byproduct of __ __ that is excreted unchanged by the __.
muscle metabolism; kidneys
130
The body excretes waste molecules via urination and the role of the kidney is to concentrate the urine, such that waste molecules can be excreted with __ __ of __ and __. The concentration of the excreted molecules determines the urine's __ __.
minimal loss; water; nutrients
specific gravity
131
Adults generally have a specific gravity in the range of ___ to ___.
1.000 to 1.030
132
Increases in specific gravity (increased __ of solutes in the __) may be associated with: (7)
concentration; urine
1. Dehydration
2. Diarrhea
3. Emesis
4. Excessive sweating
5. Urinary tract/ bladder infection
6. Decreased blood flow to the kidney (especially as a result of heart failure)
7. Excess of antidiuretic hormone caused by Syndrome of Inappropriate Antidiuretic Hormone
133
Specific Gravity > ___ is consistent with frank dehydration. Hypovolemic patient usually have a specific gravity > ___.
1. 035
| 1. 015
134
Dehydration is a more serious problem for __ and __.
For infants, they experience greater insensible water loss through rapid respirations and have an increase need for water owing to their __ __ __. The __ __ is rapidly depleted in an infant affecting not only the __ and __, but also the __. This is indicated by:
1.)
2.)
3.)
infants/elderly
high metabolic rate
vascular compartment
heart/brain
kidneys
1. decreased urine output
2. increased lethargy
3. dry mucous membranes
135
Electrolyte losses can influence water balance significantly b/c electrolyte changes lead to __ __ change between compartments We can do this via __ __ such as having them drink water or things like __ if we are looking at a child who is sick and who is __ excessively. We can also treat dehydration with __ __ such as __ __ or __ __ and give electrolytes such as __ or __ which we can __
osmotic pressure
oral rehydration; Pedialyte ; vomiting
intravenous fluids; normal saline; lactated ringer's; K ; Mg ; intravenously
136
Isotonic dehydration
refers to a proportionate loss of fluid and electrolytes
137
Hypotonic dehydration
Loss of more electrolytes than water
138
Hypertonic dehydration
Loss of more water than electrolytes
139
B/c isotonic dehydration refers to a proportionate loss of fluid and electrolytes, serum electrolytes stay in a __ __.
normal range
140
Causes of isotonic dehydration include: (5)
1. Fasting
2. Diarrhea
3. Vomiting
4. Burns
5. Hemorrhage
141
Clinical manifestations of isotonic dehydration: (5)
1. dry mucous membranes
2. oliguria
3. dry skin
4. impaired skin integrity
5. other sx of hypovolemia (tachycardia, hypotension)
142
Ways we can treat isotonic dehydration: (3)
1. Administer normal saline
2. Administer lactated Ringer's
3. Administer oral hydration
143
Hypertonic Dehydration: refers to a loss of more __ than __. Therefore, serum electrolytes will be __.
fluid; electrolytes
| elevated
144
Causes of hypertonic dehydration:
1. Having extended fever
2. Diabetes insipidus - lose a lot of fluid via urination
3. diabetes mellitus
4. reduced fluid intake
145
Clinical manifestations of hypertonic dehydration: signs of ______ including:
(5)
Signs of hypernatremia including:
1. thirst
2. lethargy
3. agitation
4. seizures
5. coma
146
Treatment for hypertonic dehydration:
| GIVING __ __ such as (3).
HYPOTONIC solutions
1. .45 normal saline
2. .25 normal saline
3. D5W (Dextrose in water)
147
With diabetes insipidus (DI), there is a reduction in the release or action of __. __ is responsible for the _ of water.
ADH; ADH; reabsorption
148
Causes of DI include:
1. CNS disorders (e.g., brain tumors, head injury, infection)
2. Kidney Damage
3. Medications (Lithium)
149
In DI, the __ __ and the __ __ do not appropriately reabsorb water. This leads to: (4)
renal tubules; collecting ducts;
1. decreased water reabsorption
2. increased urine output
3. increased serum osmolality
4. sx of dehydration and hypernatremia
150
What can cause hypotonic dehydration? (3)
1. Addison's disease
2. Overuse of diuretics
3. Marathons & other long strenuous activities where H20 is the only intake (no electrolyte intake)
151
Clinical manifestations of hypotonic dehydration: (3)
1. confusion
2. Possible sz/ coma
3. N/V
152
Treatments of hypotonic dehydration:
1. Giving hypertonic fluids such as 3% NaCl
| 2. Administering Hypertonic fluids
153
Hypervolemia, or extracellular fluid excess, has no change in __. It's an __ fluid gain with an excess of __ and __
osmolality
isotonic
water/ sodium
154
Causes of hypervolemia: (5)
1. Chronic renal failure, acute glomerulonephritis (the kidneys are not functioning the way they normally should. B/c of this, they're not excreting enough urine and water is retained)
2. CHF (the heart fails to pump blood throughout the body the way it should therefore fluid is retained)
3. Liver failure, Cirrhosis
4. Hormone imbalances ( Cushing's disease, hyperaldosteronism, corticosteroid therapy) As previously discussed, steroids cause water reabsorption.
5. In addition, if someone has excess fluid intake either PO or increased IV infusions of isotonic solutions such as normal saline, they are also at risk for hypervolemia
155
Clinical manifestations of hypervolemia:
1. )
2. )
1. Edema
| 2. Circulatory Overload
156
Clinical manifestations of hypervolemia: Edema:
| This can be seen in the __ or as manifested by __ __ or __ __ which we see in pts with __
extremities; pulmonary edema; pulmonary congestion; CHF
157
Circulatory Overload can be manifested by __ __, __ __ __ (__) and elevated __
bounding pulses; jugular vein distention (JVD),
| BP
158
Treatment for a pt with hypervolemia: treat the __ __! For example, a pt with chronic renal failure would be under __ to remove the excess fluid
If we have a pt with CHF, we can give __ such as __ in order to increase __ __ of __.
We can also implement __ __. Typically in CHF pts they have a _ L __ __ a day.
underlying cause; dialysis
diuretics; Lasix; urinary excretion; water
fluid restriction; 1 L fluid restriction
159
Nursing interventions of hypervolemia: (3)
1. monitor intake/output - weigh patients daily
2. monitor respiratory status (pt with hypervolemia/pulmonary edema will have dyspnea/SOB)
3. monitor skin and mucous membrane
160
we can look at overhydation as being:
| 3
1. isoosomostic
2. hyperosomotic
3. hypotonic
161
Isoosmotic Overhydation:
Over hydration either orally or via IV with isotonic solution; can lead to edema
162
Hyperosmotic Overhydration:
Over-administration of IV or oral hypertonic solution; leads to fluid shifts in the vasculature;
Causes increased plasma volume; decreased intracellular fluid
This can cause increase in BP causing hypertensive crisis
163
Hypotonic Overhydration:
Caused by Syndrome of Inappropriate ADH (SIAHD) or ingestion of a large volume of water which causes hyponatremia
This can lead to death due to hyponatremia and CNS disturbance
164
With SIADH, there is an __ of __.
overproduction; ADH
165
SIADH is caused by:
1. CNS disorders (brain tumors, head injury, stroke)
2. Malignancies (small cell lung cancer)
3. Medications (thiazides, TCA, Opioids
166
SIADH leads to: (4)
1. Dilutional hyponatremia and decreased serum osmolality
2. there is a decrease in plasma osmolality below the normal volume and increase in urine
3. this leads to water retention and decreased urine output
4. sx of fluid overload and hyponatremia
167
Edema is the excessive amount of fluid in the __ __ which causes __ of the tissues
interstitial compartment
swelling
168
What are the 4 main causes of edema?
1. Increased capillary hydrostatic pressure
2. loss of plasma proteins
3. obstruction of lymphatic circulation
4. increased capillary permeability
169
Edema d/t increased capillary hydrostatic pressure:
Prevents the turn of blood from the __ __ to the __ __ of the capillary OR
forces an excessive amount of fluid __ of the capillary __ the tissues
interstitial compartment; venous end
out; into
170
An example of increased capillary hydrostatic pressure d/t forcing an excessive amount of fluid out of the capillary into the tissues
pulmonary edema
171
Specific causes of edema related to increased hydrostatic pressure include:
increased blood volume associated with:
1. kidney failure
2. pregnancy
3. CHF
4. Administration of excessive fluids
172
Edema d/t loss of plasma proteins:
Particularly __ which results in the decrease in plasma __ pressure.
The presence of fewer plasma proteins allows more fluid to __ the capillary and less fluid to __ to the __ end of the capillary. This can occur in pts with __ __ or __ __.
__ levels may drop acutely in __ patients who may have large areas of __ __
albumin; osmotic
leave; return ; venous
kidney disease; liver disease
Protein; burn; burned skin
173
Edema d/t obstruction of lymphatic circulation: such an obstruction usually causes a __ edema b/c excessive fluid and proteins are not returned to the __ __. This situation may develop if a __ or __ damages a __ __
localized; general circulation;
| tumor; infection; lymph node
174
Edema d/t increased capillary permeability: this causes __ edema and may result from an __ __ or __;
__ and other chemical mediators like __ are released from cells following tissue injury causing increased capillary permeability and increased __ __ into the __ area. __ also leaks into the __ compartment, increasing the __ pressure in the interstitial fluid thus holding more fluid in the interstitial area
```
localized; inflammatory response; infection
Histamine; bradykinin
fluid movement;
interstitial;
Proteins;
interstitial;
osmotic
```
175
With edema, there can be functional impairment such as (3) :
1. restriction of joint movement
2. reduced vital capacity
3. impaired diastole
176
Reasons for pain associated with edema (3)
1. edma exerts pressure on nerves locally
2. headache with cerebral edema
3. stretching of capsule in organs (kidney, liver)
177
Edema causes impaired __ __. __ leads to tissue breakdown
arterial circulation
| ischemia
178
If someone who has __ edema, for example b/c of trauma or dental work, dentures may not fit well or it may be difficult to __ __ __.
oral
take accurate impressions
179
Edema on skin: the swollen area is very susceptible to __ __ b/c of the __ __.
tissue breakdown
| increased pressure
180
Third-spacing is when fluid shifts __ of the blood and __ the body cavity/tissue. Examples: (4)
The fluid is __ __ __ as circulating fluid volume
Simply __ the patient will not reflect this shift and fluid distribution (vascular compartment -> interstitial space)
out; into
1. pt with liver failure who has ascites
2. increased fluid in abdominal cavity
3. Peritonitis: inflammation/infection of the peritoneal membrane
4. burns
no longer available
weighing
181
Most clinically important electrolytes include:
Na+, K+, Ca+ Mg+ PO4-, Cl-
182
Extracellular fluid comprises __ of total body fluid. It can be broken down into: (3)
1/3
1. Intravascular fluid such as blood
2. Transcellular fluid such as CSF
3. Interstitial fluid such as those surrounding the cells
183
Primary electrolytes found in ECF include: (3)
Na, Cl, Ca
184
Intracellular fluid = __ body fluids in adults and contains:
(4)
2/3
O2, K, Mg, Glucose
185
Sodium is the primary extracellular fluid cation (over__). Diffusion of Na occurs between the vascular and interstitial fluids. Na transport across the cell membrane are controlled by the Na/K pump or __ ___ resulting in Na levels high outside the cell and low inside the cell.
90%
active transport
186
Na is actively secreted into __ and other body secretions. It exists in the body primarily in the form of __ and ___.
mucus
salt (NaCl) and sodium bicarbonate
187
Na is lost from:
perspiration/ urine/ feces
188
Levels of sodium are controlled primarily by kidneys through the action of ____
aldosterone
189
Sodium levels are essential in the (5):
1. acid-base balance (sodium bicarbonate & sodium phosphate)
2. osmotic forces
3. conduction of nerve impulses
4. muscle contractions
5. cellular chemical reactions and membrane transport
190
Alterations in Na result in __ __.
CNS manifestations
191
Hyponatremia causes: (3)
1. Direct loss of Na from the body (vomiting/ diarrhea)
2. Diuretic Use
3. Excess of water in the extracellular compartment such as with inappropriate administration of hypotonic IV fluids and SIADH which leads to dilution of Na
192
Clinical Manifestations of Hyponatremia: (4)
If it is due to sodium loss: sx/signs include: (3)
If it is due to dilutional hyponatremia, what for s/s of __.
REMEMBER NEUROLOGIC
1. lethargy
2. confusion
3. sz
4. coma
1. lightheadedness
2. increased thirst
3. decreased urine output
OVERLOAD
193
Treatment for hyponatremia: (2)
1. give them salt tabs or hypertonic solution like 3& NS
2. Restric water
194
Causes of Hypernatremia: (4)
1. Water deficiency
2. A deficiency in the synthesis or release of ADH such as diabetes insipidus or excess Na intake and inadequate water intake
3. Inappropriate administration of hypertonic IVFs
4. Cushing Disease/Syndrome: Increased secretion of ACTH (adenocorticotropic hormone) from the anterior pituitary (secondary hypercortisolism). This is most often as a result of a pituitary adenoma (specifically pituitary basophilism) or due to excess production of hypothalamus CRH (Corticotropin releasing hormone) that stimulates the synthesis of cortisol by the adrenal glands
195
Clinical Manifestations of hypernatremia:
1. neurologic sx - decreased LOC, confusion, sz, and coma
2. if due to sodium gain, think of fluid overload
3. if due to net water loss, think of hypovolemia - such as thirst, lethargy agitation and impaired level of consciousness
196
Treatment of hypernatremia: (2)
1. Restrict Na
| 2. Replete volume so we can give hypotonic solutions to treat the hypovolemia and draw more Na to the cell
197
K is ingested in foods and excreted out of urine under the influence of ___
Aldosterone
198
Foods high in K:
bananas, citrus fruits, tomatoes, lentils
199
The hormone __ promotes movements of __ into the cells
insulin; K
200
K is important in __ __ and __ of all muscle types especially __ __
nerve conduction/ contractions; cardiac muscles
201
Abnormal K levels both high and low have a significant and serious effect on the contractions of __ __ causing changes in __ .
cardiac muscles; EKGs
202
Acidosis shifts _ ions __ of the cells and into the __ fluid where it doesn't belong
K; out; extracellular
203
Alkalosis tends to move more _ ions _ the cells
K; into
204
With acidosis, many H ions diffuse from the blood into the interstitial fluid b/c of the high hydrogen ion concentration in the blood. When these H ions move into the cell, they __ __ out of the cell to maintain electrochemical __. Then the excess K ions in the interstitial fluid diffuse into the blood leading to __. The reverse occurs with alkalosis.
displace K ions
neutrality
hyperkalemia
205
Acidosis also promotes H ion __ by the kidneys and __ of K to the body
excretion; retention
206
Essential fxns of K (3)
1. transmission and conduction of nerve impulses
2. normal cardiac rhythms
3. skeletal and smooth muscle contractions
207
Changes in pH affect K+ balance: H ions accumulate in the ___ during state of acidosis.
K+ shifts __ to maintain a balance of cations across the membrane
ICF
out
208
Causes of hypokalemia: (10)
1. Reduced intake of K
2. Low K Diet
3. Abnormal loss via the kidneys/GI tract especially from v/d
4. Magnesium deficiency
5. Treatment of DKA
6. Cushing Syndrome
7. Alcoholism
8. Malnutrition
9. Diuretics use
10. Metabolic alkalosis
209
Hypokalemia cause: Treatment of DKA: __ plays a role in K going into and out of the cell; DKA is treated with insulin b/c of __ __ in the blood; Not only does glucose goes into the cell, __ also goes into the cell, creating less __ or __ in the extracellular space.
insulin
high glucose; K
K; hypokalemia
210
Hypokalemia - Clinical Manifestations (7)
1. Bradycardia
2. Skeletal muscle weakness
3. Weakness of respiratory muscles
4. Decreased GI motility
5. Impaired regulation of arterial blood flow
Severe Manifestations
6. Shallow respirations from the weakness of the respiratory muscles
7. Polyuria
211
Treatment - Hypokalemia (3)
1. We can give IV or oral K
2. KCL supplements orally or IV have a great impact on absorption
3. We can also use K sparing diuretics such as Aldactone or increase the dietary K
212
Hyperkalemia - caused by: (12)
1. increase intake of K such as with IV supplementation, herbal supplementation, or increase in the diet high in K
2. shift of K from the intracellular space to the extracellular space
3. metabolic acidosis
4. Decreased renal excretion and you see this in pts with renal failure
5. Insulin deficiency
6. Cell trauma
7. Multiple transfusions
8. Pt on medications such as digoxin, ACE inhibitors, potassium sparing diuretics such as Aldactone
9. Traumatic injuries, burns
10. Renal failure
11. Hyperglycemia
12. Aldosterone deficit (Addison’s disease)
213
Hyperkalemia: caused by aldosterone deficit: ADDISON'S DISEASE ->
rare, chronic endocrine system disorder in which the adrenal glands do not produce sufficient steroid hormones (glucocorticoids and mineralocorticoids)
214
Clinical manifestations of hyperkalemia: (10)
1. Tingling of lips and fingers
2. Restlessness
3. Intestinal cramping
4. Diarrhea
5. Increased neuromuscular irritability
o With severe attacks you can have
6. Muscle weakness
7. Loss of muscle tone
8. Flaccid paralysis
9. Cardiac dysrhythmias
10. Respiratory arrest
215
Treatment of hyperkalemia: (5)
1. D50 plus insulin to bring more K to the cell (transient (short) therapy for urgent hyperkalemia)
2. IV calcium with bring more K to the cell
3. Kaexalate- promote K to be excreted in the stool, but it causes diarrhea
4. Sodium Bicarbonate- potassium moves into the cells (transient therapy for urgent hyperkalemia)
5. Diuretics
216
Calcium balance: controlled by: __ ___ and __ but also influenced by Vitamin __ and __ ion levels
parathyroid hormone; calcitonin; D; phosphate
217
__ blood calcium levels stimulate the secretion of parathyroid hormone which increases calcium absorption from the __ ___, ___ and promotes reabsorption from ___
low
digestive tract, kidneys, bone
218
Vitamin D may be __ or __ in the skin in the presence of __ __ such as the sun; then must be activated by the __.
ingested; synthesized; UV rays; kidneys
219
Vitamin D promotes __ __ from the __ and __ in the blood
calcium movement; bone; intestines
220
Calcium and phosphate ions in the ECF have a ___ relationship
Ex: If calcium is high, phosphate is __.
The product of calcium and phosphate concentration should be a ___ ___
reciprocal; low
| constant volume
221
Calcium is essential for: (4)
1. Structures of bones and teeth
2. Blood clotting
3. Hormone secretion
4. Cell receptor function
222
99% of calcium is located in the bone as ___ with balance controlled by parathyroid hormone and calcitonin
hydroxyapatite
223
Clinical Manifestations- Hypocalcemia (7)
1. Muscle cramps
2. Hyperactive reflexes
3. Hyperactive bowel sounds
4. Paresthesias
5. Positive Chvostek and Trousseau sign
6. Delayed heart conduction
7. Remember increased neuromuscular excitability
224
The effects of hypocalcemia on cardiac and skeletal muscle differs-
Skeletal muscle spasm:
Weaker Contraction of Cardiac muscle spasm:
results from the increased irritability of the nerves associated with muscle fibers
directly related to the calcium deficit
225
Adequate calcium is __ __ skeletal muscle cells to provide for contractions;
contractions of cardiac muscle relies on available __ __ __passing through the calcium channels. This is the basis for the action of cardiac drugs known as __ __ __.
stored in
extracellular calcium ions
calcium channel blockers
226
Treatment for hypocalcemia:
1. Give oral or IV calcium
| 2. Important to treat the underlying cause
227
Hypercalcemia is a warning sing of __
cancer
228
Causes of hypercalcemia:
```
o Hyperparathyroidism which occurs in 2/3 of cases
o Increased intake of calcium such as with calcium supplements or diets high in calcium
o Vitamin D overdose
o Prolonged demobilization
o Thiazide Diuretics like HCTZ
♣ Malignancy
♣ Hypophosphatemia
♣ Thyrotoxicosis
♣ Pheochromocytoma
```
229
clinical manifestations of hypercalcemia
```
o Muscle weakness
o Hypoactive reflexes
o Tingling (around the mouth)
o Intestinal cramping
o Hypoactive bowel sounds
Constipation
6. cardiac arrest
7. lethargy
```
230
In hypercalcemia there is __ neuromuscular excitability
DECREASED
231
Treatment of hypercalcemia
o Hydrate to reduce instance of developing calcium stones
o Calcitonin and biphosphanates to bring down the calcium levels
o Excretion of calcium with loop diuretics and giving isotonic saline and infusions
232
__ % of total body magnesium is stored in the bone
50%
233
Magnesium serum levels are leaked to both _ and __ levels
K ; calcium
234
Magnesium is found in (6) and is important in many __ __, __ __ and __ __.
green vegetables, nuts, bananas, oranges, peanut butter, chocolate ;
enzyme reactions
protein synthesis
DNA synthesis
235
Hypomagnesemia is caused by:
o results from malabsorption or malnutrition often associated with chronic alcoholism
o low serum levels may occur with loop diuretics
o diabetic ketoacidosis
o hyperparathyroidism
o hyperaldosteronism
o Renal dysfunction
o Hyperthyroidism
236
Clinical manifestations hypomagnesemia:
```
o Neuromuscular hyperirritability
♣ Tremors
♣ Involuntary repetitive movements
♣ Insomnia
♣ Personality changes
♣ Increased heart rate with arrhythmias
```
237
Treatment of hypomagnesemia
o IV Magnesium replacement
238
People with __ __ __ should not take magnesium containing drugs and should check for all over the counter drug labels for magnesium content
chronic kidney disease
239
Hypermagnesemia occurs with:
o Occurs with renal failure
| o Occurs with excess ingestion of magnesium containing antacids such as milk or magnesia or maalox
240
Hypermagnesemia- clinical manifestations
```
o Depresses neuromuscular function
♣ Decreased reflexes
♣ Lethargy
♣ Muscle weakness
♣ Respiratory depression
♣ Cardiac arrhythmias
```
241
Hypermagnesemia treatment:
1. stop intake
| 2. pt may need dialysis
242
Phosphate is located primarily in the __, but also circulate in the __ and __. It is important in ___ (__).
Seen in __ and __ __
bone; ICF; ECF
metabolism (ATP)
bone; tooth mineralization
243
__ __ __ = acid-base balance
phosphate buffer system
244
Phosphate has a __ relationship with calcium
| __ calcium __ phosphate; vice versa
reciprocal
| high; low
245
Hypophosphatemia may result from:
```
o Malabsorption syndromes
o Diarrhea
o excessive use of antacids
o alkalosis
o hyperparathyroidism
o neurologic function
♣ tremors
♣ hyporeflexia
♣ paresthesia
♣ confusion
♣ anorexia
♣ difficulty in swallowing
```
246
Hyperphosphatemia is caused by:
renal failure
247
Chloride ions tend to follow __ b/c of the attraction of the __ __ on the ions
sodium
electrical charge
248
High Na levels = __ Cl levels
High
249
Chloride and __ ions which are both negatively charged can exchange places as the blood circulates through the body in order to maintain and assist in acid-base balance
bicarbonate
250
As bicarbonate ions are used up in binding up with metabolic acids, __ ions diffuse __ of RBCs into the serum to maintain the __ __ ions in the blood.
The reverse can occur when serum levels of Cl decrease and bicarb ions:
Cl; out
same negative
leave their RBCs to maintain electrical neutrality`
251
Low serum chloride leads to high serum bicarbonate or __ = __ shift
alkalosis; chloride
252
Low serum chloride is usually associated with alkalosis in the early stages of:
vomiting when hydrochloric acid is lost from the stomach
253
causes of hyperchloremia:
1. Excess chloride ions may develop with the excessive intake of sodium chloride orally or IV
2. Hypernatremia due to other causes leading to edema and weight gain
