Exam 2 (Ch. 17) PPT Flashcards
Fluid Volume Imbalances
What is a homeostasis disruption?
Fluid and electrolyte imbalances arise when a significant illness or injury interferes with the body’s ability to maintain a stable internal environment (homeostasis).
Fluid Volume Imbalances
What type of clients do you think could have a fluid
volume imbalance?
Vulnerability: Patients experiencing major physiological stress are at risk. This includes those with:
Acute illnesses: Infections, fevers, gastrointestinal issues (vomiting, diarrhea)
Chronic diseases: Heart failure, kidney disease, diabetes
Trauma: Burns, fractures, head injuries
Surgical procedures: Especially those involving significant blood loss or NPO status
Extremes of age: Infants and elderly individuals are more susceptible due to immature or declining organ function.
A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess first for potential fluid volume imbalance?
Clients:
- A 78-year-old client with a history of heart failure admitted for exacerbation of shortness of breath.
- A 35-year-old client with a fractured tibia scheduled for open reduction internal fixation (ORIF) in the morning.
- A 50-year-old client with well-controlled type 2 diabetes admitted for routine blood glucose monitoring.
- A 20-year-old client with gastroenteritis experiencing nausea, vomiting, and diarrhea for the past 24 hours.
4 A 20-year-old client with gastroenteritis experiencing nausea, vomiting, and diarrhea for the past 24 hours.
Rationale: The client with gastroenteritis is at the highest risk for rapid fluid volume deficit due to the ongoing losses from vomiting and diarrhea. This poses an immediate threat to their physiological stability. While the other clients have potential or chronic risks, the gastroenteritis patient’s acute fluid loss takes priority.
Scenario: A client is admitted with a diagnosis of heart failure exacerbation. The nurse monitors the client’s daily weights and observes the following trend:
Day 1: 70 kg
Day 2: 71.5 kg
Day 3: 72.8 kg
Question: What is the most likely explanation for the client’s weight gain?
A. Fluid volume deficit
B. Fluid volume overload
C. Improved nutritional intake
D. Increased muscle mass
B. Fluid volume overload
Rationale: In heart failure exacerbation, the heart’s pumping ability is compromised, leading to fluid retention. The progressive weight gain over the three days strongly suggests fluid accumulation rather than fluid loss, improved nutrition, or muscle gain.
Which of the following clients are at increased risk for developing a fluid volume deficit? (Select all that apply.)
A. A client with uncontrolled diabetes mellitus
B. A client with syndrome of inappropriate antidiuretic hormone (SIADH)
C. A client with profuse sweating due to heat exposure
D. A client experiencing continuous vomiting and diarrhea
E. A client with chronic kidney disease
F. A client with a head injury resulting in increased intracranial pressure
A, C, D, and E
Rationale:
A. Uncontrolled Diabetes: High glucose levels lead to osmotic diuresis, resulting in excessive fluid loss.
C. Profuse Sweating: Sweating is a physiological response to heat, but excessive sweating without adequate fluid replacement can lead to dehydration.
D. Vomiting and Diarrhea: These directly result in the loss of fluids and electrolytes.
E. Chronic Kidney Disease: Damaged kidneys may have difficulty regulating fluid balance, potentially leading to both deficits and excesses, but in this case, we are focusing on potential deficits.
Fluid Volume Deficit (Hypovolemia)
What is hypovolemia, what are some causes?
Hypovolemia refers to a decrease in the volume of circulating blood in the body. It’s often used interchangeably with dehydration, but technically, dehydration refers to a loss of water specifically, while hypovolemia can include loss of other fluids and electrolytes.
Causes:
▪ Abnormal loss of bodily fluids
▪ Diarrhea
▪ Vomiting
▪ Hemorrhage
▪ Polyuria
▪ Inadequate fluid intake
▪ Overuse of diuretics
▪ NG Suction
▪ High fever
▪ Heatstroke
A nurse is caring for a client with severe vomiting and diarrhea. Which of the following findings would indicate fluid volume deficit? (Select all that apply.)
A. Bounding pulse
B. Decreased skin turgor
C. Hypertension
D. Increased urine specific gravity
E. Flat neck veins
F. Moist mucous membranes
B, D, E
Rationale:
Decreased skin turgor: A classic sign of dehydration.
Increased urine specific gravity: Indicates concentrated urine, as the kidneys try to conserve water.
Flat neck veins: Suggests decreased venous return due to reduced blood volume.
Hypovolemia - Manifestations
What are some S/S of hypovolemia?
Neurological: Restlessness, drowsiness, lethargy, confusion, seizures, coma (in severe cases). These reflect the impact of dehydration on brain function.
Sensory/Hydration: Thirst, dry mucous membranes.
Integumentary: Cold, clammy skin, decreased skin turgor, decreased capillary refill.
Cardiovascular: Decreased blood pressure, decreased heart rate, increased respiratory rate.
Renal: Decreased urine output.
General: Weakness, dizziness, weight loss.
A nurse is assessing a client with suspected hypovolemia. Which of the following findings are consistent with fluid volume deficit? (Select all that apply.)
A. Increased skin turgor
B. Moist mucous membranes
C. Restlessness and confusion
D. Decreased capillary refill
E. Bounding pulse
F. Decreased urine output
C, D, F
Rationale: Restlessness/confusion (neurological changes), decreased capillary refill (integumentary), and decreased urine output (renal) are all consistent with hypovolemia.
A client with severe diarrhea is exhibiting manifestations of fluid volume deficit. The nurse notes a decreased heart rate. What is the nurse’s most appropriate action?
A. Administer intravenous fluids as prescribed.
B. Document the finding and continue to monitor the client.
C. Assess the client for other signs and symptoms of hypovolemia and notify the healthcare provider.
D. Check the client’s medication administration record for medications that may lower the heart rate.
C
Rationale: The decreased heart rate is an atypical finding in hypovolemia and warrants further investigation. The nurse should assess for other signs and symptoms, review the client’s history and medications, and promptly notify the provider about this concerning finding.
A nurse is caring for a client with persistent vomiting and diarrhea. Which of the following assessments is the highest priority?
A. Assessing the client’s skin turgor.
B. Monitoring the client’s urine output.
C. Auscultating the client’s lung sounds.
D. Checking the client’s neurological status.
D
Rationale: While all assessments are important, neurological changes (such as confusion, lethargy, or decreased level of consciousness) can indicate worsening hypovolemia and require immediate intervention to prevent potential complications like seizures or coma. Therefore, neurological status is the highest priority.
Fluid Volume Excess (Hypervolemia)
What is hypervolemia? What causes it?
Hypervolemia, also known as fluid overload, is a condition characterized by an abnormal increase in the volume of circulating blood in the body. It involves an excess of both water and sodium.
Abnormal retention of fluids
Causes:
Heart Failure: The heart’s inability to effectively pump blood can lead to fluid buildup.
Renal Failure: Impaired kidney function reduces the body’s ability to eliminate excess fluids.
Long-term Corticosteroid Use: These medications can cause sodium and water retention.
Excessive Isotonic or Hypotonic IV Fluids: Overadministration of these fluids can lead to fluid overload.
Hypervolemia - Manifestations
What are some S/S of Hypervolemia?
▪ Headache, confusion, lethargy
▪ Peripheral Edema
▪ Jugular vein distention
▪ Bounding pulse, increased blood
pressure
▪ Polyuria with normal renal function
▪ Dyspnea, crackles, pulmonary
edema
▪ Muscle spasms
▪ Weight Gain
▪ Seizures, coma
A patient with heart failure is admitted with fluid volume excess. Which of the following assessment findings is the highest priority for the nurse to address?
A. Edema in the feet and ankles.
B. Crackles in the lungs.
C. Weight gain of 2 pounds.
D. Jugular venous distention (JVD).
B
Rationale: Crackles in the lungs indicate fluid in the lungs (pulmonary edema), which can impair oxygenation and lead to respiratory distress. This is the highest priority as it poses an immediate threat to the patient’s well-being.
A patient with chronic renal failure is admitted with hypervolemia. Which of the following interventions would the nurse anticipate to be prescribed by the healthcare provider?
A. Increased oral fluid intake.
B. Administration of hypotonic intravenous fluids.
C. Restriction of dietary sodium.
D. Encouraging consumption of foods high in potassium.
C
Rationale: Sodium restriction is a key component of managing hypervolemia as sodium causes the body to retain water. The other options would worsen fluid overload in this patient.
A patient is receiving intravenous fluids at a high rate. The nurse observes the following signs and symptoms: crackles in the lungs, increased blood pressure, and bounding pulse. What is the nurse’s most appropriate action?
A. Slow down the IV infusion rate and notify the healthcare provider.
B. Administer oxygen and diuretics as prescribed.
C. Document the findings and continue to monitor the patient.
D. Check the patient’s electrolyte levels.
A
Rationale: These are classic signs of fluid overload due to the rapid IV infusion. The most appropriate action is to slow the infusion rate to prevent further fluid accumulation and notify the provider about the patient’s status. The other actions may be necessary but are secondary to stopping the immediate cause of the problem.
Nursing Management- Fluid Imbalance
What are some key nursing managements for fluid imbalances?`
▪ Assess patient for manifestations of fluid imbalances.
▪ Give IV fluids and medications as ordered.
▪ Give O2 therapy as ordered.
▪ Implement fall precautions.
▪ Monitor patient for effectiveness of therapy.
▪ Obtain daily weights and vital signs.
▪ Accurate intake and output.
▪ Elevate edematous extremities.
A patient with fluid volume excess develops shortness of breath and crackles in the lungs. What is the nurse’s most appropriate initial action?
A. Administer oxygen therapy as ordered.
B. Notify the healthcare provider.
C. Elevate the head of the bed.
D. Administer diuretics as prescribed.
A
Rationale: While all options are important, the most immediate action is to administer oxygen to address the patient’s respiratory distress.
What is paracentesis? Why is it performed?
Definition: A procedure in which a needle is inserted into the abdomen to remove excess fluid (ascites) from the peritoneal cavity.
Reasons for procedure: Ascites (fluid buildup in the abdomen) can be caused by liver disease, heart failure, kidney disease, or cancer. Paracentesis is done to relieve abdominal pressure, improve breathing, and obtain fluid for diagnostic testing.
What are some nursing considerations for paracentesis?
Nursing considerations:
Explain the procedure to the patient.
Obtain informed consent.
Assist the patient to void before the procedure to reduce the risk of bladder puncture.
Position the patient in a semi-Fowler’s or sitting position.
Monitor vital signs throughout the procedure.
Measure abdominal girth before and after the procedure.
Observe for signs of complications (e.g., bleeding, infection, peritonitis).
What is thoracentesis? Why is it performed?
Definition: A procedure in which a needle is inserted into the chest cavity (pleural space) to remove excess fluid or air.
Reasons for procedure: Pleural effusion (fluid buildup around the lungs) can be caused by heart failure, pneumonia, cancer, or pulmonary embolism. Thoracentesis is done to relieve respiratory distress, obtain fluid for diagnostic testing, or instill medication into the pleural space.
What are some nursing considerations for thoracentesis?
Nursing considerations:
Explain the procedure to the patient.
Obtain informed consent.
Position the patient upright with arms resting on an overbed table.
Monitor vital signs throughout the procedure.
Observe for signs of complications (e.g., pneumothorax, bleeding, infection).
Encourage deep breathing and coughing after the procedure.
Obtain a post-procedure chest x-ray as ordered.
What are the 3 Common Crystalloid Solutions?
- Hypotonic
- Hypertonic
- Isotonic
IV Fluid and Electrolyte Replacement
What are the 2 purposes of IV fluid therapy?
Maintenance: To provide ongoing daily needs for fluids and electrolytes when oral intake is insufficient or not possible. This could be due to various reasons like surgery, illness, or inability to swallow.
Replacement: To correct existing fluid or electrolyte deficits that have occurred due to losses (e.g., vomiting, diarrhea, hemorrhage) or ongoing conditions.
IV Fluid and Electrolyte Replacement
How are IV fluids categorized?
By tonicity
- This refers to the concentration of solutes in the fluid compared to the concentration of solutes in the blood (plasma).
A patient is admitted with dehydration due to severe vomiting and diarrhea. Which of the following is the MOST important initial step in managing this patient’s fluid needs?
A. Administering antiemetics to stop the vomiting.
B. Inserting an IV catheter and initiating fluid replacement.
C. Obtaining a detailed medical history and performing a physical exam.
D. Ordering laboratory tests to assess electrolyte levels.
C
Rationale: While all steps are important, obtaining a medical history and performing a physical exam are crucial first to assess the severity of dehydration and determine the appropriate course of treatment.
A patient is receiving a hypertonic IV solution. Which of the following assessments should the nurse prioritize during the infusion?
A. Monitoring urine output.
B. Assessing for signs of fluid overload.
C. Checking the IV site for infiltration.
D. Monitoring blood glucose levels.
B
Rationale: Hypertonic solutions can cause fluid to shift from the cells into the vascular space, potentially leading to fluid overload. Monitoring for signs of fluid overload is the priority.
Hypotonic IV Fluids
What are hypotonic IV fluids? What are their effect on fluid distribution?
Hypotonic IV fluids have a lower osmolality (concentration of solutes) than plasma (blood).
Effect on Fluid Distribution: Because of the lower osmolality, hypotonic fluids dilute the extracellular fluid (ECF). This causes water to move from the ECF into the intracellular fluid (ICF) via osmosis, leading to cell swelling.
Key Monitoring Point: It is crucial to monitor for changes in mentation (mental status) as rapid shifts in fluid balance can lead to cerebral edema (swelling of the brain).
Hypotonic IV Fluids
What are some uses for hypotonic IV fluids?
Maintenance Fluids: Hypotonic solutions can be used for routine maintenance of fluids, especially when patients are NPO (nothing by mouth) and need fluids to replace insensible losses (e.g., sweating, breathing).
Hypernatremia Treatment: They are also used to treat hypernatremia (high sodium levels) by diluting the excess sodium in the ECF.
Which of the following statements are correct regarding hypotonic IV fluids? (Select all that apply.)
A. They have a higher osmolality than plasma.
B. They cause water to move from the ECF to the ICF.
C. They can be used to treat hypernatremia.
D. They are appropriate for patients with increased ICP.
E. They can lead to cell swelling.
B, C, E
Rationale: Hypotonic solutions have a lower osmolality than plasma and are contraindicated in patients with increased ICP as they can worsen cerebral edema.
A patient is ordered to receive a hypotonic IV solution. Which of the following assessments should the nurse prioritize before initiating the infusion?
A. Checking the patient’s blood glucose level.
B. Assessing the patient’s neurological status.
C. Monitoring the patient’s urine output.
D. Assessing the patient’s skin turgor.
B
Rationale: Changes in mentation can be an early sign of cerebral edema, a potential complication of hypotonic fluid administration. Therefore, assessing neurological status is the priority.
A patient receiving a hypotonic IV solution develops a sudden change in mentation (confusion). Which of the following actions should the nurse take FIRST?
A. Slow down the IV infusion rate.
B. Notify the healthcare provider.
C. Assess the patient’s vital signs.
D. Stop the infusion and administer a hypertonic solution.
A
Rationale: The change in mentation could indicate cerebral edema. The FIRST action is to slow the infusion rate to minimize further fluid shift into the cells. The healthcare provider should be notified, and vital signs should be assessed, but slowing the infusion is the priority.
D5W (5% Dextrose in Water)
What type of crystalloid solutions is D5W?
D5W is technically considered isotonic because its initial osmolality is similar to that of plasma. However, the dextrose (sugar) is rapidly metabolized by the body, leaving behind free water and becoming hypotonic.
D5W (5% Dextrose in Water)
What are the metabolic effect and net results of D5W?
Metabolic Effect: The dextrose is quickly metabolized into carbon dioxide and water, providing a small amount of calories (170 cal/L) and essentially becoming free water.
Net Result: The net result of D5W infusion is the provision of free water, which dilutes the body fluids.
D5W (5% Dextrose in Water)
What are the uses of D5W?
Replacing Water Losses: D5W is used to replace water losses, such as those due to dehydration or excessive sweating.
Preventing Ketosis: The small amount of dextrose can help prevent ketosis (a metabolic state caused by fat breakdown) in patients who are NPO (nothing by mouth).
Provides 170 cal/L
Not a Replacement for Electrolytes
D5W (5% Dextrose in Water)
What are some risk of D5W?
Hyperglycemia: In some patients, particularly those with diabetes, D5W can cause hyperglycemia (high blood sugar).
Fluid Overload: Like any IV fluid, D5W can contribute to fluid overload if infused in large amounts or too rapidly.
Dilution of Electrolytes: Because D5W dilutes body fluids, it can also dilute electrolyte concentrations, potentially leading to imbalances.
Which of the following statements are correct regarding D5W? (Select all that apply.)
A. It is technically considered isotonic.
B. It provides electrolytes.
C. It provides calories.
D. It can be used to treat dehydration.
E. It can cause hyperglycemia.
A, C, D, E
A patient with dehydration is ordered to receive D5W. Which of the following assessments should the nurse prioritize before initiating the infusion?
A. Checking the patient’s blood glucose level.
B. Assessing the patient’s neurological status.
C. Monitoring the patient’s urine output.
D. Assessing the patient’s skin turgor.
A
Rationale: Because D5W can cause hyperglycemia, checking the patient’s baseline blood glucose level is the priority, especially for diabetic patients.
A patient is receiving D5W for maintenance fluids. Which of the following findings would indicate that the patient is developing fluid overload?
A. Decreased blood pressure.
B. Crackles in the lungs.
C. Poor skin turgor.
D. Increased urine output.
B
Rationale: Crackles in the lungs are a sign of pulmonary edema (fluid in the lungs), which indicates fluid overload.
A patient with a history of diabetes is ordered to receive D5W. Which of the following actions should the nurse take to minimize the risk of hyperglycemia?
A. Infuse the D5W at a rapid rate.
B. Monitor the patient’s blood glucose level regularly.
C. Administer insulin before the D5W infusion.
D. Use a hypotonic solution instead of D5W.
B
Rationale: Regular blood glucose monitoring is essential to detect and manage hyperglycemia. Slowing the infusion rate might help, but monitoring is the priority. Insulin administration would depend on the glucose level and physician orders. A hypotonic solution might not be appropriate for the patient’s specific fluid and electrolyte needs.
Isotonic IV Fluids
What are the osmolality and fluid distribution for isotonic IV fluids?
Osmolality: Isotonic solutions have a similar osmolality (concentration of dissolved particles) to that of the body’s extracellular fluid (ECF), particularly the plasma.
Fluid Distribution: When infused, isotonic solutions primarily remain within the extracellular space (both the intravascular and interstitial compartments). There is minimal to no net movement of fluid across cell membranes into the intracellular space (ICF).
Isotonic IV Fluids
What are the effect on cells and primary uses of isotonic IV fluids?
Effect on Cells: Because there’s no significant fluid shift, isotonic solutions do not cause cells to shrink or swell.
Primary Use: Isotonic fluids are ideal for replacing fluid volume deficits that occur in conditions like:
* Hemorrhage (blood loss)
* Dehydration (loss of fluids)
* Vomiting and Diarrhea
* Surgery
Isotonic IV Fluids
What are somethings to monitor for with isotonic IV fluids?
Fluid Overload: Signs include edema (swelling), crackles in the lungs, jugular venous distention (JVD), and rapid weight gain.
Electrolyte Imbalances: Although isotonic fluids are generally balanced, rapid or excessive infusion can still lead to electrolyte disturbances.
A patient who experienced significant blood loss during surgery requires intravenous fluid replacement. Which type of IV fluid would be MOST appropriate to administer initially?
A. 0.45% Normal Saline (1/2 NS)
B. D5W (5% Dextrose in Water)
C. 0.9% Normal Saline (NS)
D. 3% Hypertonic Saline
C
Rationale: 0.9% Normal Saline is an isotonic solution that is commonly used for initial fluid resuscitation in cases of blood loss or dehydration.
Normal Saline
What is normal saline’s tonicity, compostions, & uses?
Other Names: NS, 0.9% saline, NSS (Normal Saline Solution)
Tonicity: Isotonic - meaning it has a similar concentration of dissolved particles as the body’s extracellular fluid (ECF).
Composition: Contains slightly more sodium chloride (NaCl) than the ECF.
Use Cases:
* Fluid and Sodium Loss: Used when both fluid and sodium are lost, such as in hemorrhage, vomiting, and diarrhea.
* Blood Product Administration: The only solution that can be used with blood products. This is because other solutions can cause red blood cells to swell and rupture (hemolysis).
Normal Saline
What are some important considerations for normal saline and what should you monitor?
Volume Expansion: Since it’s isotonic, it expands the ECF volume without causing a significant shift of fluid into or out of the cells.
Electrolyte Imbalances: It doesn’t provide other electrolytes, so prolonged use can lead to imbalances.
Acid-Base Balance: Can cause mild metabolic acidosis in large volumes due to the high chloride content.
Monitoring
* Fluid Overload: Signs include edema (swelling), crackles in the lungs, jugular venous distention (JVD), and rapid weight gain.
* Electrolyte Imbalances: Especially potassium, as it can be diluted.
Which of the following statements accurately describe normal saline (0.9% NaCl)? (Select all that apply.)
A. It is a hypotonic solution.
B. It is used to replace both fluid and sodium losses.
C. It is the only solution compatible with blood products.
D. It can cause cells to shrink.
E. It can lead to electrolyte imbalances with prolonged use.
B, C, E
A patient who experienced significant blood loss during surgery requires intravenous fluid replacement. Which type of IV fluid would be MOST appropriate to administer initially?
A. 0.45% Normal Saline (1/2 NS)
B. D5W (5% Dextrose in Water)
C. 0.9% Normal Saline (NS)
D. Lactated Ringer’s (LR)
C
Rationale: Normal saline is an isotonic solution that is commonly used for initial fluid resuscitation in cases of blood loss or dehydration. While Lactated Ringer’s is also an option, NS is often preferred in emergencies due to its simplicity.
Lactated Ringer’s Solution
What is Lactated Ringer’s tonicity, compostions, & uses?
Tonicity: Isotonic - meaning it has a similar concentration of dissolved particles as the body’s extracellular fluid (ECF).
Composition: Contains sodium, potassium, chloride, calcium, and lactate. The lactate is metabolized by the liver into bicarbonate, which helps buffer acidity.
Use Cases:
* Expanding ECF: Used to expand the ECF volume, such as in situations involving fluid loss due to surgery, burns, and gastrointestinal (GI) losses (vomiting, diarrhea).
* Electrolyte Replacement: Provides electrolytes, helping to replenish those lost in various conditions.
Lactated Ringer’s Solution
What are some contraindication of Lactated Ringer’s Solution?
3
- Liver Problems: Contraindicated in patients with liver impairment as they may have difficulty metabolizing lactate into bicarbonate.
- Hyperkalemia: Contraindicated in patients with high potassium levels as LR contains potassium.
- Severe Hypovolemia: Use with caution in severe hypovolemia as rapid infusion can lead to electrolyte imbalances.
Lactated Ringer’s Solution
What are some important considerations for Lactated Ringer’s Solution and what should you monitor?
Fluid Resuscitation: LR is often used for fluid resuscitation in trauma and burn patients.
Metabolic Alkalosis: While it can help buffer acidity, excessive administration can lead to metabolic alkalosis.
Monitoring: When administering LR, it’s essential to monitor for:
* Fluid Overload: Signs include edema (swelling), crackles in the lungs, jugular venous distention (JVD), and rapid weight gain.
* Electrolyte Imbalances: Especially potassium and calcium, as LR contains these electrolytes.
* Acid-Base Balance: Monitor for signs of metabolic alkalosis.
Which of the following statements accurately describe Lactated Ringer’s (LR) solution? (Select all that apply.)
A. It is a hypotonic solution.
B. It contains sodium, potassium, chloride, calcium, and lactate.
C. It is used to expand the extracellular fluid volume.
D. It is contraindicated in patients with liver problems.
E. It can lead to hyperkalemia.
B, C, D
Rationale: LR is isotonic, not hypotonic. It is contraindicated in hyperkalemia as it contains potassium.
A patient with severe burns requires intravenous fluid replacement. Which type of IV fluid would be MOST appropriate to administer initially?
A. 0.45% Normal Saline (1/2 NS)
B. D5W (5% Dextrose in Water)
C. 0.9% Normal Saline (NS)
D. Lactated Ringer’s (LR)
D
Rationale: LR is often preferred in burn patients due to its balanced electrolyte composition and its lactate content, which can help buffer metabolic acidosis often seen in burn injuries.
Hypertonic IV Fluids
What are the osmolality, fluid shift, and key monitoring for hypertonic IV fluids?
Osmolality: Hypertonic solutions have a higher osmolality (concentration of dissolved particles) compared to plasma (blood).
Fluid Shift: Due to this higher concentration, they draw water out of the cells into the extracellular fluid (ECF). This leads to cell shrinkage and expansion of the ECF volume and requires frequent monitoring.
Key Monitoring:
* Blood Pressure: Can increase due to the increased fluid volume in the ECF.
* Lung Sounds: Monitor for signs of fluid overload or pulmonary edema as fluid is drawn into the vascular space.
* Serum Sodium Levels: Hypertonic solutions can significantly impact sodium levels, so close monitoring is crucial.
Hypertonic IV Fluids
What are some uses of hypertonic IV fluids?
Hypertonic solutions are typically used in specific situations, such as:
* Severe Hyponatremia (low sodium levels): To quickly increase sodium levels.
* Cerebral Edema (swelling in the brain): To draw fluid out of the brain tissue and reduce swelling.
Administration: These solutions should be administered cautiously and usually via a central line due to the risk of vein irritation.
Rate of Infusion: The infusion rate is carefully controlled to avoid rapid fluid and electrolyte shifts.
Which of the following statements are correct regarding hypertonic IV fluids? (Select all that apply.)
A. They have a lower osmolality than plasma.
B. They cause water to move from the ICF to the ECF.
C. They can be used to treat severe hyponatremia.
D. They can cause cells to shrink.
E. They require frequent monitoring of blood pressure, lung sounds, and serum sodium levels.
B, C, D, E
A patient is receiving a hypertonic saline solution for severe hyponatremia. Which of the following assessments should the nurse prioritize during the infusion?
A. Checking the patient’s blood glucose level.
B. Assessing the patient’s neurological status.
C. Monitoring the patient’s urine output.
D. Assessing the patient’s skin turgor.
B
Rationale: Changes in mentation can be a sign of rapid shifts in electrolytes and fluid balance, including cerebral edema. Therefore, neurological assessment is the priority.
D5 1/2 NS (5% Dextrose in 0.45% Normal Saline)
What is D5 1/2 NS’s tonicity, compostions, & uses?
Tonicity: Technically, it’s initially hypertonic due to the dextrose, but the dextrose is quickly metabolized, leaving a hypotonic solution (0.45% NS). So, the net effect is hypotonic.
Components: Contains dextrose (sugar) and 0.45% normal saline (half-strength saline).
Uses:
* Common Maintenance Fluid: Often used for maintenance IV fluids, providing hydration, calories, and some electrolytes.
* Replaces Fluid Loss: Can be used to replace fluid losses, but it’s important to consider the electrolyte content in relation to the patient’s specific needs.
* Potassium Chloride (KCl) Addition: Potassium chloride (KCl) is often added to D5 1/2 NS to meet the patient’s daily potassium needs or to replace potassium deficits.
D5 1/2 NS (5% Dextrose in 0.45% Normal Saline)
What are some important considerations for D5 1/2 NS and what should you monitor?
Dextrose Metabolism: The dextrose provides calories and is quickly metabolized, leaving free water that dilutes the extracellular fluid.
Electrolyte Content: 0.45% NS provides sodium and chloride, but in lower amounts than normal saline. It may not be sufficient for significant sodium losses.
Monitoring:
* Fluid Overload: Signs include edema, crackles in the lungs, jugular venous distention (JVD), and rapid weight gain.
* Electrolyte Imbalances: Especially sodium, potassium, and chloride.
* Hyperglycemia: Due to the dextrose content.
* Changes in Mental Status: Can be related to either electrolyte imbalances or hydration status.
Which of the following statements are correct regarding D5 1/2 NS? (Select all that apply.)
A. It is initially hypotonic.
B. It is commonly used for maintenance fluids.
C. It provides calories.
D. It can be used to replace fluid losses.
E. Potassium chloride (KCl) is often added to it.
B, C, D, E
A patient is receiving D5 1/2 NS with KCl. The nurse notes that the patient’s potassium level is 5.8 mEq/L. What is the nurse’s BEST action?
A. Increase the IV flow rate.
B. Hold the current IV infusion and notify the healthcare provider.
C. Administer a potassium-wasting diuretic.
D. Document the finding and continue the infusion as prescribed.
B
Rationale: A potassium level of 5.8 mEq/L is considered high (hyperkalemia). The nurse should hold the IV infusion containing KCl and notify the provider.
Colloids
What is the definition of colloids, what is it’s effect on coagulation?
Definition: Colloids are intravenous solutions containing large molecules that do not readily cross capillary membranes. They primarily stay within the vascular space (blood vessels).
Effect on Coagulation: All colloids affect blood coagulation to some extent by interfering with coagulation factor VII. This is an important consideration, especially in patients with bleeding disorders.
Colloids
What are some types of colloids?
Human Plasma Products:
* Albumin: A protein that helps maintain oncotic pressure. Available in various concentrations (e.g., 5%, 25%).
* Fresh Frozen Plasma (FFP): Contains clotting factors and plasma proteins. Used to treat clotting disorders or replace multiple clotting factors.
* Blood: Whole blood or packed red blood cells (PRBCs) are also considered colloids due to their cellular components.
Semisynthetics:
* Dextran: A polysaccharide that expands plasma volume. Different molecular weights are available.
* Starches (e.g., Hespan, Voluven): Also used for volume expansion.
Colloids
What are some uses of colloids? How are they administered?
Uses: Colloids are used to treat conditions involving fluid volume deficits or low oncotic pressure, such as:
* Shock (hypovolemic, septic)
* Severe burns
* Liver failure
* Kidney disease
Administration: Colloids are generally administered intravenously. The rate of infusion depends on the specific product and the patient’s condition.
Colloids
What should the nurse monitor for with colloids?
- Fluid Overload: Signs include edema, crackles in the lungs, jugular venous distention (JVD), and rapid weight gain.
- Allergic Reactions: Especially with dextran and starches.
- Coagulation Disorders: Due to the potential effect on coagulation.
- Electrolyte Imbalances: Fluid shifts can affect electrolyte concentrations.
Which of the following statements are correct regarding colloids? (Select all that apply.)
A. They readily cross capillary membranes.
B. They increase oncotic pressure in the blood.
C. They can interfere with blood coagulation.
D. Albumin is an example of a colloid.
E. They cause fluid to shift from the interstitial space to the vascular space.
B, C, D, E
A patient with a known history of bleeding disorder is ordered to receive dextran. Which action by the nurse is MOST appropriate?
A. Administer the dextran as prescribed.
B. Question the order with the healthcare provider.
C. Monitor the patient’s blood pressure closely.
D. Ensure that the patient has a patent IV access.
B
Rationale: Dextran can interfere with coagulation, so it may not be appropriate for a patient with a bleeding disorder. The nurse should question the order with the healthcare provider.
Potassium Imbalances
What are some cause of hypokalemia?
Vomiting
Gastric suction
Prolonged diarrhea
Diuretics and steroids
Inadequate intake
Large urine output
Potassium Imbalances
What are some cause of hyperkalemia?
Cared
Cellular Movement of K from ICF to ECF (burns)
Adrenal Insufficiency with Addison’s Disease
Renal Failure
Drugs (potassium sparing diuretics)
A patient with hypokalemia is ordered to receive IV potassium chloride (KCl). Which action by the nurse is the HIGHEST priority?
A. Administer the KCl via a peripheral IV line.
B. Infuse the KCl at a rate of 40 mEq/hr.
C. Monitor the patient for signs of phlebitis at the IV site.
D. Assess the patient’s cardiac rhythm.
D
Rationale: Cardiac arrhythmias are a potential complication of both hypokalemia and hyperkalemia. Monitoring the cardiac rhythm is the priority when administering IV KCl. KCl should be administered via a central line when possible due to vein irritation and should be infused slowly (typically no more than 10-20 mEq/hr unless in a critical situation).
Potassium Imbalances: Signs and Symptoms
What are some S/S of hypokalemia?
A Sic Walt
Alkalosis
Shallow Respirations
Irritability
Confusion & Drowsiness
Weakness & Fatigue
Arrhythmias
Lethargy
Thready Pulse
Potassium Imbalances: Signs and Symptoms
What are some S/S of hyperkalemia?
Murder
Muscle Weakness
Urine output little or none
Respiratory Failure (due to muscle weakness)
Decreased cardiac contractility (weak pulse/low HR)
Early: muscle twitches/cramps
Rhythm changes: Tall peaked T waves, prolonged QT interval
A patient’s potassium level is 6.2 mEq/L. Which of the following EKG changes would the nurse expect to see?
A. Flattened T waves
B. Peaked T waves
C. Prominent U waves
D. Prolonged PR interval
B
Rationale: Peaked T waves are a characteristic EKG finding in hyperkalemia.
Nursing Management of Hypokalemia
What are 2 forms of potassium replacement?
Oral: For mild to moderate hypokalemia. Potassium supplements are available in various forms (e.g., tablets, liquids, powders).
IV: For more severe hypokalemia or when oral intake is not feasible. Important: IV potassium must be diluted and administered slowly via an infusion pump to prevent cardiac arrhythmias. It can cause vein irritation, so central line administration is preferred if possible.
Dietary Measures: Encourage consumption of potassium-rich foods (e.g., bananas, oranges, raisins, apricots, spinach, potatoes).
Nursing Management of Hypokalemia
What should be monitored with patients with hypokalemia?
Renal Function: Essential to ensure the kidneys can excrete excess potassium. Impaired renal function increases the risk of hyperkalemia with potassium replacement.
Cardiac Status: Monitor for cardiac arrhythmias (irregular heart rhythms) as hypokalemia can affect cardiac conduction.
Digitalis Toxicity: Hypokalemia increases the risk of digitalis toxicity in patients taking digoxin (a heart medication). Monitor for signs of toxicity (e.g., nausea, vomiting, visual disturbances).
Nursing Management of Hyperkalemia
What are some medications used to treat hyperkalemia?
Dietary Restriction: Limit intake of potassium-rich foods.
Dialysis: May be necessary in patients with renal failure and severe hyperkalemia.
Sodium Polystyrene Sulfonate (Kayexalate): A cation exchange resin that binds potassium in the gastrointestinal tract, promoting its excretion in the feces. Administered orally or rectally.
Calcium Gluconate: Administered IV in emergency situations to protect the heart from the effects of hyperkalemia. It does not lower potassium levels but stabilizes the cardiac membrane.
Sodium Bicarbonate: Administered IV to temporarily shift potassium into cells. It also helps correct metabolic acidosis, which often accompanies hyperkalemia.
Regular Insulin and Dextrose: Insulin promotes the uptake of glucose by cells, and potassium follows glucose into the cells, thus lowering serum potassium levels. Dextrose is given to prevent hypoglycemia.
Diuretics (e.g., Furosemide): Increase potassium excretion by the kidneys.
Nursing Management of Hyperkalemia
What are should be monitored with patients with hyperkalemia?
ECG: Closely monitor the ECG for changes associated with hyperkalemia (peaked T waves, widened QRS complex).
Potassium Levels: Regularly monitor serum potassium levels to assess the effectiveness of treatment.
Renal Function: Assess renal function to ensure the kidneys can excrete potassium.
Acid-Base Balance: Monitor for metabolic acidosis.
A nurse is caring for a patient with hypokalemia. Which of the following interventions should be included in the plan of care? (Select all that apply.)
A. Administer IV potassium chloride (KCl) bolus.
B. Encourage consumption of potassium-rich foods.
C. Monitor the patient’s cardiac rhythm.
D. Administer a potassium-sparing diuretic.
E. Assess the patient’s renal function.
F. Educate the patient about the signs and symptoms of hyperkalemia.
B, C, E
Rationale: IV KCl should never be administered as a bolus due to the risk of cardiac arrest. Potassium-sparing diuretics can worsen hypokalemia. Patient education about hyperkalemia is important, but the question focuses on interventions for hypokalemia.
A patient with hyperkalemia has a potassium level of 6.5 mEq/L and is exhibiting muscle twitching and paresthesia. Which of the following interventions should the nurse prioritize?
A. Administer sodium polystyrene sulfonate (Kayexalate).
B. Administer calcium gluconate.
C. Restrict dietary potassium intake.
D. Monitor the patient’s ECG.
B
Rationale: While all options are important, the patient is exhibiting neuromuscular symptoms of hyperkalemia, indicating potential cardiac involvement. Calcium gluconate is the priority as it protects the heart from the effects of hyperkalemia.
Sodium Imbalances
What is the normal range for sodium?
136 mEq/L - 145 mEq/L
Sodium Imbalances
What are some causes of hyponatremia?
Vomiting
Diuretics
Excessive administration of dextrose and water IVs
Burns
Wound drainage
Excessive water intake
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Elderly (unable to excrete free water)
Fasting diets
Nasogastric suction
Sodium Imbalances
What are some causes of hypernatremia?
Model
Medications; Meals (too much sodium intake)
Osmotic diuretics
Diabetes insidious
Excess H2O loss
Low H2O intake
A patient with hypernatremia has a sodium level of 158 mEq/L and is exhibiting confusion and agitation. Which action by the nurse is the HIGHEST priority?
A. Administering a hypotonic IV solution.
B. Restricting dietary sodium.
C. Ensuring patient safety due to altered mental status.
D. Monitoring urine output.
C
Rationale: The patient’s altered mental status poses an immediate safety risk. Ensuring patient safety is the priority.
Signs and Symptoms of Sodium Imbalances
What are some S/S of hyponatremia?
Salt Loss
Stupor/Coma
Anorexia
Lethargy
Tendon reflexes decreased
Limp Muscles
Orthostatic hypotension
Seizures
Stomach cramping
Signs and Symptoms of Sodium Imbalances
What are some S/S of hypernatremia?
Fried Salt
Flushed skin
Restless, irritable, anxious, confused
Increased blood pressure & fluid retention
Edema (peripheral & pitting)
Decreased Urine output & dry mouth
Skin Flushed
Agitation
Low grade fever
Thirst
Nursing Management of Hyponatremia
What are the dietary management and IV fluid management of hyponatremia?
Dietary Management: Include sodium-enriched foods in the diet (e.g., beef broth, tomato juice). However, dietary sodium alone may not be sufficient to correct hyponatremia in many cases.
Intravenous Fluids:
* Lactated Ringer’s (LR): May be used for replacement in some cases, but it’s important to consider the patient’s overall electrolyte status.
* High Concentration of 0.9% Normal Saline: Hypertonic saline (e.g., 3% NaCl) may be used in severe cases or when rapid correction is needed, but it requires careful monitoring due to the risk of fluid overload and rapid sodium correction.
Fluid Restriction: May be implemented if the hyponatremia is mild and caused by excess water (e.g., in SIADH).
Nursing Management of Hyponatremia
What are somethings to monitor with patients with hyponatremia?
Intake and Output (I&O): Essential to track fluid balance.
Daily Weights: Changes in weight can indicate fluid shifts.
Serum Sodium Levels: Regular monitoring is crucial to assess the effectiveness of treatment and prevent overcorrection.
Nursing Management of Hypernatremia
What are the dietary management and IV fluid management of hypernatremia?
Dietary Management: Decrease sodium in the diet
ntravenous Fluids:
* Hypotonic IV Solutions: 0.3% Normal Saline, 0.45% Normal Saline, or Dextrose 5% in water (D5W) are used to gradually replace water deficits and lower sodium levels.
Nursing Management of Hypernatremia
What are somethings to monitor with patients with hyponatremia?
Daily Weights: To monitor fluid status.
Serum Sodium Levels: Regular monitoring is crucial to assess the effectiveness of treatment and prevent overcorrection.
Calcium Imbalances
What is the normal range for calcium?
9.0 mg/dL - 10.5 mg/dL
Calcium Imbalances
What are some causes of hypocalcemia?
Renal insufficiency
Malnutrition
Low magnesium level
Pancreatitis
Hypoparathyroidism
High phosphate level
Loop diuretics
Chronic alcohol use
Post-thyroid surgery
Calcium Imbalances
What are some causes of hypercalcemia?
Hyperparathyroidism
Excess dairy intake
Steroids and loop diuretics use
Inadequate intake (This seems counterintuitive and likely refers to inadequate fluid intake leading to concentrated calcium levels.)
Calcium-containing antacids (Tums)
Thiazide diuretics
Vitamin A or D overdose
Immobility
A patient with hypocalcemia is exhibiting muscle spasms and tetany. Which action by the nurse is the HIGHEST priority?
A. Administering oral calcium supplements.
B. Monitoring the patient’s cardiac rhythm.
C. Assessing the patient’s Chvostek’s and Trousseau’s signs.
D. Preparing for IV calcium administration.
B
Rationale: Muscle spasms and tetany can progress to seizures or laryngospasm, which can compromise the patient’s airway and breathing. Therefore, monitoring the cardiac rhythm for potential arrhythmias is the priority.
A patient with hypercalcemia is ordered to receive IV fluids and furosemide (a loop diuretic). Which of the following outcomes would indicate that the treatment is effective?
A. Increased serum calcium level.
B. Decreased urine output.
C. Improved muscle strength.
D. Increased urine calcium excretion.
D
Rationale: The goal of treatment is to increase calcium excretion in the urine, thus lowering the serum calcium level.
Signs and Symptoms of Calcium Imbalances
What are some S/S of hypocalcemia?
Cats
Convulsions
Arrhythmias
Tetany
Spasms & Stridor
Signs and Symptoms of Calcium Imbalances
What are some S/S of hypercalcemia?
BACKME
Bone pain
Arrhythmias
Cardiac Arrest
Kidney Stones
Muscle Weakness
Excessive Urination
Nursing Management of Hypocalcemia
What are some medications used for the management of hypocalcemia?
IV Calcium Gluconate or Calcium Chloride: Used for acute symptomatic hypocalcemia. Calcium gluconate is generally preferred over calcium chloride due to a lower risk of tissue necrosis if extravasation occurs. Administer slowly to avoid cardiac arrhythmias.
Vitamin D Supplements: Enhance calcium absorption from the gut. May be given orally or IM.
Nursing Management of Hypocalcemia
What are some additional management of hypocalcemia? (not medication)
Dietary Management: Increase calcium intake through diet (dairy products, leafy green vegetables, fortified foods).
Diuretic Considerations: If the patient is on loop diuretics (which can increase calcium excretion), the provider may consider switching to thiazide diuretics (which can decrease calcium excretion).
Airway Management: Laryngeal stridor (a high-pitched whistling sound during breathing) can occur due to laryngospasm (spasm of the vocal cords) in severe hypocalcemia. Maintaining a patent airway is crucial.
Seizure Precautions: Hypocalcemia can increase the risk of seizures. Implement seizure precautions as needed (padded side rails, oxygen and suction at bedside).
Nursing Management of Hypercalcemia
What are some medications used to manage hypercalcemia?
Medications:
* Calcitonin: A hormone that inhibits bone resorption and increases calcium excretion by the kidneys. It acts quickly but its effect is transient.
* Loop Diuretics (e.g., Furosemide): Increase calcium excretion by the kidneys.
* Bisphosphonates (e.g., Pamidronate, Zoledronic Acid): Inhibit bone resorption and are considered the gold standard for treating hypercalcemia, especially when caused by malignancy.
Medication Discontinuation: Stop any medications that contribute to hypercalcemia (e.g., calcium supplements, thiazide diuretics, some antacids).
Nursing Management of Hypercalcemia
What are some additional management of hypercalcemia? (not medication)
Dietary Management: A low-calcium diet may be recommended.
Hydration: Encourage oral intake of 3000-4000 mL of fluids daily to dilute calcium and prevent kidney stone formation. IV hydration with isotonic saline may be needed in some cases.
Dialysis: May be necessary in severe cases or in patients with renal impairment.
Mobility: Encourage mobilization as tolerated. Immobility can exacerbate hypercalcemia by promoting bone resorption.
A patient is receiving IV calcium gluconate for symptomatic hypocalcemia. The nurse notes that the patient’s heart rate has decreased from 80 to 60 beats per minute. Which of the following actions should the nurse take FIRST?
A. Stop the infusion of calcium gluconate.
B. Notify the healthcare provider.
C. Assess the patient’s blood pressure.
D. Document the finding and continue to monitor.
A
Rationale: Bradycardia can be a sign of calcium toxicity. The nurse should stop the infusion first and then notify the provider.
Magnesium Imbalances
What is the normal magnesium range?
1.3 mEq/L - 2.1 mEq/L
Magnesium Imbalances
What are some causes of hypomagnesemia?
Alcoholism
Gastrointestinal suction
Diarrhea
Intestinal fistulas
Uncontrolled diabetes mellitus
Malabsorption syndrome
Proton-pump inhibitor (PPI) therapy (e.g., omeprazole, esomeprazole, pantoprazole)
Magnesium Imbalances
What are some causes of hypermagnesemia?
Renal failure
IV administration of magnesium
Antacids and laxatives (especially those containing magnesium)
Hypothyroidism
Metastatic bone disease
A patient with hypomagnesemia is exhibiting muscle tremors and tetany. Which action by the nurse is the HIGHEST priority?
A. Administering oral magnesium supplements.
B. Monitoring the patient’s cardiac rhythm.
C. Assessing the patient’s deep tendon reflexes.
D. Preparing for IV magnesium sulfate administration.
B
Rationale: Muscle tremors and tetany can progress to seizures or laryngospasm, which can compromise the patient’s airway and breathing. Therefore, monitoring the cardiac rhythm for potential arrhythmias is the priority.
A patient with hypermagnesemia is ordered to receive IV calcium gluconate. Which of the following outcomes would indicate that the medication is effective?
A. Increased magnesium level.
B. Improved muscle strength.
C. Increased heart rate.
D. Increased urine output.
C
Rationale: Calcium gluconate antagonizes the cardiac effects of hypermagnesemia, particularly bradycardia. Therefore, an increased heart rate would indicate that the medication is effective.
A patient with a history of alcohol abuse is admitted to the hospital. The nurse anticipates which of the following magnesium-related abnormalities?
A. Hypermagnesemia due to increased magnesium intake.
B. Hypomagnesemia due to malnutrition and malabsorption.
C. Normal magnesium levels as long as the patient is hydrated.
D. Fluctuating magnesium levels depending on the patient’s oral intake.
B
Rationale: Alcohol abuse is a common cause of hypomagnesemia due to poor dietary intake, malabsorption, and increased renal excretion of magnesium.
Signs and Symptoms of Magnesium Imbalances
What are some S/S of hypomagnesemia?
Starved
Seizures
Tetany
Anorexia & arrhythmias
Rapid heart rate
Vomiting
Emotional liability
Deep tendon reflexes increased
Signs and Symptoms of Magnesium Imbalances
What are some S/S of hypermagnesemia?
LVDS
Low everything (BP, HR, RR, Reflexes)
Vasodilation
Diaphoresis
Skeletal Muscle Weakness
Nursing Management of Hypomagnesemia
What are dietary management and magnesium replacement used to treat hypomagnesemia?
Dietary Management: Increase dietary intake of magnesium-rich foods (e.g., green leafy vegetables, nuts, legumes, whole grains).
Magnesium Replacement:
* Oral: For mild to moderate hypomagnesemia. Magnesium oxide is a common oral supplement.
* IV: For severe hypomagnesemia or when oral intake is not feasible. Magnesium sulfate is the typical IV form. Administer slowly and cautiously via an infusion pump due to the risk of hypotension, cardiac arrest, and respiratory arrest. Rapid administration can cause these complications.
Seizure Precautions: Hypomagnesemia can increase the risk of seizures. Implement seizure precautions as needed (padded side rails, oxygen and suction at bedside).
Nursing Management of Hypomagnesemia
What are somethings to monitor hypomagnesemia?
Vital Signs: Monitor for hypotension, especially during IV magnesium administration.
Cardiac Rhythm: Monitor for cardiac arrhythmias (irregular heart rhythms) as hypomagnesemia can affect cardiac conduction.
Neurological Status: Assess for changes in mental status, tremors, or tetany.
Deep Tendon Reflexes: Check for hyperreflexia (increased reflexes) which is a sign of hypomagnesemia.
Nursing Management of Hypermagnesemia
What are some managements/treatments for hypermagnesemia?
Discontinue Magnesium: Stop any magnesium-containing medications (e.g., supplements, antacids, laxatives).
Support Ventilation: Monitor respiratory status closely and provide support as needed, as hypermagnesemia can cause respiratory depression.
Dietary Management: Educate the patient about reducing intake of magnesium-rich foods.
Medications:
IV Calcium Gluconate: Administered to antagonize the effects of excess magnesium on the cardiac muscle. It does not lower magnesium levels but stabilizes the cardiac membrane.
Diuretics (e.g., Furosemide): Increase magnesium excretion by the kidneys.
Dialysis: May be necessary in patients with renal impairment and severe hypermagnesemia.
Nursing Management of Hypermagnesemia
What are somethings to monitor for with hypermagnesemia?
Cardiac Rhythm: Closely monitor the ECG for bradycardia (slow heart rate) and heart block.
Vital Signs: Monitor for hypotension and respiratory depression.
Neurological Status: Assess for drowsiness, lethargy, confusion, and decreased deep tendon reflexes.
Urine Output: Monitor urine output to ensure adequate renal function and magnesium excretion.
A patient with hypermagnesemia has a magnesium level of 3.0 mEq/L and is exhibiting drowsiness and decreased deep tendon reflexes. Which of the following interventions should the nurse prioritize?
A. Administering oral magnesium supplements.
B. Monitoring the patient’s cardiac rhythm.
C. Assessing the patient’s respiratory rate and depth.
D. Encouraging increased fluid intake.
C
Rationale: Drowsiness and decreased reflexes can indicate central nervous system depression and potential respiratory depression, which is the most immediate threat to the patient.
A patient is receiving IV magnesium sulfate for hypomagnesemia. The nurse notes that the patient’s blood pressure has decreased from 140/90 to 110/70 mm Hg. Which of the following actions should the nurse take FIRST?
A. Increase the IV magnesium sulfate rate.
B. Stop the infusion of magnesium sulfate.
C. Notify the healthcare provider.
D. Assess the patient’s respiratory rate.
B
Rationale: Hypotension is a potential side effect of IV magnesium sulfate. The nurse should stop the infusion first and then notify the provider.
Phosphate Imbalances
What is the normal range for phosphate?
3.0 mg/dL - 4.5 mg/dL
Phosphate Imbalances
What are some causes of hypophosphatemia
Malabsorption syndromes
Chronic diarrhea
Malnutrition, Vitamin D deficiency
Parenteral nutrition (TPN)
Chronic alcohol use
Phosphate-binding antacids
Phosphate Imbalances
What are some causes of hyperphosphatemia
Renal failure
Phosphate enemas (Fleet)
Phosphate-containing laxatives (e.g., bowel prep for colonoscopy like OsmoPrep)
Sickle cell anemia
Rhabdomyolysis (muscle breakdown)
A patient with hypophosphatemia is exhibiting muscle weakness and shallow respirations. Which action by the nurse is the HIGHEST priority?
A. Administering oral phosphate supplements.
B. Monitoring the patient’s cardiac rhythm.
C. Assessing the patient’s neurological status.
D. Preparing for IV phosphate replacement.
B
Rationale: Shallow respirations indicate potential respiratory muscle weakness, which can compromise the patient’s oxygenation. Therefore, monitoring the cardiac rhythm for potential arrhythmias is the priority.
A patient with hyperphosphatemia is ordered to receive calcium carbonate (a phosphate-binding antacid). Which of the following outcomes would indicate that the medication is effective?
A. Increased serum phosphate level.
B. Decreased serum calcium level.
C. Increased urine output.
D. Decreased serum phosphate level.
D
Rationale: Calcium carbonate binds to phosphate in the GI tract, preventing its absorption and thus lowering serum phosphate levels.
Signs and Symptoms of Phosphate Imbalances
What are some S/S of hypophosphatemia?
ALOW
Arrhythmias
Loss of appetite
Osteoporosis
Weakness, fatigue
Signs and Symptoms of Phosphate Imbalances
What are some S/S of hyperphosphatemia?
MADS
Muscle Spasms & tetany
Arrhythmias
Dry Nails
Seizures
Nursing Management of Hypophosphatemia
What are some dietary management and phosphate supplements?
Dietary Management: Increase dairy intake (a good source of phosphorus).
Phosphate Supplements:
* Oral: Available in various forms.
* IV: Sodium phosphate or potassium phosphate may be given for severe cases. Important:
- Monitor serum calcium and phosphate levels every 6 to 12 hours during IV administration.
- During IV therapy, monitor for signs of hypocalcemia (due to the inverse relationship between phosphate and calcium), hyperkalemia (if potassium phosphate is used), hypotension, and dysrhythmias. Administer slowly and cautiously.
Nursing Management of Hyperphosphatemia
What are some dietary, medications, and other managements of hyperphosphatemia?
Treat Underlying Condition: Address the underlying cause of hyperphosphatemia (e.g., renal failure).
Dietary Management: Restrict intake of foods high in phosphate, such as dairy products.
Medications:
* Calcium Carbonate: A phosphate binder that helps prevent the absorption of phosphate from the GI tract. Administer with meals.
* Loop Diuretics: May be used to promote phosphate excretion by the kidneys.
Dialysis: May be necessary in severe cases, especially in patients with renal failure.
Correct Hypocalcemia: If hypocalcemia is present (due to the inverse relationship with phosphate), institute measures to correct calcium levels (e.g., calcium supplements, vitamin D).
A patient with hyperphosphatemia is exhibiting numbness and tingling in the extremities and muscle cramps. Which of the following interventions should the nurse prioritize?
A. Administering calcium carbonate.
B. Restricting dietary phosphate.
C. Monitoring the patient’s cardiac rhythm.
D. Assessing the patient’s respiratory status.
C
Rationale: The patient’s neuromuscular symptoms suggest potential hypocalcemia (due to the inverse relationship with phosphate), which can lead to cardiac arrhythmias. Monitoring the cardiac rhythm is the priority.
A patient is receiving IV sodium phosphate for hypophosphatemia. The nurse notes that the patient’s calcium level has decreased from 8.5 mg/dL to 7.8 mg/dL. Which of the following actions should the nurse take FIRST?
A. Increase the IV phosphate rate.
B. Stop the infusion of sodium phosphate.
C. Notify the healthcare provider.
D. Assess the patient’s neurological status.
B
Rationale: A decrease in calcium during phosphate replacement can indicate developing hypocalcemia. The nurse should stop the infusion first and then notify the provider.
What are the mm for each grade of edema (1+, 2+, 3+, 4+)?
1+: 2 mm
2+: 4 mm
3+: 6 mm
4+: 8 mm
What is Chvostek’s sign? (Hypocalcemia)
Contraction of facial muscles in response to a light tap over the facial nerve in front of the ear
What is Trousseau’s signs?
Carpal spasm induced by inflating BP cuff above the systolic pressure for a few minutes
