fluid and electrolyte balance Flashcards
1
Q
When assessing patients’ fluid and electrolyte status, nurses should also review
A
health history
lab data
clinical assessment
2
Q
adults total body weight in water
A
50% to 60% of total body weight is water
3
Q
infants body weight in water
A
75% to 80% of total body weight is water.
4
Q
body fluid that is intracellular
A
2/3
5
Q
fluid in extracellular
A
1/3
6
Q
most common tyoe of fluid volume deficit
A
istonic dehydration
7
Q
contributing factors to volume deficit
A
- Excess GI loss
- Diaphoresis
- Fever
- Hemorrhage
- Insufficient intake
- Burns
***Diuretic therapy - Aging: Older adults have less body water and decreased thirst.
8
Q
deficit manifestations
A
- Weight loss
- Dry mucus membranes
- Increased heart rate and respirations
- Thready pulse
- Capillary refill less than 3 seconds
- Weakness, fatigue
- Orthostatic hypotension
- Poor skin turgor
9
Q
deficit manifestations
A
- Weight loss
- Dry mucus membranes
- Increased heart rate and respirations
- Thready pulse
- Capillary refill less than 3 seconds
- Weakness, fatigue
- Orthostatic hypotension
- Poor skin turgor
10
Q
deficit late signs
A
- Oliguria: less than 30ml per hour
- Decreased CVP
- Flattened neck veins
11
Q
normal CVP
A
up to 20
- less not a lot of blood volume
12
Q
procedure for deficitlabs
A
- Serum electrolytes: sodium decreases, electrolytes decrease
- BUN/creatinine
- HCT increase
- Urine specific gravity and osmolarity
13
Q
specific gravity
A
1.010- 1.030
14
Q
deficit nurse interventions
A
Monitor vital signs
Monitor skin turgor
Maintain strict I&O
Weigh patient daily
Monitor labs as ordered
15
Q
meds for deficit
A
- electrolyte replacement
- intravenous fluids
16
Q
istonic indication, characteristics, types s
A
Indication: Treatment of vascular system fluid deficit
Characteristics: Concentration is equal to plasma
Types of solution:
- Normal saline (0.9% NS)
- Lactated Ringers (LR)
- 5% dextrose in water (D5W)
17
Q
hypotonic indication, characteristics, types of solution
A
Indication: Treatment of intracellular dehydration
Characteristics: Lower osmolality than ECF.
Types of solution:
- 0.45% normal saline ( ½ NS)
- 2.5 % dextrose in 0.45% NS( D25 45%NS)
18
Q
hypertonic indication, characteristics, types of solutions
A
Indication: Used only when serum osmolality is critically low
Characteristics: Osmolality is higher than the ECF.
Types of solution:
- 10% dextrose in water (D10W)
- 50% dextrose in water (D50W)
- 5% dextrose in 0.9% (D5NS)
- 5% dextrose in 0.45% (D51/2NS)
19
Q
contributing factors to excess
A
Kidney failure
Heart failure
Cirrhosis
Interstitial to plasma fluid shifts
Burns
Hypertonic fluids
Excessive water intake
20
Q
excess clinical manifestations
A
- Cough, dyspnea, crackles
- Increased blood pressure
- Tachypnea and tachycardia
- Bounding pulse
- Weight gain (1L of water = 1kg )
- Increased urine output
- Increased central venous pressure
- Edema
21
Q
excess diagnostic procedures
A
- Serum: electrolytes, BUN, creatinine, HCT
- Urine: Specific gravity and osmolality
- Chest X-ray if respiratory complications are present.
+Increased work of breathing
+Tachypnea
+Low O2 saturation
22
Q
excess interventions (vitals)monitor
A
- Monitor respiratory rate, symmetry, and effort
- Monitor heart sounds
- Monitor for edema
1. Measure on scale:
2. 1+ ( minimal) to 4+ (severe)
3. Monitor dependent edema by measuring circumference of extremities.
23
Q
excess nursing interventions
A
Monitor for ascites
Measure abdominal girth
Weigh patient daily
Maintain strict I&O
Monitor vital signs
24
Q
excess interventions meds wise
A
- Administer diuretics
- Limit fluid intake
- Provide frequent skin care
- Use semi-Fowler’s position- 30
- Reposition patient minimum of every 2 hours
Restrict sodium intake
25
electrolytes
Sodium(Na+)
Potassium (K+)
Calcium (Ca2+)
Bicarbonate (HCO3)
Magnesium (Mg2+)
Chloride (C1-)
Hydrogen phosphate (HPO42-).
26
intracellular electrolytes
Potassium
Phosphorus
Magnesium
27
major extracellular
Sodium
Calcium
Chloride
Bicarbonate
28
risk factora for low K+meds,body
Adverse effects of medications:
- Corticosteroids
- Diuretics
- Digitalis: digoxin`
- Abuse of laxatives
Body fluid loss:
- Vomiting
- Diarrhea
- Wound drainage
- NG suction
29
risk facotrs for low k+(disease)
Excessive diaphoresis
Kidney disease
Dietary deficiency
Alkalosis
30
s/s of low K+
- Muscle weakness, cramping
- Fatigue
- Nausea, vomiting
- Irritability, confusion
- Decreased bowel motility
+++Dysrhythmias
- Flat/inverted Twaves
31
nursing intervention for low K+
- Monitor ECG
- Assess respirator status
- Initiate fall precautions
- Monitor I&O
- Anticipate monitoring lab values
- Give potassium replacement as ordered
+Oral
+ IV
- Patient education
32
high k+ risk factors(disease)
Renal failure
Adrenal insufficiency
Acidosis
Excessive potassium intake
33
medications for high k+
potassium-sparing diuretics
ace inhibitors
34
high k+ clinical manifestations
Peaked T-waves
Ventricular dysrhythmias
Muscle twitching and numbness
Muscle weakness (late)
Increased bowel motility
35
high K+ nursing interventions
Monitor ECG
Assess bowel sounds
Question dialysis
Dietary teaching
36
meds for high k+
Kayexalate (monitor bowel sounds)
50% glucose with insulin
Calcium gluconate
Bicarbonate
Loop Diuretics
37
risk factors for low NA
GI loss
SIADH
Adrenal insufficiency
Water intoxication
Excessive diaphoresis
+ 1st seizure precaustion and neuro precaution and IV access
38
high Na clinical manifestations
39
meds for low Na
Diuretics
Anticonvulsants
SSRIs
Lithium
40
clinical manifestations for low Na
Weakness
Lethargy
Confusion
Seizures
Headache
Muscle cramps, twitching
Hypotension
Tachycardia
Weight gain/edema
41
nursing interventions for low Na
Sodium replacement (oral, Gtube, IV)
Restrict oral fluid intake
Daily weight
Monitor strict I&O
42
high Na risk factors
Water deficit (dehydration)
GI loss
Hypertonic tube feedings
Diabetes insipidus (DI)
Burns
Heatstroke
43
clinical manifesations for high NA
- Fever
- Swollen, dry tongue
- Dry mucous membranes
- Hallucinations
- Lethargy, restlessness, irritability
- Seizures
- Tachycardia
- Hypertension
- Hyperreflexia, twitching
- Pulmonary edema
44
nursing interventions for high Na
Daily weights
Monitor I&O
Seizure precautions
IV infusion of hypotonic or isotonic fluid as ordered
Diuretics
Dietary sodium restrictions
Increase oral fluid intake
45
clinical manifestations for low Ca
Tetany, cramps
Paresthesia
Dysrhythmias
Trousseau’s sign
Chvostek’s sign
Seizures
Hyperreflexia
Impaired clotting time
46
risk factors for low ca
Hypoparathyroidism
Hypomagnesemia
Kidney failure
Vitamin D deficiency
47
disease process for low ca
Celiac
Lactose intolerance
Crohn’s disease
Alcohol abuse
48
nursing intervention low ca
- Seizure precautions
- IV calcium replacement
- Daily calcium supplements as ordered
- Vitamin D therapy
- Monitor for orthostatic hypotension
- Dietary education
49
risk factors fior high Ca
Hyperparathyroidism
Malignant disease
Prolonged immobilization
Vitamin D excess
Lithium
Digoxin toxicity
Overuse of calcium supplements
50
clinical manifestations for high Ca
- Muscle weakness/hyporeflexia
- Kidney stones/flank pain
- Dysrhythmias
- Lethargy/coma
- Polyuria, polydipsia, dehydration
- Pathologic fractures/deep bone pain
- Hypertension
- Nausea/Vomiting
51
nursing interventions for high ca
- Increase mobility
- Isotonic IVF as ordered
Medications
- Lasix
- Glucocorticoids
- Calcium chelators
- Dialysis
- Cardiac monitoring
52
risk factors for low mag
GI loss
Alcoholism
Hypocalcemia
Hypokalemia
DKA
Malabsorption
TPN
Laxative abuse
Acute MI
53
clinical manifestations for low mag
Numbness
Dysrhythmias
Trousseau’s sign
Chvostek’s sign
Agitation, confusion
Hyperreflexia
Hypertension
Insomnia, irritability
Anorexia, Nausea/Vomiting
54
nursing interventions for low mag
Seizure precautions
Monitor swallowing
Anticipate medications
IV magnesium sulfate
PO magnesium salts
Strict I&O
Assess respirator status
ECG monitoring
55
risk factors for high mag
Renal failure
Excessive Mag therapy
Adrenal insufficiency
Laxative overuse
Lithium toxicity
Extensive soft tissue injury or necrosis
56
high mag clinical manifestations
Hypotension
Drowsiness
Bradycardia
Coma
Cardiac arrest
Hyporeflexia
Nausea, vomiting
Facial flushing
57
nursing intervention for high mag
Mechanical ventilation
IV fluids: LR or NS as ordered
Monitor respiratory status
Monitor ECG/Blood pressure
Assess deep tendon reflexes
58
high mag medications
IV calcium gluconate
Loop diuretics
59
nursing intervention for high mag
Mechanical ventilation
IV fluids: LR or NS as ordered
Monitor respiratory status
Monitor ECG/Blood pressure
Assess deep tendon reflexes
60
meds for high mag
IV calcium gluconate
Loop diuretics
61
lungs controlling acid base
Regulate carbonic acid through respiration
62
kidneys controlling acid base
Regulate bicarbonate by retention or excretion
63
metabolic acidosis risk factors
Diarrhea
Fever
Hypoxia
Starvation
Seizure
Renal failure
DKA
Dehydration
64
clinical manifestations metabolic acidosis
Bradycardia
Weak pulses
Hypotension
Tachypnea
Flaccid paralysis
Confusion
Lethargy
Warm, flushed, dry skin
Kussmaul’s respirations
65
nursing interventions metabolic acidosis
Place patient on monitor
Anticipate checking blood gases
Access?
While workup is being done, try to identify underlying cause
Anticipate administering fluids, electrolytes
66
risk factors for metabolic alkalosis
Ingestion of antacids
GI suction
Hypokalemia
TPN
Blood transfusion
Prolonged vomiting
67
manifestations for metabolic alkalosis
Dizziness
Paresthesias
Hypertonic muscles
Decreased respirations
68
respiratory acidosis risk factors
Respiratory depression
Pneumothorax
Airway obstruction
Inadequate ventilation
69
respiraotry acidosis manifestations
Dizziness
Palpitations
Muscle twitching
Convulsions
70
respiratory acidosis nursing interventions
Maintain patent airway
Regulation of ventilation therapy
Assess respiratory status
Bronchodilators
Mucolytics
+Mucomyst
Reversal agents for narcotics
+Narcan
71
respiraotry alkalosis risk factors
Hyperventilation
Hypoxemia
Altitude sickness
Asphyxiation
Asthma
Pneumonia
72
respiraotry alkalosis manifestations
Tachypnea
Anxiety
Tetany
Carpal pedal spasms
Palpitations
Chest pain
73
respiraotry alkalosis clinical manifestations
Tachypnea
Anxiety
Tetany
Carpal pedal spasms
Palpitations
Chest pain
74
respiraotry alkalosis nursing interventions
Regulate oxygen therapy
Reduce anxiety
Rebreathing techniques
75
Analyze the following blood gas:
pH 7.20 pCO2 37.5 HCO3 18
Respiratory alkalosis.
Metabolic alkalosis.
Metabolic acidosis.
Respiratory acidosis.
c
76
For ATI and Med Surg II……
A nurse is caring for a patient in the post anesthesia recovery unit (PACU) The patient is receiving Morphine PRN every hour and is sleeping. What acid base imbalance will the nurse anticipate?
Respiratory alkalosis.
Metabolic alkalosis.
Metabolic acidosis.
Respiratory acidosis.
4
77
A nurse is caring for a patient in the post anesthesia recovery unit (PACU) who had abdominal surgery. The patient has a respiratory acidosis. What will the nurse prioritize when reporting to the provider?
Patient has a pain level of 8.
Patient has absent bowel sounds.
The patient has a respiratory rate of 5.
The patient’s HR is 105.
c
78
what type of solution is tpn
hypertonic IV bolus
79
what does it do
TPN prevents or corrects nutritional deficiencies and minimize the adverse effects of malnourishment.
80
where is tpn administered
Administration is usually through a central line
- Tunneled triple lumen catheter
- Single- or double-lumen peripherally inserted central (PICC) line
81
what is tpn made up of
Contains complete nutrition, including calories in a high concentration (10% to 50%) of dextrose, lipids/ essential fatty acids, protein, electrolytes, vitamins, and trace elements.
82
ppn
Partial parenteral nutrition or peripheral parenteral nutrition (PPN) is less hypertonic, intended for short-term use, and administered in a large peripheral vein.
83
risk from tpn
phlebitis
84
flow rate for tpn
- The flow rate is gradually increased and gradually decreased to allow body adjustment
- ! Never abruptly stop TPN. An abrupt rate change can alter blood glucose levels significantly.
- Follow sterile procedures to minimize the risk of sepsis.
- TPN solution is prepared by the pharmacy using aseptic technique with a laminar flow hood.
85
changing tpn
- Change tubing and solution bag (even if not empty) every 24 hr.
- A filter is added to the tubing to collect particles from the solution.
- Use sterile procedures, including a mask, when changing the central line dressing (per facility procedure).
- Keep dextrose 10% in water at the bedside in case the solution is unexpectedly ruined or the next bag is not available.
+Prevent hypoglycemia
+Refrigerate TPN before use
86
A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should be included in the plan of care? (Select all that apply.)
a. Obtain a capillary blood glucose four times daily.
b. Administer prescribed medications through a secondary port on the TPN IV tubing.
c. Monitor vital signs three times during the 12‑hr shift.
d. Change the TPN IV tubing every 24 hr.
e. Ensure a daily aPTT is obtained.
a,c,d,
87
A nurse is caring for a client who is receiving TPN. The current bag of solution was hung 24 hr ago, and 400 mL remains to infuse. Which of the following is the appropriate action for the nurse to take?
a. Remove the current bag and hang a new bag.
b. Infuse the remaining solution at the current rate and then hang a new bag.
c. Increase the infusion rate so the remaining solution is administered within the hour and hang a new bag.
d. Remove the current bag and hang a bag of lactated Ringer’s.
a
88
blood osmolarity
concentration of things in and out of the cell
89
most phosphorus given in iv
20 meq
90
how long is a full dose of potassium given over
2hr
91
when CO2 increases
PH decreases
92
what labs do you look at to see if tpn is working
albunin and electrolites
93
what can be used in replace of tpn
D10
94
cronic tpn can lead to
liver failure
95
can you use tpn line for anything else
nooo
