Fluid and Electrolytes Flashcards
Hypovolemia
Fluid is less than needed to meet body requirements. The most common type is isotonic dehydration
Hypovolemia Contributing Factors
-excess GI loss (V/D)
-diaphoresis
-fever
-hemorrhage
-insufficient intake
-burns
-diuretic therapy
-Aging: older adults have decreased body water and thirst
Hypovolemia Clinical Manifestations
-weight loss (most accurate)
-dry mucous membranes
-increase HR and resp
-thready pulse (weak)
-cap refill less than 3
-weakness, fatigue
-orthostatic hypotension
-poor skin turgor
Hypovolemia Late Signs
-oliguria (no urine)
-decreased central venous pressure
-flattened neck veins
Hypovolemia Diagnostic Procedures
-serum electrolytes
-BUN/ creatinine
-HCT (high)
-urine specific gravity and osmolarity (more solutes in urine=dehyration 1.030)
Hypovolemia Nursing Interventions
-monitor vitals
-Monitor skin turgor
-maintain strict I&O
-daily weight
-monitor labs as ordered
-fluid replacement
–increase oral fluid intake
–initiate oral rehydration solution
–anticipate giving IV fluid for severe dehydration/maintain as ordered
-fall precautions
Hypovolemia Medications
-electrolyte replacement
-IV fluids
Hypervolemia
fluid intake or retention is greater than the body needs
Hypervolemia Contributing Factors
-kidney failure
-heart failure
-cirrhosis
-excessive water intake
-Interstitial to plasma fluid shifts
–burns
–hypertonic fluids
Hypervolemia Clinical Manifestations
-cough, dyspnea, crackles
-high BP
-tachypnea &tachycardia
-bounding pulse
weight gain (1L or water=1kg)
-increase urine output
-increase CVP
edema
Hypervolemia Diagnostic Procedures
-serum: electrolytes, BUN, creatinine, HCT
-urine: specific gravity and osmolality
-chest x-ray if respiratory complications are present
–increase work of breathing
–tachypnea
–decreased O2 sat
Hypervolemia Nursing Interventions
-monitor resp rate, symmetry, and effort
-heart sounds
-edema
-ascites
-measure and girth
-daily weight
-strict I&O
-vitals
-admin diuretics
-limit fluid intake
-provide frequent skincare
-semi flower position (30 degrees)
-restrict sodium
Hypocalcemia Risk Factors
<9.0
-hypoparathyroidism
-hypomagnesemia
-kidney failure
-vitamin D deficiency
Hypocalcemia Disease Processes
-celiac
-lactose intolerance
-crohn’s
-alcohol abuse
Hypocalcemia Clinical Manifestations
-tetany (muscle spasms), cramps
-paresthesia
-dysrhythmias
-Trousseau’s sign
-Chvostek’s skin
-seizures
-hyperreflexia
-impaired clotting time
Hypocalcemia nursing interventions
-seizure precations
-IV calcium replacement
-daily calcium supplements
-vitamin D therapy
-monitor for orthostatic hypotension
-dietary education
Hypercalcemia Risk Factors
> 10.5
-hyperparathyroidism
-malignant disease
-prolonged immobilization
-vitamin D excess
-lithium
-digoxin therapy
-overuse of calcium supp
Hypercalcemia Clinical Manifestations
-muscle weakness/hyporeflexia
-kidney stones/flank pain
-dysrhythmias
-lethargy/coma
-polyuria, polydipsia, dehydration
-pathologic fractures/deep bone pain
-hypertension
-N/V
Hypercalcemia Nursing Interventions
-increase mobility
-isotonic IVF
-medications (lasix, glucocorticoids, calcium chelators)
-dialysis
-cardiac monitoring
Hypomagnesium Risk Factors
<1.2
-GI loss
-alcoholism
-hypocalcemia
-hypokalemia
-DKA
-malabsorption
-TPN
-laxative abuse
-acute MI
Hypomagnesium Clinical Manifestations
-numbness
-dysrhythmias
-Trousseau’s sign
-Chevostek’s sign
-agitation, confusion
-hyperreflexia
-hypertension
-insomnia, irritability
-anorexia, N/V
Hypomagnesium Nursing Interventions
-seizure precautions
-monitor swallowing
-anticipate med (IV mag sulfate, PO mag salts)
-strict I&O
-assess respirator status
-ECG monitoring
Hypermagnesium Risk Factors
> 2.2
-renal failure
-excessive mag therapy
-adrenal insufficiency
-laxative abuse
-lithium toxicity
-extensive tissue injury or necrosis
Hypermagnesium Clinical Manifestations
-hypotension
-drowsiness
-bradycardia
-coma
-cardiac arrest
-hyporeflexia
-N/V
-facial flushing
Hypermagnesium Medications
-IV calcium gluconate
-Loop diuretics
Hypermagnesium Nursing Interventions
-mechanical ventilation
-IV fluids: LR or NS
-monitor resp status
-Monitor EKG/BP
-assess deep tendon reflexes
Hypokalemia Risk Factors
<3.5
-adverse med effects (corticosteroids, diuretics, digitalis, laxative abuse)
-body fluid loss (vomiting, diarrhea, wound drainage, NG suction, excessive diaphoresis)
-kidney disease
-dietary deficiency
-alkalosis
Hypokalemia Clinical Manifestations
-muscle weakness, cramping
-fatigue
-N/V
-irritability, confusion
-decrease bowel motility
-dysrhythmias
-flat/inverted T waves
Hypokalemia Nursing Interventions
-monitor EKG
-assess resp status
-fall precautions
-monitor I&O
-anticipate monitoring lab values
give potassium replacement (PO, IV)
-heart rate: arrythmias
Hyperkalemia Risk Factors
> 4.5
-renal failure
-adrenal insufficiency
-acidosis
-excessive potassium intake
Hyperkalemia Clinical Manifestations
-peaked T-waves
-ventricular dysrhythmias
-muscle twitching/numbness (late)
-increase bowel motility
Hyperkalemia Nursing Interventions
-monitor EKG
-assess bowel sounds
-question dialysis
-dietary teaching
Hyperkalemia Med Admin
-kayexalate (monitor bowel sounds)
-50% glucose w insulin
-calcium gluconate
-bicarbonate
-loop diuretics
Hyponatremia Risk Factors
<135
-GI loss
-SIADH
-adrenal insufficiency
-water intoxication
-excessive diaphoresis
Hyponatremia Clinical Manifestations
-weakness
-lethargy
-confusion
-seizures
-headache
-muscle cramps, twitching
-hypotension
-tachycardia
-weight gain/edema
Hyponatremia Nursing Interventions
-sodium replacement (PO, Gtube, IV)
-restrict oral fluid intake
-daily weight
-strict I&O
Hypernatremia Risk Factors
> 145
-water deficit (dehydration)
-GI loss
-hypertonic tube feedings
-diabetes insipidus
-burns
-heatstroke
-diet
Hypernatremia Clinical Manifestaions
-fever
-swollen, dry tongue
-dry mucous membranes
-hallucinations
-lethargy, restlessness, irritability
-seizures
-tachycardia
-hypertension
-hyperreflexia, twitching
-pulmonary edema
Hypernatremia Nursing Interventions
-daily weight
-monitor I&O
-seizure precautions
-IV infusion of hypotonic or isotonic fluid
-diuretics
-dietary sodium restrictions
-increase oral fluid intake
