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326 Acute & Chronic > Fluid, Electrolyte, and Acid-Base Imbalances > Flashcards

Fluid, Electrolyte, and Acid-Base Imbalances Flashcards

1
Q

What is homeostasis? What are volume imbalances reflected by?

A
  • Body fluids and electrolytes
  • Transport nutrients, electrolytes, & oxygen to cells while carrying waste away from cells
  • Occurs most in patients w/ major illness
  • Imbalances are often reflected by changes in perfusion, gas exchange, mobility, and cognition
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2
Q

What are volume imbalances accompanied by?

A

Volume imbalances are often accompanied by electrolyte imbalances

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3
Q

List 4 lab indicators of fluid status and their normal ranges.

A
  • Serum/Plasma osmolality: 280-295 mOsm/kg
    > 295 = concentration of the solute is too great (water content too little); water deficit
    < 275 = too little solute for the amount of water; water excess
  • Blood urea nitrogen (BUN): 8-21 mg/dL
  • Creatinine: 0.5-1.2 mg/dL
  • Specific gravity: 1.005-1.030; high = dehydration
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4
Q

What are some causes of hypovolemia?

A
  • Excessive loss of fluid
    > GI loss (vomiting, NG suction, diarrhea, fistula drainage)
  • Polyuria (diabetes insipidus)
  • Insufficient intake of fluid
  • Increased insensible water loss or perspiration (high fever, heatstroke)
  • Osmotic diuretics or Overuse of diuretics
  • Fluid shifts (from plasma to interstitial)
    > Burns
    > Pancreatitis
  • Hemorrhage
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5
Q

What are some clinical manifestations of hypovolemia?

A
  • Decreased capillary refill
  • Confusion, restlessness, drowsiness, lethargy
  • Cold clammy skin
  • Postural hypotension, increased pulse
  • Increased RR
  • Weight loss
  • Decreased skin turgor
  • Oliguria; Concentrated urine output
  • Weakness, dizziness
  • Thirst, dry mucous membranes
  • Seizures, coma
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6
Q

What are some labs to test for hypovolemia?

A
  • Serum sodium
  • Hemoglobin & hematocrit
  • Serum osmolality
  • BUN and creatinine
  • Urine specific gravity
  • Urine osmolality
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7
Q

What are some complications of hypovolemia?

A
  • Hypovolemic shock
    ~ Hypotension
    ~ Tachycardia
    ~ Cues of hypoperfusion
    > Cool, clammy skin
    > Oliguria progressing to anuria
    > Decreased LOC
    > Tachypnea
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8
Q

How do you ASSESS (Recognize Cues) for hypovolemia?

A
  • Ask about hx of problems involving the kidneys, heart, GI system, or lungs
    ~ Diabetes, renal failure, heart failure, liver disease
  • Diuretics? Corticosteroids?
  • Any recent changes in body weight?
  • Ask patient what they do to replace fluid & electrolytes
  • Any functional problems that could lead to the lack of ability to obtain food or fluids
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9
Q

How do you DIAGNOSE (Analyze Cues & Prioritize Hypothesis) hypovolemia?

A
  • Hypovolemia
  • Deficient Knowledge-Fluid Volume Management
  • Impaired Tissue Perfusion
  • Altered Blood Pressure
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10
Q

What PLANNING (Generate Solutions) can you do for hypovolemia?

A
  • Achieve and maintain fluid balance
  • Be free from complications from abnormal fluid levels
  • Adhere to the prescribed care plan
  • Recognize factors that can lead to a fluid imbalance and take preventative action
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11
Q

What are some IMPLEMENTATIONS (Take-Action) you can do for hypovolemia?

A
  • Identify and treat cause; monitor for effectiveness
  • Encourage oral intake; provide fluid patient enjoys
  • Administer isotonic IVF as ordered
  • Physical assessment (CV, respiratory [give supplemental O2 as ordered], VS, mucous membranes, skin turgor, UOP)
  • Safety- risk for falls! (d/t postural hypotension; muscle weakness, dizziness)
  • Delegate to UAP/AP/CNA
    ~ Daily weight & VS
    ~ I’s & O’s
    ~ Oral care
    ~ Skin care
    ~ Assist w/ repositioning & toileting
    ~ Encourage fluids
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12
Q

What are some EVALUATIONS (Evaluate Outcomes) for hypovolemia?

A
  • Labs WNL?
  • Adequate oral intake?
  • I’s & O’s equal?
  • Physical assessment- WNL?
  • Weight stable?
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13
Q

What are some causes of hypervolemia?

A
  • Heart failure
  • Renal failure
  • Cirrhosis
  • Long-term corticosteroid use
  • Cushing syndrome
  • Increased sodium intake
  • Polydipsia (excessive thirst)
  • Syndrome of inappropriate antidiuretic hormone (SIADH)
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14
Q

What are some clinical manifestations of hypervolemia?

A
  • Bounding pulse, Increased BP
  • Dyspnea, crackles, pulmonary edema
  • Confusion, headache, lethargy
  • Edema
  • Ascites
  • Increased urine output
  • JVD
  • Muscle spasms
  • S3 heart sound
  • Weight gain (notify provider if over 1 kg overnight)
  • Seizures, coma
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15
Q

What are some labs to test for hypervolemia?

A
  • Serum sodium
  • Hematocrit
  • BUN
  • Serum osmolality
  • Albumin
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16
Q

What is a complication of hypervolemia?

A

Pulmonary edema

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17
Q

How do you ASSESS (Recognize Cues) for hypervolemia?

A
  • Ask about hx of problems involving the kidneys, heart, and/or GI system
    ~Diabetes, renal failure, heart failure, liver disease
  • Corticosteroids?
  • Sodium intake?
  • Edema?
  • Urinating more frequently?
  • Any recent gain in body weight?
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18
Q

How do you DIAGNOSE (Analyze Cues & Prioritize Hypothesis) hypervolemia?

A
  • Hypervolemia
  • Deficient Knowledge-Fluid Volume Management
  • Impaired Tissue Perfusion
  • Altered Blood Pressure
  • Risk for Impaired Skin Integrity
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19
Q

What PLANNING (Generate Solutions) can you do for hypervolemia?

A
  • Achieve and maintain fluid balance
  • Be free from complications from abnormal fluid levels
  • Adhere to the prescribed care plan
  • Recognize factors that can lead to a fluid imbalance and take preventative action
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20
Q

What are some IMPLEMENTATIONS (Take-Action) you can do for hypervolemia?

A
  • Identify and treat cause
  • Fluid restriction
  • Discontinue (DC) IVF
  • Physical assessment (CV [bounding pulse, JVD, S3, elevated BP], respiratory [dyspnea, crackles, elevated RR, give supplemental O2 as ordered], VS, urine characteristic and amount)
  • Diuretics
  • Dialysis (may be required)
  • Delegate to UAP/AP/CNA
    ~ Daily weights, VS
    ~ I’s & O’s
    ~ Oral care
    ~ Skin care
    ~ Assist w/ repositioning & toileting
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21
Q

What are some EVALUATIONS (Evaluate Outcomes) for hypervolemia?

A
  • Labs WNL?
  • Adequate oral intake?
  • I’s &O’s equal?
  • Physical assessment- WNL?
  • Weight stable?
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22
Q

What is sodium?

A
  • Main cation of ECF; 95% in ECF
  • Major role in maintaining the concentration and volume of ECF
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23
Q

What is the role of sodium?

A
  • Generates and transmits nerve impulses & muscle contractility
  • Regulating acid-base balance
  • Controls distribution of water in the body
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24
Q

What is the normal range of sodium?

A

135-145 mEq/L

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25
Q

What are some causes of hypernatremia?

A
  • Excess sodium intake (hypertonic or excessive isotonic IVF, Enteral tube feedings not getting enough of a water bolus)
  • Reduced water intake/ Limited ability to express thirst (cognitively impaired)
  • Excess water loss (diarrhea, vomiting, perspiration, fever, etc.)
  • Uncontrolled Diabetes
  • Cushing syndrome
  • Medications (diuretics)
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26
Q

What are some clinical manifestations of hypernatremia?

A
  • Nonspecific neurological changes
    ~ Agitation
    ~ Restlessness
    ~ Lethargy
    ~ Coma
    ~ Seizure
  • Weakness, muscle cramps
  • Thirst
  • Cues of dehydration
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27
Q

What is the serum sodium range for hypernatremia?

A

Serum sodium > 145 mEq/L

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28
Q

What are some complications of hypernatremia?

A
  • Restlessness
  • Weakness
  • Disorientation
  • Delusions
  • Hallucinations
  • Severe: Seizures, stupor, coma, death
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29
Q

What are some nursing interventions for hypernatremia?

A
  • Assessment
  • Isotonic IVF (0.9% sodium chloride), usually
  • D5W if the problem is excess sodium
  • Diuretics can help promote excretion of sodium
  • Restrict dietary sodium
  • Ensure adequate water intake
  • Monitor serum sodium levels and response to therapy
  • Monitor fluid status
    ~ Daily weight & I’s & O’s
  • Initiate seizure precautions if needed
    ~ Bed in a low, locked position
    ~ Side rails padded
    ~ Suction equipment at bedside
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30
Q

What are some causes of hyponatremia?

A
  • Excess sodium loss (diarrhea, vomiting, NG suctioning, fistulas, adrenal insufficiency, diuretics, burns, wound drainage)
  • Inadequate sodium intake (fasting diets)
  • Excess water gain (hypotonic IVFs, polydipsia)
  • Heart failure
  • Cirrhosis
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31
Q

What are some manifestations of hyponatremia?

A
  • Nausea and vomiting
  • Personality changes
  • Confusion
  • Irritability
  • Cold, clammy skin
  • Dry mucous membranes
  • Seizure, coma, permanent brain death if not treated
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32
Q

What is the serum sodium range for hyponatremia?

A

Serum sodium < 135 mEq/L

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33
Q

What are some complications of hyponatremia?

A
  • Lethargy
  • Confusion
  • Weakness
  • Fatigue
  • Muscle cramps
  • Postural hypotension
  • Severe: seizure, coma, death
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34
Q

What are some nursing interventions for hyponatremia?

A
  • Assessment
  • Isotonic sodium-containing IVF
  • Monitor fluid status
    ~ Daily weight & I’s & O’s
  • Encourage PO intake
  • Hold diuretics
  • Monitor neurologic changes
  • Patient education
  • Monitor sodium levels and response to therapy
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35
Q

What is potassium?

A

Major intracellular cation; 98% in ICF

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36
Q

What is the role of potassium?

A
  • Essential for neuromuscular function
    ~ Sodium potassium pump
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37
Q

What is the normal range of potassium?

A

3.5-5.0 mEq/L

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38
Q

What are some causes of hyperkalemia?

A
  • Excess potassium intake (excess potassium containing drugs, potassium-containing salt substitute, excess or rapid IV potassium supplementation)
  • Shift of potassium out of cells (acidosis, sepsis, burns, tumor lyse syndrome)
  • Failure to eliminate potassium (adrenal insufficiency, renal disease, certain medications)
39
Q

What are some manifestations of hyperkalemia?

A
  • Abdominal cramping, diarrhea, vomiting
  • Confusion
  • Fatigue, irritability
  • Irregular pulse
  • Loss of muscle tone
  • Muscle weakness, cramps
  • Paresthesia
  • Tetany
40
Q

What is the serum potassium for hyperkalemia?

A

Serum potassium > 5.0 mEq/L

41
Q

What are some complications of hyperkalemia?

A
  • Generalized fatigue & weakness
  • Muscle cramps
  • Palpitations
  • Paresthesia
  • ECG/EKG changes
  • Cardiac arrest
42
Q

What are some nursing interventions for hyperkalemia?

A
  • Assessment
  • Obtain ECG/EKG
  • Serum potassium levels
  • Dietary modification
  • Withhold any potassium supplements
  • IV dextrose and insulin (50% Dextrose w/ 10 units of insulin)
  • Inhaled albuterol
  • Loop or thiazide diuretics
  • IV Calcium administration
  • Sodium polystyrene sulfonate (kayexalate)
  • In emergencies or patients w/ ESRD- dialysis
43
Q

What are some causes for hypokalemia?

A
  • Potassium loss (diaphoresis, diarrhea, vomiting, fistulas, NG suctioning, ileostomy drainage, diuretics, magnesium depletion, dialysis)
  • Shift of potassium into cells (alkalosis, insulin therapy)
  • Lack of potassium intake (low potassium diet, starvation)
44
Q

What are some manifestations for hypokalemia?

A
  • Constipation, nausea, paralytic ileus
  • Fatigue
  • Hyperglycemia
  • Irregular, weak pulse
  • Muscle weakness, leg cramps
  • ECG/EKG changes
  • Paresthesia
  • Decreased reflexes
  • Shallow respirations
45
Q

What is the serum potassium range for hypokalemia?

A

Serum potassium < 3.5 mEq/L

46
Q

What are some complications for hypokalemia?

A
  • Muscle weakness
  • Decreased GI motility
  • Cardiac dysrhythmias
  • Respiratory failure
  • Cardiac or respiratory arrest
  • Death
47
Q

What are some nursing interventions for hypokalemia?

A
  • Assessment
  • Obtain ECG/EKG
  • Serum potassium levels
  • Administer PO or IV potassium chloride(KCl) supplementation/replacement
  • Increased dietary intake of potassium-rich foods
  • Patient education
48
Q

How do you safely administer IV KCl?

A
  • Always dilute IV KCl; do not give as a bolus or IVP
  • Invert IV bags several times to ensure even distribution in the bag
  • Should NOT exceed 10 mEq/hr (unless patient is in a CCU w/ continuous cardiac monitoring and central line access)
  • Use infusion pump
  • Monitor IV site at least hourly for phlebitis and/or infiltration)
49
Q

Describe magnesium.

A
  • second most abundant intracellular cation
  • kidneys & GI system regulate serum magnesium
50
Q

What is the role of magnesium?

A
  • plays a key role in essential cellular processes; needed for cellular functioning
    ~ carbohydrate metabolism
    ~ DNA and protein synthesis
    ~ Blood glucose control
    ~ BP regulation
51
Q

What is the normal lab value for magnesium?

A

1.3-2.1 mg/dL

52
Q

What causes hypermagnesemia?

A
  • medications containing magnesium (antacids, laxatives, overreplacement of magnesium [esp. for treatment of eclampsia])
  • renal issues: Adrenal insufficiency, renal failure
  • cancer & Cancer treatments: - metastatic bone disease, tumor lyse syndrome
  • intestinal hypomotility
53
Q

What are the clinical manifestations of hypermagnesemia?

A
  • decreased pulse, decreased BP, decreased RR
  • decreased deep tendon reflexes
  • flushed, warm skin, esp. facial
  • lethargy, drowsiness
  • nausea, vomiting
  • muscle weakness
  • urinary retention
  • risk of bleeding
  • dysrhythmias
  • heart block
  • asystole
54
Q

What are the lab values for hypermagnesemia?

A

serum magnesium > 2.1 mg/dL

55
Q

What are the complications of hypermagnesemia?

A
  • hypotension refractory to vasopressors
  • stupor
  • coma
  • respiratory failure
  • cardiac arrest
  • death
56
Q

What are the nursing interventions for hypermagnesemia?

A
  • assessment
  • monitor VS
  • stop any magnesium-containing drugs
  • limit intake of magnesium-rich foods
  • if renal function is adequate, increase fluids and diuretics to promote urinary excretion of magnesium
  • administer calcium gluconate to oppose the effects of excess magnesium on cardiac muscle
  • patient w/ impaired renal function may need dialysis
  • patient education
    ~ diet
    ~ medications
57
Q

What causes hypomagnesemia?

A
  • GI issues (prolonged malnutrition, malabsorption issues, chronic alcohol abuse, GI tract fluid losses)
  • increased urinary output
  • proton pump inhibitor (PPI) therapy (omeprazole)
  • hyperglycemia
58
Q

What are the clinical manifestations of hypomagnesemia?

A
  • increased BP, Increased HR
  • dysrhythmias
  • anorexia, nausea, vomiting
  • muscle cramping
  • tremors
  • seizures
  • positive Trousseau and Chvostek sign
  • confusion, disorientation, irritability
59
Q

What are the lab values for hypomagnesemia?

A

serum magnesium < 1.3 mg/dL

60
Q

What are the complications of hypomagnesemia?

A
  • seizures
  • ventricular fibrillation
  • cardiac arrest
61
Q

What are the nursing interventions for hypomagnesemia?

A
  • assessment
  • cardiac monitoring
  • evaluate potassium and calcium
  • fall precautions
  • seizure precautions
  • oral supplementation (magnesium oxide, magnesium gluconate; obtain order and administer IV magnesium sulfate if PO cannot be tolerated)
  • patient education
  • referral to alcohol abstinence programs (if needed)
62
Q

Describe calcium.

A
  • main cation in bones & teeth
  • parathyroid hormone (PTH) and calcitonin regulate calcium levels
  • bones contain 99% of the body’s calcium; the rest is in plasma
    ~ Of the calcium in plasma, 50% is bound to plasma proteins, mainly albumin
  • Calcium absorption requires the active form of vitamin D
  • role of Ca++:
    ~ transmission of nerve impulses
    ~ myocardial & muscle contractions
    ~ blood clotting
63
Q

What is the normal lab value range for calcium?

A

9.0-10.5 mg/dL

64
Q

What causes hypercalcemia?

A
  • excess dairy intake
  • medications (thiazide diuretics, calcium-containing antacids lithium, theophylline, vitamins A and D)
  • renal issues: Adrenal insufficiency, chronic renal failure
  • prolonged immobilization
  • hyperparathyroidism
  • cancer w/ bone metastasis
65
Q

What are the clinical manifestations of hypercalcemia?

A
  • increased BP
  • confusion, decreased memory
  • fatigue, lethargy, weakness
  • depressed deep tendon reflexes
  • renal calculi
  • nausea, vomiting, anorexia
  • polyuria, dehydration
  • ECG/EKG changes: short QT interval, short ST segment, & ventricular dysrhythmias
  • seizure, coma
66
Q

What are the lab values for hypercalcemia?

A

serum calcium > 10.5 mg/dL

67
Q

What are the complications of hypercalcemia?

A
  • confusion
  • lethargy
  • cardiac rhythm changes
  • heart block
  • coma
  • cardiac arrest
68
Q

What are the nursing interventions for hypercalcemia?

A
  • assessment
  • stabilization & reduction of calcium levels
  • IV biphosphates (gold standard, but takes 2-4 days to achieve max. effect)
  • calcitonin (immediate effect)
  • encourage weight-bearing exercises if possible
  • hydration w/ 0.9% NaCl (normal saline)
  • encourage PO hydration (if not contraindicated)
  • treatment of malignancy/cancer
  • removal of parathyroid gland
  • dialysis (only for life-threatening situations)
69
Q

What causes hypocalcemia?

A
  • malnutrition, vitamin D deficiency
  • tumor lyse syndrome
  • medications (bisphosphonates, loop diuretics)
  • diarrhea
  • chronic alcohol use
  • acute pancreatitis
  • decreased magnesium decreased albumin
  • increased phosphate level
70
Q

What are the clinical manifestations of hypocalcemia?

A
  • decreased BP
  • confusion, depression, irritability
  • fatigue, weakness
  • hyperreflexia, muscle cramps
  • smooth muscle spasms (laryngeal and bronchial)
  • numbness & tingling in extremities and around the mouth
  • decreased myocardial contractility
  • ECG/EKG changes: prolonged QT interval, elongated ST segment
  • positive Trousseau and Chvostek sign
71
Q

What are the lab values for hypocalcemia?

A

serum calcium < 9.0 mg/dL

72
Q

What are the complications of hypocalcemia?

A
  • refractory hypotension
  • laryngospasms
  • decompensated heart failure
  • cardiovascular collapse
  • dysrhythmias
73
Q

What are the nursing interventions for hypocalcemia?

A
  • protection and maintenance of airway
  • assessment
  • cardiac monitoring
  • IV access
  • oral calcium and vitamin D supplements
  • encourage diet in high-calcium foods
  • IV replacement of calcium (IV calcium gluconate)
  • treat other electrolyte abnormalities (esp. magnesium)
  • if patient is on loop diuretics, call HCP to change to thiazide diuretics
74
Q

Describe respiratory compensation.

A
  • retaining or removing CO2
  • begins compensating in 5-15 mins
75
Q

Describe renal compensation.

A
  • excretion or retention of hydrogen and bicarbonate
  • may take 24 hours
76
Q

Define uncompensated.

A
  • pH is abnormal, and either PaCO2 or HCO3- is also abnormal
  • there is no indication that the opposite system has tried to correct the imbalance
77
Q

Define partially compensated.

A
  • pH is abnormal, and both the PaCO2 or HCO3- are also abnormal
  • this indicates that the opposite system has attempted to correct for the other but has not been completely successful
78
Q

Define fully compensated.

A
  • if pH is normal, and both the PaCO2 or HCO3- are abnormal
  • the normal pH indicates that one system has been able to compensate for the other
79
Q

What causes respiratory acidosis?

A
  • altered ventilation
  • CO2 retention
80
Q

What are the complications of respiratory acidosis?

A
  • paralysis
  • coma
81
Q

What are the lab values for respiratory acidosis?

A
  • pH < 7.35
  • PaCO2 > 45
  • if compensated, HCO3- > 26
82
Q

What are nursing interventions for respiratory acidosis?

A
  • maintain airway
  • monitor VS and ABGs
  • administer bronchodilators to open constricted airways
  • administer supplemental oxygen
  • chest physiotherapy
  • removal of foreign objects from the airway
  • chest tube insertion
  • intubation for mechanical ventilation
83
Q

What causes respiratory alkalosis?

A
  • increased alveolar ventilation
    ~ anxiety
    ~ hyperventilation
84
Q

What are the complications of respiratory alkalosis?

A
  • seizures
  • chest pain
85
Q

What are the lab values for respiratory alkalosis?

A
  • pH > 7.45
  • PaCO2 < 35
  • when compensated, HCO3- < 22
86
Q

What are nursing interventions for respiratory alkalosis?

A
  • encourage slow, deep breathing
  • monitor VS
  • identify and eliminate the causative agent
    ~ reduce fever?
    ~ eliminate a source of sepsis?
  • apply supplemental oxygen
  • sedative or anxiolytic therapy
  • provide emotional support and reassurance
  • assist w/ ADLs
87
Q

What causes metabolic acidosis?

A
  • nonvolatile acids
    ~ ketoacidosis, lactic acidosis
  • loss of alkali through GI tract
88
Q

What are the complications of metabolic acidosis?

A
  • cardiac dysrhythmia
  • renal encephalopathy
89
Q

What are the lab values for metabolic acidosis?

A
  • ph < 7.35
  • HCO3- < 22
  • if compensated, PaCO2 < 35
90
Q

What are nursing interventions for metabolic acidosis?

A
  • monitor hemodynamic status
    ~ BP, HR, RR, and cardiac rhythm
  • assess peripheral vascular status
    ~ palpate temperature of extremities
    ~ check capillary refill
    ~ palpate distal pulses
    ~ check the sensation in the lower limbs
  • administer sodium bicarbonate as ordered
  • provide reassurance and teaching
91
Q

What causes metabolic alkalosis?

A
  • increased loss of acid, usually through the GI tract
    ~ vomiting, NG suctioning
92
Q

What are the complications of metabolic alkalosis?

A
  • dysrhythmias
  • coma
93
Q

What are the lab values for metabolic alkalosis?

A
  • ph > 7.45
  • HCO3- > 26
  • if compensated, PaCO2 > 45
94
Q

What are the nursing interventions for metabolic alkalosis?

A
  • hemodynamic monitoring
  • assess LOC
  • electrolyte supplements
  • provide reassurance and teaching

326 Acute & Chronic (3 decks)

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