Fluid, Electrolyte, and Acid-Base Imbalances Flashcards
What is homeostasis? What are volume imbalances reflected by?
- 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
What are volume imbalances accompanied by?
Volume imbalances are often accompanied by electrolyte imbalances
List 4 lab indicators of fluid status and their normal ranges.
- 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
What are some causes of hypovolemia?
- 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
What are some clinical manifestations of hypovolemia?
- 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
What are some labs to test for hypovolemia?
- Serum sodium
- Hemoglobin & hematocrit
- Serum osmolality
- BUN and creatinine
- Urine specific gravity
- Urine osmolality
What are some complications of hypovolemia?
- Hypovolemic shock
~ Hypotension
~ Tachycardia
~ Cues of hypoperfusion
> Cool, clammy skin
> Oliguria progressing to anuria
> Decreased LOC
> Tachypnea
How do you ASSESS (Recognize Cues) for hypovolemia?
- 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
How do you DIAGNOSE (Analyze Cues & Prioritize Hypothesis) hypovolemia?
- Hypovolemia
- Deficient Knowledge-Fluid Volume Management
- Impaired Tissue Perfusion
- Altered Blood Pressure
What PLANNING (Generate Solutions) can you do for hypovolemia?
- 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
What are some IMPLEMENTATIONS (Take-Action) you can do for hypovolemia?
- 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
What are some EVALUATIONS (Evaluate Outcomes) for hypovolemia?
- Labs WNL?
- Adequate oral intake?
- I’s & O’s equal?
- Physical assessment- WNL?
- Weight stable?
What are some causes of hypervolemia?
- Heart failure
- Renal failure
- Cirrhosis
- Long-term corticosteroid use
- Cushing syndrome
- Increased sodium intake
- Polydipsia (excessive thirst)
- Syndrome of inappropriate antidiuretic hormone (SIADH)
What are some clinical manifestations of hypervolemia?
- 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
What are some labs to test for hypervolemia?
- Serum sodium
- Hematocrit
- BUN
- Serum osmolality
- Albumin
What is a complication of hypervolemia?
Pulmonary edema
How do you ASSESS (Recognize Cues) for hypervolemia?
- 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?
How do you DIAGNOSE (Analyze Cues & Prioritize Hypothesis) hypervolemia?
- Hypervolemia
- Deficient Knowledge-Fluid Volume Management
- Impaired Tissue Perfusion
- Altered Blood Pressure
- Risk for Impaired Skin Integrity
What PLANNING (Generate Solutions) can you do for hypervolemia?
- 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
What are some IMPLEMENTATIONS (Take-Action) you can do for hypervolemia?
- 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
What are some EVALUATIONS (Evaluate Outcomes) for hypervolemia?
- Labs WNL?
- Adequate oral intake?
- I’s &O’s equal?
- Physical assessment- WNL?
- Weight stable?
What is sodium?
- Main cation of ECF; 95% in ECF
- Major role in maintaining the concentration and volume of ECF
What is the role of sodium?
- Generates and transmits nerve impulses & muscle contractility
- Regulating acid-base balance
- Controls distribution of water in the body
What is the normal range of sodium?
135-145 mEq/L
What are some causes of hypernatremia?
- 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)
What are some clinical manifestations of hypernatremia?
- Nonspecific neurological changes
~ Agitation
~ Restlessness
~ Lethargy
~ Coma
~ Seizure - Weakness, muscle cramps
- Thirst
- Cues of dehydration
What is the serum sodium range for hypernatremia?
Serum sodium > 145 mEq/L
What are some complications of hypernatremia?
- Restlessness
- Weakness
- Disorientation
- Delusions
- Hallucinations
- Severe: Seizures, stupor, coma, death
What are some nursing interventions for hypernatremia?
- 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
What are some causes of hyponatremia?
- 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
What are some manifestations of hyponatremia?
- Nausea and vomiting
- Personality changes
- Confusion
- Irritability
- Cold, clammy skin
- Dry mucous membranes
- Seizure, coma, permanent brain death if not treated
What is the serum sodium range for hyponatremia?
Serum sodium < 135 mEq/L
What are some complications of hyponatremia?
- Lethargy
- Confusion
- Weakness
- Fatigue
- Muscle cramps
- Postural hypotension
- Severe: seizure, coma, death
What are some nursing interventions for hyponatremia?
- 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
What is potassium?
Major intracellular cation; 98% in ICF
What is the role of potassium?
- Essential for neuromuscular function
~ Sodium potassium pump
What is the normal range of potassium?
3.5-5.0 mEq/L
What are some causes of hyperkalemia?
- 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)
What are some manifestations of hyperkalemia?
- Abdominal cramping, diarrhea, vomiting
- Confusion
- Fatigue, irritability
- Irregular pulse
- Loss of muscle tone
- Muscle weakness, cramps
- Paresthesia
- Tetany
What is the serum potassium for hyperkalemia?
Serum potassium > 5.0 mEq/L
What are some complications of hyperkalemia?
- Generalized fatigue & weakness
- Muscle cramps
- Palpitations
- Paresthesia
- ECG/EKG changes
- Cardiac arrest
What are some nursing interventions for hyperkalemia?
- 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
What are some causes for hypokalemia?
- 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)
What are some manifestations for hypokalemia?
- Constipation, nausea, paralytic ileus
- Fatigue
- Hyperglycemia
- Irregular, weak pulse
- Muscle weakness, leg cramps
- ECG/EKG changes
- Paresthesia
- Decreased reflexes
- Shallow respirations
What is the serum potassium range for hypokalemia?
Serum potassium < 3.5 mEq/L
What are some complications for hypokalemia?
- Muscle weakness
- Decreased GI motility
- Cardiac dysrhythmias
- Respiratory failure
- Cardiac or respiratory arrest
- Death
What are some nursing interventions for hypokalemia?
- 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
How do you safely administer IV KCl?
- 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)
Describe magnesium.
- second most abundant intracellular cation
- kidneys & GI system regulate serum magnesium
What is the role of magnesium?
- plays a key role in essential cellular processes; needed for cellular functioning
~ carbohydrate metabolism
~ DNA and protein synthesis
~ Blood glucose control
~ BP regulation
What is the normal lab value for magnesium?
1.3-2.1 mg/dL
What causes hypermagnesemia?
- 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
What are the clinical manifestations of hypermagnesemia?
- 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
What are the lab values for hypermagnesemia?
serum magnesium > 2.1 mg/dL
What are the complications of hypermagnesemia?
- hypotension refractory to vasopressors
- stupor
- coma
- respiratory failure
- cardiac arrest
- death
What are the nursing interventions for hypermagnesemia?
- 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
What causes hypomagnesemia?
- GI issues (prolonged malnutrition, malabsorption issues, chronic alcohol abuse, GI tract fluid losses)
- increased urinary output
- proton pump inhibitor (PPI) therapy (omeprazole)
- hyperglycemia
What are the clinical manifestations of hypomagnesemia?
- increased BP, Increased HR
- dysrhythmias
- anorexia, nausea, vomiting
- muscle cramping
- tremors
- seizures
- positive Trousseau and Chvostek sign
- confusion, disorientation, irritability
What are the lab values for hypomagnesemia?
serum magnesium < 1.3 mg/dL
What are the complications of hypomagnesemia?
- seizures
- ventricular fibrillation
- cardiac arrest
What are the nursing interventions for hypomagnesemia?
- 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)
Describe calcium.
- 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
What is the normal lab value range for calcium?
9.0-10.5 mg/dL
What causes hypercalcemia?
- 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
What are the clinical manifestations of hypercalcemia?
- 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
What are the lab values for hypercalcemia?
serum calcium > 10.5 mg/dL
What are the complications of hypercalcemia?
- confusion
- lethargy
- cardiac rhythm changes
- heart block
- coma
- cardiac arrest
What are the nursing interventions for hypercalcemia?
- 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)
What causes hypocalcemia?
- malnutrition, vitamin D deficiency
- tumor lyse syndrome
- medications (bisphosphonates, loop diuretics)
- diarrhea
- chronic alcohol use
- acute pancreatitis
- decreased magnesium decreased albumin
- increased phosphate level
What are the clinical manifestations of hypocalcemia?
- 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
What are the lab values for hypocalcemia?
serum calcium < 9.0 mg/dL
What are the complications of hypocalcemia?
- refractory hypotension
- laryngospasms
- decompensated heart failure
- cardiovascular collapse
- dysrhythmias
What are the nursing interventions for hypocalcemia?
- 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
Describe respiratory compensation.
- retaining or removing CO2
- begins compensating in 5-15 mins
Describe renal compensation.
- excretion or retention of hydrogen and bicarbonate
- may take 24 hours
Define uncompensated.
- 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
Define partially compensated.
- 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
Define fully compensated.
- 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
What causes respiratory acidosis?
- altered ventilation
- CO2 retention
What are the complications of respiratory acidosis?
- paralysis
- coma
What are the lab values for respiratory acidosis?
- pH < 7.35
- PaCO2 > 45
- if compensated, HCO3- > 26
What are nursing interventions for respiratory acidosis?
- 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
What causes respiratory alkalosis?
- increased alveolar ventilation
~ anxiety
~ hyperventilation
What are the complications of respiratory alkalosis?
- seizures
- chest pain
What are the lab values for respiratory alkalosis?
- pH > 7.45
- PaCO2 < 35
- when compensated, HCO3- < 22
What are nursing interventions for respiratory alkalosis?
- 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
What causes metabolic acidosis?
- nonvolatile acids
~ ketoacidosis, lactic acidosis - loss of alkali through GI tract
What are the complications of metabolic acidosis?
- cardiac dysrhythmia
- renal encephalopathy
What are the lab values for metabolic acidosis?
- ph < 7.35
- HCO3- < 22
- if compensated, PaCO2 < 35
What are nursing interventions for metabolic acidosis?
- 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
What causes metabolic alkalosis?
- increased loss of acid, usually through the GI tract
~ vomiting, NG suctioning
What are the complications of metabolic alkalosis?
- dysrhythmias
- coma
What are the lab values for metabolic alkalosis?
- ph > 7.45
- HCO3- > 26
- if compensated, PaCO2 > 45
What are the nursing interventions for metabolic alkalosis?
- hemodynamic monitoring
- assess LOC
- electrolyte supplements
- provide reassurance and teaching
