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MedSurg Nursing; N1110 > Fluid & Electrolyte Imbalances > Flashcards

Fluid & Electrolyte Imbalances Flashcards

1
Q

What are fluids used for in the body?

A

Aide in cellular metabolism
Substance for blood volume
Regulate body temperature
Transport solutes (electrolytes, glucose, protein)

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2
Q

Where are fluids located within the body?

A 
Intracellular Fluid (ICF)
Extracellular Fluid (ECF): Interstitial fluid, intravascular fluid
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3
Q

What organ/system does Antidiuretic Hormone (ADH) work on?

A

Kidneys/Renal System

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4
Q

What is the role of Antidiuretic Hormone (ADH) when it is released?

A

To conserve fluids through the kidneys

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5
Q

What environment within the body will cause Antidiuretic Hormone (ADH) to be released?

A 
When volume (pressure) within the body/vascular system is low
i.e. the patient is dehydrated
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6
Q

When will the release of Antidiuretic Hormone (ADH) be inhibited?

A

When volume (pressure) within the body/vascular system is at an appropriate level or high

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7
Q

What organ/system does Aldosterone work on?

A

Kidneys/Renal System

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8
Q

What is the role of Aldosterone when is it released?

A

To conserve sodium through the kidneys.

When sodium is conserved, fluid follows, thus indirectly conserving fluid

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9
Q

What environment within the body will cause Aldosterone to be released?

A

When volume (pressure) within the body/vascular system is low (i.e. the patient is dehydrated)

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10
Q

When will the release of Aldosterone be inhibited?

A

When volume (pressure) within the body/vascular system is at an appropriate level or high

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11
Q

What is the definition of sensible fluid loss?

A

When one is aware of the fluid loss from the body

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12
Q

What are examples of sensible fluid loss?

A

Urination

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13
Q

What is the definition of insensible fluid loss?

A

When one is unaware of the fluid being lost from the body or one cannot measure it

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14
Q

What are examples of insensible fluid loss?

A

Perspiration
Respiration
Elimination of feces
Emesis

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15
Q

What mechanism is activated by the brain when the body losses fluid?

A

The thirst mechanism

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16
Q

What mechanism to aide in maintaining fluid balance is depressed in the older adult?

A

The thirst mechanism

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17
Q

Which population is at greatest risk for dehydration?

A

Older adults

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18
Q

What are causes of fluid loss/deficit?

A 
Inadequate fluid intake
Hemorrhage (bleeding)
GI Losses (emesis, stool)
Fever 
Diuretic Use
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19
Q

What are the clinical manifestations of fluid deficit?

A 
Thirs
Acute weight loss
Urine changes: dark, concentrated, malodorous urine, decreased output
Constipation
Dry skin
Dry mucous membranes
Hypotension
Tachycardia
Orthostatic Hypotension
Mental status changes: lightheaded/dizzy, confusion, disorientation, weakness, lethargy
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20
Q

What is orthostatic hypotension?

A

Hypotension that occurs with position changes, such as going from lying to sitting, lying to standing, or sitting to standing

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21
Q

What is the best way to monitor fluid status in a patient?

A

Monitor weight daily

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22
Q

What are causes of fluid volume overload?

A

Excess fluid intake (either PO or IV)
Renal Failure
Heart Failure

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23
Q

When there is excess fluid in the body, what state is the body in?

A

Hypervolemic state

Excess fluid volume causes hypervolemia

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24
Q

What population is most at risk for developing fluid volume overload? Why?

A

Older adult population

More likely to have comorbidities such as chronic kidney disease (renal failure) and/or chronic heart failure

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25
Q

What are the clinical manifestations of fluid volume overload?

A

Acute, rapid weight gain (2 lbs or more over 24-28 hours)
Urine changes: polyuria (if kidneys and heart are functioning), light diluted non-concentrated urine
Bounding pulses (with normal heart rate)
Jugular Venous Distention (JVD)
Hypertension
Peripheral edema
Pulmonary Edema (ranging from mild to severe): crackles upon auscultation, tachypnea, dyspnea, labored breathing, decreased O2 saturation
Neurological Changes

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26
Q

What is the most concerning clinical manifestation with fluid volume overload?

A

Changes in respiratory status. Pulmonary edema can occur.

A.B.C’s!

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27
Q

What are the two types of edema?

A

Pitting

Non-Pitting

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28
Q

An individual has large, swollen lower extremities. When the nurse touches the area, there is no indentation. How would the nurse document this?

A

Non-pitting edema.

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29
Q

What is the definition of 1+ pitting edema?

A

Mild edema; depression disappears rapidly

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30
Q

What is the definition of 2+ pitting edema?

A

Moderate edema; depression disappears in 10-15 seconds

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31
Q

What is the definition of 3+ pitting edema?

A

Moderately severe edema; depression disappears in about one minute

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32
Q

What is the definition of 4+ pitting edema?

A

Severe edema; depression can last more than two minutes

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33
Q

What is the priority nursing action when a patient is reporting difficulty breathing and has s/s of pulmonary edema?

A

Ensure head of bed is at 90 degress (High Fowlers Position)

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34
Q

What medication drug class promotes the excretion of fluids via the urine? What is the most common medication within this drug class?

A

Diuretics

Furosemide (or Lasix)

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35
Q

What interventions can the nurse implement to help improve edema in the lower extremities?

A

Elevate legs

Apply compression stockings

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36
Q

What can cause an imbalance of electrolytes within the body?

A 
Malnutrition
Dehydration
Over hydration
Nausea, Vomiting, Diarrhea
Sweating
Medications (such as diuretics)
37
Q

What is the role of sodium?

A

Helps to maintain serum osmolality
Important for optimal cell function (especially within the CNS)
Important for optimal nerve and muscle function

38
Q

Sodium and potassium have what kind of relationship?

A

Inverse (opposite)

39
Q

What are the clinical manifestations of hyponatremia?

A 
Mental status changes!
Disorientation
Confusion
Agitation
Dizziness
Headaches
Lethargy
Muscle Weakness
Possible Seizures 
Eventual Coma
40
Q

What nursing interventions should be implemented when a patient is experiencing hyponatremia?

A 
Safety is key! Seizure precautions, low bed, siderails up x 2, bed alarm on, room close to the nurse's station
Monitor weights daily
Monitor intake and output
Replace sodium
Restrict "free" water
41
Q

What are the clinical manifestations of hypernatremia?

A

Thirst
Mental status changes: irritability, agitation, confusion
Muscle excitability causing twitching, tremors, possible seizures

42
Q

What nursing interventions should be implemented when a patient is experiencing hypernatremia?

A

Safety is key! Seizure precautions, low bed, siderails up x 2, bed alarm on, room close to the nurse’s station
Monitor weights daily
Monitor intake and output
Restrict sodium

43
Q

What are dietary sources of sodium?

A 
Table salt
Canned food items
Processed foods
Soda
Seasoned salts
Soy Sauce
44
Q

What is the role of potassium?

A

Aides in the proper function of cardiac, skeletal and smooth muscle

45
Q

What is the most common potassium imbalance?

A

Hypokalemia

46
Q

What are the most common causes of hypokalemia?

A

Inadequate intake via the diet
Excessive loss via urine or through emesis/stool
Medication use; diuretics such as Furosemide (Lasix)

47
Q

How does hypokalemia affect the cardiovascular system?

A

Weak pulses
Can cause an arrhythmia
Potential cardiac arrest!

48
Q

How does hypokalemia affect the respiratory system?

A

Causes ineffective, shallow respirations because the skeletal muscles are weakened and cannot aide in breathing

49
Q

How does hypokalemia affect the musculoskeletal system?

A

Decreases skeletal muscle activity
Causes muscle cramping
Causes weakness and fatigue of muscles

This leads to shallow, ineffective respirations (thus affecting the respiratory system)

50
Q

How does hypokalemia affect the nervous system?

A

Causes mental status changes such as lethargy

51
Q

How does hypokalemia affect the gastrointestinal system?

A

Slows motility of the GI system
Causes nausea and vomiting because food cannot be digested as easily
Causes distention and constipation

52
Q

What nursing interventions should be implemented when a patient is experiencing hypokalemia?

A

Priority: Cardiac monitor (acute care setting only)

Give medications and/or foods to help increase potassium levels

53
Q

As a patient’s potassium levels increase from low to normal, what symptoms should improve?

A

Cardiac and smooth muscle strength should incresae
Muscle cramping should decrease and skeletal muscle strength should improve
Heart rate and rhythm should be regular

54
Q

If a potassium level is < 3.5 mEq/L and the patient is scheduled to receive Furosemide (Lasix), should the nurse give it?
(Assume there are no orders for potassium replacement)

A

No, the nurse should hold the medication and call the doctor to notify and request further instructions.
Giving the Furosemide (Lasix) would further deplete the potassium level and cause hypokalemia.

55
Q

What are the most common causes of hyperkalemia?

A 
Excessive potassium intake
Kidney Failure (the kidneys are not working, they cannot get rid of the potassium in the blood via the urine)
Medications
56
Q

How does hyperkalemia affect the cardiovascular system?

A

Can cause an arrhythmia

Possible cardiac arrest!

57
Q

How does hyperkalemia affect the musculoskeletal system?

A

Muscle twitching
Muscle cramps
Eventual muscle weakness

58
Q

How does hyperkalemia affect the gastrointestinal system?

A

Increases GI motility

Causes diarrhea

59
Q

What nursing interventions should be implemented when a patient is experiencing hyperkalemia?

A

Priority: Cardiac monitor (acute care setting only)
Administer medications to decrease potassium levels
Restrict potassium rich foods

60
Q

What are dietary sources of potassium?

A 
Spinach
Broccoli
Tomatoes
Potatoes
Avocados
Bananas
Oranges
Orange Juice
Carrots
Green Beans
Salt Substitutes
Legumes, Nuts, Seeds
61
Q

What is the role of calcium?

A

Essential for proper function of excitable muscle cells - cardiac muscle and smooth muscle
Helps to control blood pressure (smooth muscle cell control)

62
Q

Where is calcium stored within the body?

A

Bones and teeth

63
Q

What other substance is required in order for calcium to be absorbed?

A

Vitamin D

Vitamin D aides in the absorption of calcium, without it calcium will not be absorbed from our food

64
Q

What relationship to calcium and phosphorus have?

A

Inverse (opposite)

65
Q

What are common causes of hypocalcemia?

A

Vitamin D Deficiency
Renal Disease (the kidneys active vitamin D. Without active vitamin D the body cannot absorb calcium)
Medications
Hyperphosphatemia

66
Q

How does hypocalcemia affect the cardiovascular system?

A

Causes cardiac dysrhythmias
Can cause possible cardiac arrest
Causes hypotension

67
Q

How does hypocalcemia affect the musculoskeletal system?

A

Nerve hyperexcitability
Causes hyperactive deep tendon reflexes (this mean muscle twitching)
Numbness and tingling of the fingers and around the mouth
Positive Trousseau and Chvostek signs

68
Q

What nursing interventions should be implemented when a patient is experiencing hypocalcemia?

A

Priority: Cardiac Monitor
Administer calcium via medications
Administer calcium rich foods

69
Q

Explain a positive Chvostek Sign. What does it tell us?

A

When the face is tapped just below the eye and in front of the ear the eye and face muscles will twitch

This tells us there is nerve hyperexcitability

70
Q

Explain a positive Trousseau Sign. What does it show us?

A

The hand spasms when a blood pressure cuff is inflated on the upper arm for > 3 minutes.

This shows us tetany.

71
Q

In what electrolyte imbalance is there a positive Chvostek and Trousseau Sign?

A

Hypocalcemia

72
Q

What are common causes of hypercalcemia?

A

Excessive intake of calcium
Excessive intake of vitamin D
Medications
Hypophosphatemia

73
Q

How does hypyercalcemia affect the cardiovascular system?

A

Causes cardiac dysrhythmias
Can cause cardiac arrest
Causes hypertension

74
Q

How does hypyercalcemia affect the musculoskeletal system?

A

Causes skeletal muscle weakness

75
Q

How does hypyercalcemia affect the genitourinary system?

A

Can cause kidney stones

76
Q

What nursing interventions should be implemented when a patient is experiencing hypercalcemia

A

Priority: Cardiac monitor
Decrease calcium levels
Avoid foods high in calcium

77
Q

What are dietary sources of calcium?

A 
Milk
Yogurt
Cheese
Ice Cream
Broccoli
Tofu
Rhubarb
Spinach, Greens
Medications: Calcium Carbonate (Tums)
78
Q

What is the relationship between magnesium and calcium?

A

They work together

79
Q

What is the role of magnesium in the body?

A

Function of excitable cells (cardiac muscle, nerve cells)

80
Q

What are common causes of hypomagnesemia?

A 
Decreased intake, usually related to malnutrition
Excessive loss (diarrhea)

Most commonly seen in alcoholics

81
Q

How does hypomagnesemia affect the cardiovascular system?

A

Causes cardiac dysrhythmias

Can lead to cardiac arrest

82
Q

How does hypomagnesemia affect the musculoskeletal system?

A

Hyperactive deep tendon reflexes
Can lead to tetany

(Just like hypocalcemia)

83
Q

What nursing interventions should be implemented when a patient is experiencing hypomagnesemia?

A

Priority: Cardiac monitor

Replace Magnesium via medications and/or food

84
Q

If a patient has a low calcium level, what other electrolyte would be low?

A

Magnesium

85
Q

What are common causes of hypermagnesemia?

A

Excessive intake

Renal Failure

86
Q

How does hypermagnesemia affect the cardiovascular system?

A

Can cause dysrhythmias

Possible cardiac arrest

87
Q

How does hypermagnesemia affect the musculoskeletal system?

A

Skeletal muscle weakness

Just like hypercalcemia

88
Q

What nursing interventions should be implemented when a patient is experiencing hypermagnesemia?

A

Priority: Cardiac Monitor

Decrease magnesium level

89
Q

What are dietary sources of magnesium?

A 
Nuts, Legumes
Green leafy vegetables
Seafood
Whole grains
Bananas 
Oranges 
Chocolate
Medications (Antacids such as Maalox and Mylanta, Laxatives such as Milk of Magnesium)

MedSurg Nursing; N1110 (15 decks)

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