Fluid & Electrolyte Imbalances Flashcards
What are fluids used for in the body?
Aide in cellular metabolism
Substance for blood volume
Regulate body temperature
Transport solutes (electrolytes, glucose, protein)
Where are fluids located within the body?
Intracellular Fluid (ICF) Extracellular Fluid (ECF): Interstitial fluid, intravascular fluid
What organ/system does Antidiuretic Hormone (ADH) work on?
Kidneys/Renal System
What is the role of Antidiuretic Hormone (ADH) when it is released?
To conserve fluids through the kidneys
What environment within the body will cause Antidiuretic Hormone (ADH) to be released?
When volume (pressure) within the body/vascular system is low i.e. the patient is dehydrated
When will the release of Antidiuretic Hormone (ADH) be inhibited?
When volume (pressure) within the body/vascular system is at an appropriate level or high
What organ/system does Aldosterone work on?
Kidneys/Renal System
What is the role of Aldosterone when is it released?
To conserve sodium through the kidneys.
When sodium is conserved, fluid follows, thus indirectly conserving fluid
What environment within the body will cause Aldosterone to be released?
When volume (pressure) within the body/vascular system is low (i.e. the patient is dehydrated)
When will the release of Aldosterone be inhibited?
When volume (pressure) within the body/vascular system is at an appropriate level or high
What is the definition of sensible fluid loss?
When one is aware of the fluid loss from the body
What are examples of sensible fluid loss?
Urination
What is the definition of insensible fluid loss?
When one is unaware of the fluid being lost from the body or one cannot measure it
What are examples of insensible fluid loss?
Perspiration
Respiration
Elimination of feces
Emesis
What mechanism is activated by the brain when the body losses fluid?
The thirst mechanism
What mechanism to aide in maintaining fluid balance is depressed in the older adult?
The thirst mechanism
Which population is at greatest risk for dehydration?
Older adults
What are causes of fluid loss/deficit?
Inadequate fluid intake Hemorrhage (bleeding) GI Losses (emesis, stool) Fever Diuretic Use
What are the clinical manifestations of fluid deficit?
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
What is orthostatic hypotension?
Hypotension that occurs with position changes, such as going from lying to sitting, lying to standing, or sitting to standing
What is the best way to monitor fluid status in a patient?
Monitor weight daily
What are causes of fluid volume overload?
Excess fluid intake (either PO or IV)
Renal Failure
Heart Failure
When there is excess fluid in the body, what state is the body in?
Hypervolemic state
Excess fluid volume causes hypervolemia
What population is most at risk for developing fluid volume overload? Why?
Older adult population
More likely to have comorbidities such as chronic kidney disease (renal failure) and/or chronic heart failure
What are the clinical manifestations of fluid volume overload?
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
What is the most concerning clinical manifestation with fluid volume overload?
Changes in respiratory status. Pulmonary edema can occur.
A.B.C’s!
What are the two types of edema?
Pitting
Non-Pitting
An individual has large, swollen lower extremities. When the nurse touches the area, there is no indentation. How would the nurse document this?
Non-pitting edema.
What is the definition of 1+ pitting edema?
Mild edema; depression disappears rapidly
What is the definition of 2+ pitting edema?
Moderate edema; depression disappears in 10-15 seconds
What is the definition of 3+ pitting edema?
Moderately severe edema; depression disappears in about one minute
What is the definition of 4+ pitting edema?
Severe edema; depression can last more than two minutes
What is the priority nursing action when a patient is reporting difficulty breathing and has s/s of pulmonary edema?
Ensure head of bed is at 90 degress (High Fowlers Position)
What medication drug class promotes the excretion of fluids via the urine? What is the most common medication within this drug class?
Diuretics
Furosemide (or Lasix)
What interventions can the nurse implement to help improve edema in the lower extremities?
Elevate legs
Apply compression stockings
What can cause an imbalance of electrolytes within the body?
Malnutrition Dehydration Over hydration Nausea, Vomiting, Diarrhea Sweating Medications (such as diuretics)
What is the role of sodium?
Helps to maintain serum osmolality
Important for optimal cell function (especially within the CNS)
Important for optimal nerve and muscle function
Sodium and potassium have what kind of relationship?
Inverse (opposite)
What are the clinical manifestations of hyponatremia?
Mental status changes! Disorientation Confusion Agitation Dizziness Headaches Lethargy Muscle Weakness Possible Seizures Eventual Coma
What nursing interventions should be implemented when a patient is experiencing hyponatremia?
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
What are the clinical manifestations of hypernatremia?
Thirst
Mental status changes: irritability, agitation, confusion
Muscle excitability causing twitching, tremors, possible seizures
What nursing interventions should be implemented when a patient is experiencing hypernatremia?
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
What are dietary sources of sodium?
Table salt Canned food items Processed foods Soda Seasoned salts Soy Sauce
What is the role of potassium?
Aides in the proper function of cardiac, skeletal and smooth muscle
What is the most common potassium imbalance?
Hypokalemia
What are the most common causes of hypokalemia?
Inadequate intake via the diet
Excessive loss via urine or through emesis/stool
Medication use; diuretics such as Furosemide (Lasix)
How does hypokalemia affect the cardiovascular system?
Weak pulses
Can cause an arrhythmia
Potential cardiac arrest!
How does hypokalemia affect the respiratory system?
Causes ineffective, shallow respirations because the skeletal muscles are weakened and cannot aide in breathing
How does hypokalemia affect the musculoskeletal system?
Decreases skeletal muscle activity
Causes muscle cramping
Causes weakness and fatigue of muscles
This leads to shallow, ineffective respirations (thus affecting the respiratory system)
How does hypokalemia affect the nervous system?
Causes mental status changes such as lethargy
How does hypokalemia affect the gastrointestinal system?
Slows motility of the GI system
Causes nausea and vomiting because food cannot be digested as easily
Causes distention and constipation
What nursing interventions should be implemented when a patient is experiencing hypokalemia?
Priority: Cardiac monitor (acute care setting only)
Give medications and/or foods to help increase potassium levels
As a patient’s potassium levels increase from low to normal, what symptoms should improve?
Cardiac and smooth muscle strength should incresae
Muscle cramping should decrease and skeletal muscle strength should improve
Heart rate and rhythm should be regular
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)
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.
What are the most common causes of hyperkalemia?
Excessive potassium intake Kidney Failure (the kidneys are not working, they cannot get rid of the potassium in the blood via the urine) Medications
How does hyperkalemia affect the cardiovascular system?
Can cause an arrhythmia
Possible cardiac arrest!
How does hyperkalemia affect the musculoskeletal system?
Muscle twitching
Muscle cramps
Eventual muscle weakness
How does hyperkalemia affect the gastrointestinal system?
Increases GI motility
Causes diarrhea
What nursing interventions should be implemented when a patient is experiencing hyperkalemia?
Priority: Cardiac monitor (acute care setting only)
Administer medications to decrease potassium levels
Restrict potassium rich foods
What are dietary sources of potassium?
Spinach Broccoli Tomatoes Potatoes Avocados Bananas Oranges Orange Juice Carrots Green Beans Salt Substitutes Legumes, Nuts, Seeds
What is the role of calcium?
Essential for proper function of excitable muscle cells - cardiac muscle and smooth muscle
Helps to control blood pressure (smooth muscle cell control)
Where is calcium stored within the body?
Bones and teeth
What other substance is required in order for calcium to be absorbed?
Vitamin D
Vitamin D aides in the absorption of calcium, without it calcium will not be absorbed from our food
What relationship to calcium and phosphorus have?
Inverse (opposite)
What are common causes of hypocalcemia?
Vitamin D Deficiency
Renal Disease (the kidneys active vitamin D. Without active vitamin D the body cannot absorb calcium)
Medications
Hyperphosphatemia
How does hypocalcemia affect the cardiovascular system?
Causes cardiac dysrhythmias
Can cause possible cardiac arrest
Causes hypotension
How does hypocalcemia affect the musculoskeletal system?
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
What nursing interventions should be implemented when a patient is experiencing hypocalcemia?
Priority: Cardiac Monitor
Administer calcium via medications
Administer calcium rich foods
Explain a positive Chvostek Sign. What does it tell us?
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
Explain a positive Trousseau Sign. What does it show us?
The hand spasms when a blood pressure cuff is inflated on the upper arm for > 3 minutes.
This shows us tetany.
In what electrolyte imbalance is there a positive Chvostek and Trousseau Sign?
Hypocalcemia
What are common causes of hypercalcemia?
Excessive intake of calcium
Excessive intake of vitamin D
Medications
Hypophosphatemia
How does hypyercalcemia affect the cardiovascular system?
Causes cardiac dysrhythmias
Can cause cardiac arrest
Causes hypertension
How does hypyercalcemia affect the musculoskeletal system?
Causes skeletal muscle weakness
How does hypyercalcemia affect the genitourinary system?
Can cause kidney stones
What nursing interventions should be implemented when a patient is experiencing hypercalcemia
Priority: Cardiac monitor
Decrease calcium levels
Avoid foods high in calcium
What are dietary sources of calcium?
Milk Yogurt Cheese Ice Cream Broccoli Tofu Rhubarb Spinach, Greens Medications: Calcium Carbonate (Tums)
What is the relationship between magnesium and calcium?
They work together
What is the role of magnesium in the body?
Function of excitable cells (cardiac muscle, nerve cells)
What are common causes of hypomagnesemia?
Decreased intake, usually related to malnutrition Excessive loss (diarrhea)
Most commonly seen in alcoholics
How does hypomagnesemia affect the cardiovascular system?
Causes cardiac dysrhythmias
Can lead to cardiac arrest
How does hypomagnesemia affect the musculoskeletal system?
Hyperactive deep tendon reflexes
Can lead to tetany
(Just like hypocalcemia)
What nursing interventions should be implemented when a patient is experiencing hypomagnesemia?
Priority: Cardiac monitor
Replace Magnesium via medications and/or food
If a patient has a low calcium level, what other electrolyte would be low?
Magnesium
What are common causes of hypermagnesemia?
Excessive intake
Renal Failure
How does hypermagnesemia affect the cardiovascular system?
Can cause dysrhythmias
Possible cardiac arrest
How does hypermagnesemia affect the musculoskeletal system?
Skeletal muscle weakness
Just like hypercalcemia
What nursing interventions should be implemented when a patient is experiencing hypermagnesemia?
Priority: Cardiac Monitor
Decrease magnesium level
What are dietary sources of magnesium?
Nuts, Legumes Green leafy vegetables Seafood Whole grains Bananas Oranges Chocolate Medications (Antacids such as Maalox and Mylanta, Laxatives such as Milk of Magnesium)
