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)
2
Q
Where are fluids located within the body?
A
Intracellular Fluid (ICF) Extracellular Fluid (ECF): Interstitial fluid, intravascular fluid
3
Q
What organ/system does Antidiuretic Hormone (ADH) work on?
A
Kidneys/Renal System
4
Q
What is the role of Antidiuretic Hormone (ADH) when it is released?
A
To conserve fluids through the kidneys
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
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
7
Q
What organ/system does Aldosterone work on?
A
Kidneys/Renal System
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
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)
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
11
Q
What is the definition of sensible fluid loss?
A
When one is aware of the fluid loss from the body
12
Q
What are examples of sensible fluid loss?
A
Urination
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
14
Q
What are examples of insensible fluid loss?
A
Perspiration
Respiration
Elimination of feces
Emesis
15
Q
What mechanism is activated by the brain when the body losses fluid?
A
The thirst mechanism
16
Q
What mechanism to aide in maintaining fluid balance is depressed in the older adult?
A
The thirst mechanism
17
Q
Which population is at greatest risk for dehydration?
A
Older adults
18
Q
What are causes of fluid loss/deficit?
A
Inadequate fluid intake Hemorrhage (bleeding) GI Losses (emesis, stool) Fever Diuretic Use
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
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
21
Q
What is the best way to monitor fluid status in a patient?
A
Monitor weight daily
22
Q
What are causes of fluid volume overload?
A
Excess fluid intake (either PO or IV)
Renal Failure
Heart Failure
23
Q
When there is excess fluid in the body, what state is the body in?
A
Hypervolemic state
Excess fluid volume causes hypervolemia
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
25
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
26
What is the most concerning clinical manifestation with fluid volume overload?
Changes in respiratory status. Pulmonary edema can occur.
A.B.C's!
27
What are the two types of edema?
Pitting
| Non-Pitting
28
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.
29
What is the definition of 1+ pitting edema?
Mild edema; depression disappears rapidly
30
What is the definition of 2+ pitting edema?
Moderate edema; depression disappears in 10-15 seconds
31
What is the definition of 3+ pitting edema?
Moderately severe edema; depression disappears in about one minute
32
What is the definition of 4+ pitting edema?
Severe edema; depression can last more than two minutes
33
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)
34
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)
35
What interventions can the nurse implement to help improve edema in the lower extremities?
Elevate legs
| Apply compression stockings
36
What can cause an imbalance of electrolytes within the body?
```
Malnutrition
Dehydration
Over hydration
Nausea, Vomiting, Diarrhea
Sweating
Medications (such as diuretics)
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37
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
38
Sodium and potassium have what kind of relationship?
Inverse (opposite)
39
What are the clinical manifestations of hyponatremia?
```
Mental status changes!
Disorientation
Confusion
Agitation
Dizziness
Headaches
Lethargy
Muscle Weakness
Possible Seizures
Eventual Coma
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40
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
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41
What are the clinical manifestations of hypernatremia?
Thirst
Mental status changes: irritability, agitation, confusion
Muscle excitability causing twitching, tremors, possible seizures
42
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
43
What are dietary sources of sodium?
```
Table salt
Canned food items
Processed foods
Soda
Seasoned salts
Soy Sauce
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44
What is the role of potassium?
Aides in the proper function of cardiac, skeletal and smooth muscle
45
What is the most common potassium imbalance?
Hypokalemia
46
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)
47
How does hypokalemia affect the cardiovascular system?
Weak pulses
Can cause an arrhythmia
Potential cardiac arrest!
48
How does hypokalemia affect the respiratory system?
Causes ineffective, shallow respirations because the skeletal muscles are weakened and cannot aide in breathing
49
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)
50
How does hypokalemia affect the nervous system?
Causes mental status changes such as lethargy
51
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
52
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
53
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
54
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.
55
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
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56
How does hyperkalemia affect the cardiovascular system?
Can cause an arrhythmia
| Possible cardiac arrest!
57
How does hyperkalemia affect the musculoskeletal system?
Muscle twitching
Muscle cramps
Eventual muscle weakness
58
How does hyperkalemia affect the gastrointestinal system?
Increases GI motility
| Causes diarrhea
59
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
60
What are dietary sources of potassium?
```
Spinach
Broccoli
Tomatoes
Potatoes
Avocados
Bananas
Oranges
Orange Juice
Carrots
Green Beans
Salt Substitutes
Legumes, Nuts, Seeds
```
61
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)
62
Where is calcium stored within the body?
Bones and teeth
63
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
64
What relationship to calcium and phosphorus have?
Inverse (opposite)
65
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
66
How does hypocalcemia affect the cardiovascular system?
Causes cardiac dysrhythmias
Can cause possible cardiac arrest
Causes hypotension
67
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
68
What nursing interventions should be implemented when a patient is experiencing hypocalcemia?
Priority: Cardiac Monitor
Administer calcium via medications
Administer calcium rich foods
69
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
70
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.
71
In what electrolyte imbalance is there a positive Chvostek and Trousseau Sign?
Hypocalcemia
72
What are common causes of hypercalcemia?
Excessive intake of calcium
Excessive intake of vitamin D
Medications
Hypophosphatemia
73
How does hypyercalcemia affect the cardiovascular system?
Causes cardiac dysrhythmias
Can cause cardiac arrest
Causes hypertension
74
How does hypyercalcemia affect the musculoskeletal system?
Causes skeletal muscle weakness
75
How does hypyercalcemia affect the genitourinary system?
Can cause kidney stones
76
What nursing interventions should be implemented when a patient is experiencing hypercalcemia
Priority: Cardiac monitor
Decrease calcium levels
Avoid foods high in calcium
77
What are dietary sources of calcium?
```
Milk
Yogurt
Cheese
Ice Cream
Broccoli
Tofu
Rhubarb
Spinach, Greens
Medications: Calcium Carbonate (Tums)
```
78
What is the relationship between magnesium and calcium?
They work together
79
What is the role of magnesium in the body?
Function of excitable cells (cardiac muscle, nerve cells)
80
What are common causes of hypomagnesemia?
```
Decreased intake, usually related to malnutrition
Excessive loss (diarrhea)
```
Most commonly seen in alcoholics
81
How does hypomagnesemia affect the cardiovascular system?
Causes cardiac dysrhythmias
| Can lead to cardiac arrest
82
How does hypomagnesemia affect the musculoskeletal system?
Hyperactive deep tendon reflexes
Can lead to tetany
(Just like hypocalcemia)
83
What nursing interventions should be implemented when a patient is experiencing hypomagnesemia?
Priority: Cardiac monitor
| Replace Magnesium via medications and/or food
84
If a patient has a low calcium level, what other electrolyte would be low?
Magnesium
85
What are common causes of hypermagnesemia?
Excessive intake
| Renal Failure
86
How does hypermagnesemia affect the cardiovascular system?
Can cause dysrhythmias
| Possible cardiac arrest
87
How does hypermagnesemia affect the musculoskeletal system?
Skeletal muscle weakness
| Just like hypercalcemia
88
What nursing interventions should be implemented when a patient is experiencing hypermagnesemia?
Priority: Cardiac Monitor
| Decrease magnesium level
89
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)
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