Fluid & Electrolytes (Borrowed from Brainscape Library) Flashcards
<p>Where are fluids located within the body?</p>
<p>Intracellular Fluid (ICF)<br></br>Extracellular Fluid (ECF): Interstitial fluid, intravascular fluid</p>
<p>What organ/system does Antidiuretic Hormone (ADH) work on?</p>
<p>Kidneys/Renal System</p>
<p>What is the role of Antidiuretic Hormone (ADH) when it is released?</p>
<p>To conserve fluids through the kidneys - "KEY REGULATOR OF WATER SUPPLY IN BODY"</p>
<p>What organ/system does Aldosterone work on?</p>
<p>Kidneys/Renal System</p>
<p>What is the role of Aldosterone when is it released?</p>
<p>To conserve sodium through the kidneys.<br></br>When sodium is conserved, fluid follows, thus indirectly conserving fluid - "KEY REGULATOR OF SODIUM SUPPLY IN BODY"</p>
<p>What are examples of insensible fluid loss?</p>
<p>Perspiration<br></br>Respiration<br></br>Elimination of feces<br></br>Emesis</p>
<p>What mechanism is activated by the brain when the body losses fluid?</p>
<p>The thirst mechanism</p>
<p>What mechanism to aide in maintaining fluid balance is depressed in the older adult?</p>
<p>The thirst mechanism</p>
<p>What are causes of fluid loss/deficit?</p>
<p>Inadequate fluid intake<br></br>Hemorrhage (bleeding)<br></br>GI Losses (emesis, stool)<br></br>Fever<br></br>Diuretic Use</p>
<p>What are the clinical manifestations of fluid deficit?</p>
<p>Thirst<br></br>Acute weight loss<br></br>Urine changes: dark, concentrated, malodorous urine, decreased output<br></br>Constipation<br></br>Dry skin<br></br>Dry mucous membranes<br></br>Hypotension<br></br>Tachycardia<br></br>Orthostatic Hypotension<br></br>Mental status changes: lightheaded/dizzy, confusion, disorientation, weakness, lethargy</p>
<p>What is orthostatic hypotension?</p>
<p>Hypotension that occurs with position changes, such as going from lying to sitting, lying to standing, or sitting to standing</p>
<p>What is the best way to monitor fluid status in a patient?</p>
<p>Monitor weight daily</p>
<p>What are causes of fluid volume overload?</p>
<p>Excess fluid intake (either PO or IV)<br></br>Renal Failure<br></br>Heart Failure</p>
<p>What population is most at risk for developing fluid volume overload? Why?</p>
<p>Older adult population<br></br>More likely to have comorbidities such as chronic kidney disease (renal failure) and/or chronic heart failure</p>
<p>What are the clinical manifestations of fluid volume overload?</p>
<p>Acute, rapid weight gain (2 lbs or more over 24-28 hours)<br></br>Urine changes: polyuria (if kidneys and heart are functioning), light diluted non-concentrated urine<br></br>Bounding pulses (with normal heart rate)<br></br>Jugular Venous Distention (JVD)<br></br>Hypertension<br></br>Peripheral edema<br></br>Pulmonary Edema (ranging from mild to severe): crackles upon auscultation, tachypnea, dyspnea, labored breathing, decreased O2 saturation<br></br>Neurological Changes</p>
<p>What is the most concerning clinical manifestation with fluid volume overload?</p>
<p>Changes in respiratory status. Pulmonary edema can occur.<br></br><br></br>A.B.C's!</p>
<p>An individual has large, swollen lower extremities. When the nurse touches the area, there is no indentation. How would the nurse document this?</p>
<p>Non-pitting edema.</p>
<p>What is the priority nursing action when a patient is reporting difficulty breathing and has s/s of pulmonary edema?</p>
<p>Ensure head of bed is at 90 degrees (High Fowlers Position)</p>
<p>What interventions can the nurse implement to help improve edema in the lower extremities?</p>
<p>Elevate legs<br></br>Apply compression stockings</p>
<p>What is the role of sodium?</p>
<p>Helps to maintain serum osmolality<br></br>Important for optimal cell function (especially within the CNS)<br></br>Important for optimal nerve and muscle function</p>
<p>What are the clinical manifestations of hyponatremia?</p>
<p>Mental status changes!<br></br>Disorientation<br></br>Confusion<br></br>Agitation<br></br>Dizziness<br></br>Headaches<br></br>Lethargy<br></br>Muscle Weakness<br></br>Possible Seizures<br></br>Eventual Coma</p>
<p>What nursing interventions should be implemented when a patient is experiencing hyponatremia?</p>
<p>Safety is key! Seizure precautions, low bed, siderails up x 2, bed alarm on, room close to the nurse's station<br></br>Monitor weights daily<br></br>Monitor intake and output<br></br>Replace sodium<br></br>Restrict "free" water</p>
<p>What are the clinical manifestations of hypernatremia?</p>
<p>Thirst<br></br>Mental status changes: irritability, agitation, confusion<br></br>Muscle excitability causing twitching, tremors, possible seizures</p>
<p>What nursing interventions should be implemented when a patient is experiencing hypernatremia?</p>
<p>Safety is key! Seizure precautions, low bed, siderails up x 2, bed alarm on, room close to the nurse's station<br></br>Monitor weights daily<br></br>Monitor intake and output<br></br>Restrict sodium</p>
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 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)
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
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
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 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)
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
Paraneoplastic disorders (such as lung cancer)
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 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)
Sodium (Na)
Expected Range?
Causes, symptoms of higher/lower levels?
Na: Electrolyte important for nerve/muscle function, maintaining fluid balance
Expected range: 135-145 mEq/L
Hyponatremia (<135)
- Causes: GI losses, diuretics, skin losses, SIADH
- Symptoms: Confusion (common in elderly), fatigue
Hypernatremia (>145)
- Causes: Water deprivation (elderly who don't/are offered a drink), excess sodium intake, Cushing's syndrome
- Symptoms: Confusion, muscle twitching/weakness
