Fluid & Electrolytes Part 2 (A) Flashcards
Homeostasis =
Body’s natural balance
Homeostasis is achieved when what characteristics of body fluids remain in balance?
Volume, Concentration (Osmolality), Composition (Electrolyte Composition), Acidity (pH)
Lack of just fluid =
Dehydration
Lack of water + electrolytes =
Hypovolemia
Hypovolemia is a -
Fluid volume deficit
Hypovolemia can be thought of as-
Isotonic dehydration
Lack of circulating volume =
Fluid volume deficit
BUN (Blood Urea Nitrogen) is a lab value that does what?
Measures the amount of urea nitrogen levels in the blood.
A BUN helps the provider determine -
If the kidney’s are properly functioning
Hematocrit is a part of the-
Complete Blood Panel (CBC)
The hematocrit lab value helps measure-
The % of RBC’s in the blood
The Urine Specific Gravity compares-
The density of your urine to the density of water
Urine Specific Gravity helps identify if the PT has -
Dehydration, kidney problems, or diabetes insipidus
When a PT’s body is dry, the BUN and Urine Specific Gravity are all-
Elevated
Causes of Hypovolemia:
GI Loss + Excessive Loss via Skin + Excessive Renal Loss + Third Spacing + Hemorrhage + Alteration in Intake of Fluids + Meds + Underlying healthcare conditions + Decline in total body fluid that they have + Decreased kidney function
What is Third Spacing?
When the fluid shifts from the Intravascular space (veins) to the interstitial (or third space)
Who’s at risk for hypovolemia and why?
Older adults have a decreased thirst response.
Infants & young children have an increased metabolic rate & increased body water content.
The most common cause of dehydration is-
Vomiting + Diarrhea
Mild to moderate dehydration can be treated with oral rehydration solutions in-
Small increments (5-10 ml) every 5-10 minutes to see if they can tolerate it
Dehydration Causes:
Hyperventilation + Excessive perspiration + Prolonged fever + Diabetic ketoacidosis (KDA) + Inadequate water consumption + Diabetes insipidus + Osmotic diuretics + Excessive sodium intake + Excessive hypertonic fluids
Expected findings of hypovolemia:
Alterations in vital signs + Neuromuscular alterations + GI effects + Renal Effects + Other
What alterations in vitals can you expect from a hypovolemia PT?
Hypothermia (low body temp) + Tachycardia (this is the body’s attempt to maintain normal BP) + Thready pulse (due to decreased blood volume) + Hypotension + Orthostatic hypotension (due to low amount of circulating blood volume) + Decreased central venous pressure + Tachypnea (to compensate for lack of blood volume) + Hypoxia
What neuromuscular alterations can you expect from a hypovolemia PT?
Dizziness + Syncope + Confusion + Weakness + Fatigue
What GI Effects can you expect from a hypovolemia PT?
Thirst (one of the first signs of the earliest signs of fluid volume depletion) + Dry furrowed tongue + Nausea + Vomiting + Anorexia + Acute weight loss
What Renal Effects can you expect from a hypovolemia PT?
Oliguria (decreased urine production + concentration of urine)
Aside from alterations in vitals, neuromuscular effects, GI effects, and renal effects, what other things can you expect to find in a hypovolemia PT?
Decreased cap refill + Cool clammy skin + Diaphoresis + Sunken eyeballs + Flattened neck veins + Poor skin turgor & tenting + Weight loss
What happens to Anti-Diuretic Hormone (ADH) in hypovolemia?
It Increases
Why does ADH increase when you have hypovolemia?
Because you need to retain water
More ADH =
More body water
More body water =
Less urine output
Name off 6 expected findings of hypovolemia:
Hypovolemia effects are greater in older adults + Loss of Elasticity + Decreased GFR (Glomerular Filtration Rate) + Concentrating ability of the kidneys + Loss of muscle mass + Decreased thirst sensation
Muscle holds-
More body water
Adipose tissue holds-
Less body water
Dehydration can have what as a cause or finding?
A fever
Rapid & severe dehydration can cause a PT to have-
Seizures
What do Hematocrit (HCT) levels look like in hypovolemic PT’s?
High
BUN levels should look like what in hypovolemic PT’s?
High (Above 25mg/dL) due to hemoconcentration
Urine Specific Gravity should look like what in hypovolemic PT’s?
High (greater than 1.030)
Blood Sodium should look like what in dehydrated PT’s?
High (greater than 145 mEq/L)
Blood Osmolality should be high in-
Dehydrated PT’s + Hypernatremia PT’s
Fluid loss due to a hemorrhage cause there to be-
No Hemoconcentration, which means that there should be a low BUN (Because you’re losing a lot of blood)
Normal BUN values =
8 - 25 mg/dL
Normal HCT levels =
36 - 54%
Minimum accepted urinary output =
30 ml/hour
Hemoconcentration =
Everything becomes more concentrated
What is hemoconcentration caused by?
A fluid volume deficit
Does HCT get higher or lower when you’re dry?
Higher
The volume of the RBC’s in 100 mL’s is expressed as a -
Percentage (This is how you determine hemoconcentration)
How does a nurse manage a PT with hypovolemia?
Oral or IV Therapy + Strict Input & Output + Monitor Vital Signs + Monitor changes in mental status + Monitor weight daily + Assess Gait + PT should change positions slowly + Replace fluids & electrolytes (Can be done with LR for balancing fluid and electrolytes, 0.9% normal saline for rapid volume replacement, or a blood transfusion if due to blood loss)
Monitoring weight is the-
Most accurate measurement of fluid gain / loss
Are hypovolemic PT’s a fall risk?
Yes
What would you want to educate a dehydration PT about?
Tell them to increase fluid intake.
Educate them on the causes of dehydration.
Causes of dehydration include:
Vomiting, Wound Exudate, Diarrhea, or Excessive Ostomy Losses
Occurs with significant loss of blood (lost ~ 1/5th of blood in the body) =
Hypovolemic Shock
Hypovolemic shock manifestations include:
Slowed tissue perfusion, decreased perfusion, cells become unable to carry enough oxygen because of loss of RBC’s
Nursing Actions for Hypovolemic Shock include:
Oxygen administration + Monitor oxygen saturation (<70% = medical emergency) + Stay with PT if unstable + Check vital signs every 15 minutes + Administer fluid replacement (Colloids / Crystalloids) + Vasoconstrictors (dopamine, norepinephrine, phenylephrine) + Agents to improve myocardial perfusion (sodium nitroprusside) + Positive inotropic meds (Dobutamine, milrinone) + Hemodynamic monitoring.
Dont need to know meds yet. Yippee!
Why do male adults have more water?
Lean body mass holds more water. Adult males have more lean body mass
Adipose has less water, so this puts what age/ gender demographic at the most risk?
Older Adult Females
Who is most at risk of Fluid Volume Deficit (FVD) and why?
Obese, Older Adults.
Fat cells = less water.
Older adults have less need for ICF + have more body fat.
1 L =
2.2 lbs
2% Weight Loss =
Mild Fluid Loss
5% Weight Loss =
Marked/ Moderate Fluid Loss
8% Fluid Loss =
Severe Fluid Loss
Overhydration causes:
Excessive intake.
Ineffective removal from the body.
Excess fluid/water can cause -
Hemodilation
Excess fluid can be called-
Fluid Overload
Excess water + electrolytes =
Hypervolemia
Excessive sodium causes-
Fluid Retention
Why do PT’s with a lot of edema (like congestive heart failure PT’s) have their sodium restricted?
Because sodium causes fluid retention
Severe excess of fluid can lead to -
Pulmonary Edema + Heart Failure
How do you get rid of excess water + sodium (thus treating hypervolemia?)
Natriuretic Peptides cause an increased excretion of excess water + sodium by the kidneys. Also causes an increase of aldosterone
PT’s with heart disease or impaired kidney function need-
To be on a reduced sodium diet.
Fluid intake needs to be restricted.
What Regulatory System problems can cause Hypervolemia?
Heart Failure + Kidney Disease + Cirrhosis
Aside from regulatory system problems, what else can cause Hypervolemia?
Overdose of fluids + Fluid shifts due to burns + Prolonged use of corticosteroids + Stress (severe) + Hyperaldosteronism
What are some causes of Overhydration?
Water replacement without electrolyte replacement + Syndrome of Inappropriate Antidiuretic Hormone (SIADH) + Excessive administration of D5W (IV Fluid), use of hypotonic solutions for irrigations
Fluid Volume Overload
Expected Findings, Vital Signs:
Tachycardia + Bounding Pulse + Hypertension + Tachypnea + Increased Central Veinous Pressure
Fluid Volume Overload
Expected Findings, Neuromuscular:
Weakness + Visual changes + Parasthesia’s (Pins & needles feeling) + Altered level of consciousness + Seizures (If severe) + Sudden hyponatremia / water excess
Fluid Volume Overload
Expected Findings, GI:
Ascites (fluid builds up in abdomen) + Increased motility + Enlarged liver
Fluid Volume Overload
Expected Findings, Respiratory:
Crackles + Cough + Dyspnea
Fluid Volume Overload
Expected Findings, Other Signs:
Peripheral Edema + Distended neck pains + Polyuria + Cool skin & Pallor
What lab results can you expect from someone with Fluid Volume Overload?
Decrease in Hematocrit (HCT) & Hemoglobin (HGB) + Decrease blood Osmolarity with fluid/water excess + Decrease in urine sodium & urine specific gravity + Decrease in BUN due to plasma dilution + X-Ray reveals possible pulmonary congestion
Nursing care for Fluid Volume Excess:
I/O + Daily Weight + Assess breathing sounds + Monitor peripheral edema (pitting/non-pitting) + Maintain sodium level (restrict sodium) + Fluid restrictions if prescribed + Encourage rest + Administer diuretics/ monitor the PT + Semi/High Fowler’s position + Pressure reduction mattress + Pad bony prominences/ assess + Monitor sodium & potassium levels
You’re checking for pitting edema, 1+ is how many mm?
2 mm
You’re checking for pitting edema, 2+ is how many mm?
4 mm
You’re checking for pitting edema, 3+ is how many mm?
6 mm
You’re checking for pitting edema, 4+ is how many mm?
8 mm
What things do you need to educate your PT with fluid volume excess about?
Daily weights + Low sodium diet + how to read food labels + How to keep daily record of sodium intake + Fluid restriction (divide allotment throughout the day)
Pulmonary Edema is caused by-
Several Fluid Overload/ Excess
Pulmonary Edema Manifestations =
Anxiety + Tachycardia + Increased vein distention + Premature ventricular contractions (PVC’s) + Dyspnea at rest + Change in Level Of Consciousness (LOC) + Restlessness + Lethargy + Crackles + Productive cough with frothy pink-tinged sputum
Nursing actions for pulmonary edema =
High Fowler’s position + Oxygen + Positive Airway Pressure (CPAP or BIPAP) + Possible intubation with mechanical ventilation + Morphine, nitrates, & diuretics as prescribed
Major electrolytes in the body=
Sodium + Potassium + Magnesium + Calcium + Phosphorus + Chloride
Reference Ranges:
Sodium=
136 - 145 mEq/L
Reference Ranges:
Calcium=
9 - 10.5 mg/dL
Reference Ranges:
Potassium=
3.5 - 5 mEq/L
Reference Ranges:
Magnesium=
1.3 - 2.1 mEq/L
Reference Ranges:
Chloride=
98 - 106 mEq/L
Reference Ranges:
Phosphorus=
3 - 4.5 mg/dL
Major cation in ECF =
Sodium
Where is sodium found?
In many body fluids (saliva, GI, bile)
How does sodium regulate water balance & distribution =
Maintains appropriate ECF osmolality + Maintains fluid volume by keeping correct amount of fluid in ECF + Influences H20 movement & distribution between ECF and ICF (This fluid shift helps to restore homeostasis & normal osmolality)
Sodium Imbalance =
Water Imbalance + Osmolality Changes
How do the kidneys regulate sodium?
By using ADH & Aldosterone
Has role in nerve impulse transmission =
Sodium
Regulates water balance and distribution =
Sodium
Main determinant of Osmolality =
Sodium
Whenever sodium is reabsorbed, what is absorbed with it?
Chloride & Water
More sodium = Increased ECF Osmolarity = Stimulates more ADH =
More water’s reabsorbed, less output
Less sodium = Decreased ECF Osmolarity = Inhibits ADH (Less ADH) =
More water excreted + more output
Is sodium AND water balance regulated by aldosterone production?
Yeah
More sodium = decreased aldosterone production =
Excretion of sodium & water
Less sodium = Increased aldosterone production =
Increased sodium & water reabsorption
Sodium is not stored-
In the body, must be consumed
The minimum daily range of sodium is-
< 3 gr
Foods high in Na+ =
Table salt + Canned foods (especially soups, vegetables, tuna, etc.) + Processed & packaged foods (cheese, hotdogs, bologna, jerky) + Cured meats (bacon & ham) + Pickled foods & snack foods + Condiments (ketchup, pickles, green olives) + Pizza + Cottage cheese + Vegetable juice + Buttermilk + Shrimp + Sausage
A Hyponatremia PT has a blood sodium level that’s-
Less than 136 mEq/L
Hyponatremia is caused by-
Excessive water intake in plasma or a loss of sodium rich foods
Delays/ slows depolarization =
Hyponatremia
Hyponatremia causes water to move from-
ECF into the intracellular fluid (brain cells + system swells)
Where fluids go, electrolytes-
Go
Most common cause of hyponatremia =
Excess water in the body
Hyponatremia causes =
Loss of sodium + Gain of water
Sodium lost = ECF gets-
Less concentrated
Examples that can cause hyponatremia via loss of sodium are:
GI fluid loss (suction, vomiting, diarrhea) + Renal loss (diuretics) + Skin loss (burns, wound drainage, sweating) + Irrigations with tap water (wounds, Nasogastric Tubes/NGT, sweating) + Low sodium diet (especially combine with above losses)
Examples that can cause hyponatremia via gain of water are:
Excess drinking of water w/o electrolyte replaced + Infusion of hypotonic solutions + Hypotonic tube feedings + Hypotonic IVF (like prolonged D5W)
Water gained =
ECF gets less concentrated
Hyponatremia causes the serum osmolarity to-
Decrease as fluid shifts from ECF to intracellular.
Causes of hyponatremia that drain sodium from the body are nicknamed-
The 4 D’s
What are the 4 D’s?
Drains + Diuretics + Diarrhea + Diuresis
Aside from the 4 D’s, what else can cause hyponatremia via sodium loss?
SIADH + Adrenal Insufficiency (Addison’s Disease) + Heat exhaustion or high fever
SIADH =
They retain water and dilute the sodium which becomes hemodilution
Adrenal insufficiency wastes sodium by-
Excreting it via the urine
Expected hyponatremia PT findings (Vitals) =
Hypothermia + Tachycardia + Rapid thready pulse + Hypotension + Orthostatic hypotension
Expected hyponatremia PT findings (neuromuscular alterations) =
Headache + Confusion + Lethargy + Muscle weakness with possibility of respiratory compromise + Fatigue + Decreased deep tendon reflexes + Seizures + Coma
Expected hyponatremia PT findings (GI) =
Increased GI motility + Hyperactive bowel sounds + Abdominal cramping + Anorexia + Nausea + Vomiting
Nursing care for hyponatremia involves-
Monitoring I&O, Daily Weights, Na+ labs, Vital signs, Behavioral changes.
Restrict fluid intake or high sodium intake if allowed.
Ensure safe environment.
IVF Replacement.
Type of IVF fluid replacement for treatment of hyponatremia depends on -
Severity
Moderate hyponatremia should be treated with what IVF replacement?
0.9% NS or LR
Severe hyponatremia should be treated with what IVF replacement?
3.0% NS (Hypertonic IVF)
PT with hypernatremia should be educated about:
Weigh daily + Notify HCP if weight gain of 1-2 pound in a 24-hour period or 3 pounds in a week + High-sodium diet + Food diary + Read nutrition levels
Hypernatremia =
High sodium over 145 mEq/L
How do you get hypernatremia?
Loss of water/ poor intake of water
Or
Excessive gain of sodium
Sodium gain =
ECF gets more concentrated
Name 7 examples of how a PT can gain too much sodium:
Excess salt ingestion (Table salt, high sodium diet) + Infusion of hypertonic fluids + Hypertonic IVF’s (D5NS, D5LR, D10W) + Hypertonic tube feedings without adding water + Poorly diluted baby formulas + Renal disease + Excess aldosterone secretion
Dehydration helps confirm the presence of-
Hypernatremia
Water deprivation =
Too little intake of water
Diarrhea is considered severe if it causes a loss of-
More H20 than Na+
When water is lost, ECF-
Gets more concentrated
Examples of hypernatremia caused by loss of water/ poor intake of water:
Water deprivation + Severe watery diarrhea + Increased insensible water loss (Excessive sweating, high fever)
Thirst protects against-
Hypernatremia
High Na =
Thirsty
Thirsty =
Drink fluids
Drink fluids =
Correct hypernatremia
A problem situation for hypernatremia is not-
Being able to drink or rapid Na overload
High Na means High-
Osmolality
Hypernatremia Manifestations & Lab Findings =
Key symptoms due to dehydrated cells, Na+ > 145 mEq (Serum Osmolarity > 295 mOsm), Thirst + Dry Sticky Mucous Membranes, Oliguria/ Anuria (Anuria means no urine or without urine).
NeuroCognitive: Irritable, Restless, Agitated, Seizures, Poor Memory.
Muscular: Weakness, Lethargy
Nursing Interventions for Hypernatremia =
Monitor I&O, Daily Weights, Na+ Labs, Vitals, LOC & Behavioral Changes.
Restrict sodium, Force fluids, Oral care.
Provide safe environment.
Type of IVF replacement = Hypotonic IVF (0.45% NS or 0.33% NS)
Whenever administering Hypotonic IVF to a patient, it should be administered gradually to prevent-
Fluid shift into the cells + any Cerebral Edema
Serum Potassium level should normally be-
3.5 - 5 mEq/L
Potassium is a principal-
Cation in ICF
Transmits life-sustaining electrical impulses =
Potassium
Potassium impacts what?
Cardiac muscle + Nerve tissue + Skeletal tissue + Muscle contraction
Potassium is primarily regulated by-
The Kidney
Is potassium stored in the body?
No, it must be ingested
Fruits, vegetables, spinach, and dairy products are all high in-
Potassium
Hyperkalemia is high potassium over-
5.0 mEq/L
Causes for Hyperkalemia include-
Decreased K+ Excretion & High K+ Intake
Examples of decreased potassium excretion are-
Impaired excretion; Renal Failure
Meds = Potassium-Sparing Diuretics (K+ Retained)
High K+ Intake
Examples of High K+ intake include-
Potassium supplements (Oral/ IV).
Excessive intake of dietary or K+ salt substitutes.
Excessive or rapid infusion of IV Potassium.
Massive cell damage (burns/trama).
Hyperkalemia Manifestiations + Labs =
Cell excitability + Cardiac & EKG changes, Cardiac dysrhythmia, cardiac arrest + Skeletal & abdominal muscles: leg pain, muscle cramping, followed by muscle weakness & numbness.
Lab values = K+ > 5.0 mEq/L; EKG Abnormalities
Hyperkalemia Nursing Interventions =
Check Kidney Function: U/A, BUN, Serum Creatinine + Strict I&O + Restrict dietary K+ and salt substitutes + Meds to reduce K+ (Kayexalate & Loop Diuretics) + Monitor serum K+ levels + Cardiac Monitoring + Renal Dialysis
