Fluids & Electrolytes

Question 1

Fluid Volume Deficit/Excess - Cardiovascular

Answer 1

• Deficit
  
  • Thready, increased pulse rate
  • Decreased blood pressure and orthostatic hypotension
  • Flat neck and hand veins
  • Diminished peripheral pulses
  • Decreased central venous pressure
  • Dysrhythmias
• Excess
  
  • Bounding, increased pulse rate
  • Elevated blood pressure
  • Distended neck veins
  • Elevated central venous pressure
  • Dysrhythmias

Question 2

Fluid Volume Deficit/Excess - Respiratory

Answer 2

• Deficit
  
  • Increased rate and depth of respirations
  • Dyspnea
• Excess
  
  • Increased respiratory rate (shallow respirations)
  • Dyspnea
  • Moist crackles on auscultation

Question 3

Fluid Volume Deficit/Excess - Neuromuscular

Answer 3

• Deficit
  
  • Decreased CNS activity, from lethargy to coma
  • Fever, depending on the amount of fluid loss
  • Skeletal muscle weakness
• Excess
  
  • Altered LOC
  • Headache
  • Visual disturbances
  • Skeletal muscle weakness
  • Paresthesias

Question 4

Fluid Volume Deficit/Excess - GI

Answer 4

• Deficit
  
  • Decreased motility and diminished blood sounds
  • Constipation
  • Thirst
  • Decreased body weight
• Excess
  
  • Increased motility in the GI tract
  • Diarrhea
  • Increased body weight
  • Liver enlargement
  • Ascites

Question 5

ECG Changes in Electrolyte imbalances

Answer 5

• Hypocalcemia
  
  • Prolonged ST
  • Prolonged QT
• Hypercalcemia
  
  • Shortened ST
  • Widened T
• Hypokalemia
  
  • ST depression
  • Shallow, flat or inverted T wave
  • Prominent U wave
• Hyperkalemia
  
  • Tall peaked T
  • Flat P
  • Widened QRS
  • Prolonged PR
• Hypomagnesemia
  
  • Tall T
  • Depressed ST
• Hypermagnesemia
  
  • Prolonged PR
  • Widened QRS

Question 6

Hypokalemia

Answer 6

• Manifestations
  
  • U waves
  • Weakness
  • Constipation, nausea, vomiting, hypoactive bowel sounds
  • Deep tendon hyporeflexia
  • Anxiety, lethargy, confusion
  • Orthostatic hypotension
  • Skeletal muscle weakness, leg cramps
• Causes
  
  • Excess use of diuretics or corticosteroids
  • Increased secretion of aldosterone (cushing’s)
  • Vomiting, diarrhea
  • Wound drainage (esp. GI)
  • Kidney disease
  • Alkalosis
  • Hyperinsulinism
• Interventions
  
  • replacement
    
    • Never by IV push, always diluted with a pump

Question 7

Hyperkalemia

Answer 7

• Manifestations
  
  • Weakness
  • Diarrhea
  • Cramping
  • arrhythmias w/ ST elevations, Flat P waves, Widened QRS complexes
• Causes
  
  • Decreased potassium excretion
    
    • kidney disease, adrenal insufficiency (addison’s
  • tissue damage
  • Acidosis
  • Hyperuricemia
  • Hypercatabolism
• Interventions
  
  • Potassium excreting diuretics
  • Sodium polystyrene sulfonate
  • IV calcium
  • IV hypertonic glucose w/ regular insulin

Question 8

Hyperkalemia - Interventions

Answer 8

• Administer potassium-excreting diuretics
• If renal function impaired, sodium polystyrene sulfonate
• IV calcium if hyperkalemia is severe
• Hypertonic glucose with regular insulin to move excess potassium into the cells
• If receiving transfusion, patient should receive fresh blood
• Avoid use of salt substitutes

Question 9

Hypernatremia

Answer 9

• Manifestations
  
  • Increased thirst
  • Muscle twitching (Hyperreflexia)
  • Skeletal muscle weakness; deep tendon reflexes diminished
  • Agitation, confusion, Seizures
  • Progress to coma
• Causes
  
  • Decreased sodium excretion (corticosteroids, cushing’s, kidney disease, hyperaldosteronism
  • Decreased water intake
  • Increased water loss
• Interventions
  
  • if fluid loss, IV infusions
  • Diuretics
  • Restrict sodium and fluid intake

Question 10

Hyponatremia

Answer 10

• Manifestations
  
  • Lethargy
  • Anorexia
  • Muscle cramping, muscle weakness
  • Nausea; hyperactive bowel sounds
  • Diminished deep tendon reflexes
  • HA
  • Confusion, seizures, coma
• Causes
  
  • Sodium excretion (diuretics, diaphoresis, decreased secretion of aldosterone)
  • Dilution of serum sodium (kidney disease, SIADH, hyperglycemia, hypotonic fluids, drowning)
• Interventions
  
  • if fluid volume deficit, IV NaCl
  • If fluid volume excess, osmotic diuretics
  • If client taking lithium, monitor lithium level because hyponatremia can cause diminished lithium excretion

Question 11

Hypocalcemia

Answer 11

• Manifestations
  
  • depression
  • hallucinations
  • tingling and paresthesias
  • can progress to arrhythmias and MI
  • Painful muscle spasms
  • Hyperactive deep tendon reflexes
  • Hyperactive bowel sounds
  • Positive Chvostek’s sign (contraction of facial muscles in response to tap over facial nerve in front of ear)
  • Positive Trousseau’s sign (carpal spasm induced by inflating a cuff above the systolic pressure for a few minutes)
• Causes
  
  • lactose intolerance, malabsorption syndromes (celiac, Crohn’s), inadequate vitamin D intake, ESRD
  • Diarrhea, wound drainage
  • Hyperproteinemia
  • Alkalosis
  • Calcium binders
  • Hyperphosphatemia
  • Acute pancreatitis
• Interventions
  
  • Calcium IV
    
    • warm fluid before administration, push slowly
  • Vitamin D aids in calcium absorption
  • Aluminum hydroxide reduces phosphorus levels
  • Seizure precautions
  • Monitor for bone fractures
  • Keep 10% calcium gluconate available

Question 12

Hypercalcemia

Answer 12

• Manifestations
  
  • N/V
  • can progress to cerebellar ataxia and coma
  • Increased BP
  • Bounding pulses
  • Profound muscle weakness
  • Diminished deep tendon reflexes
  • Disorientation, lethargy, coma
  • Hypoactive bowel sounds
• Causes
  
  • Increased calcium absorption
  • Decreased calcium excretion
    
    • kidney disease, thiazide diuretics
  • Increased bone resorption of calcium
    
    • hyperparathyroidism, hyperthyroidism, malignancy, use of glucocorticoids
  • Hemoconcentration
    
    • dehydration, use of lithium, adrenal insufficiency
• Interventions
  
  • Discontinue IV/oral calcium
  • thiazide diuretics may be discontinued and replaced with ones that enhance excretion of calcium
  • medications that inhibit calcium resorption (phosphorus, calcitonin, bisphosphonates, NSAIDS)
  • Dialysis if severe
  • Monitor for flank or abdominal pain
  • Strain urine for urinary stones
  • Monitor for fractures

Question 13

Hypomagnesemia

Answer 13

• Manifestations
  
  • Tachycardia
  • HTN
  • Shallow respirations
  • Twitches, paresthesias
  • Positive Trousseau and Chvostek
  • Hyperreflexia
  • Tetany, seizures
• Interventions
  
  • Restoration of calcium levels (reciprocal relationship)
  • Oral preperations of magnesium may cause diarrhea
  • Magnesium sulfate by IV

Question 14

Hypermagnesemia

Answer 14

• Manifestations
  
  • Bradycardia, dysrhythmias
  • Hypotension
  • Diminished or absent deep tendon reflexes
  • Skeletal muscle weakness
• Interventions
  
  • Diuretics to increase excretion
  • Calcium gluconate is the antidote
  • Instruct client to avoid the use of laxatives and antacids containing magnesium

Question 15

Hypophosphatemia

Answer 15

• Inverse relationship between calcium and phosphate
• Manifestations
  
  • Slowed peripheral pulses
  • Weakness
  • Decreased deep tendon reflexes
  • Confusion, seizures
  • Decreased platelet aggregation and increased bleeding
• Interventions
  
  • Administer oral phosphorus with vitamin d
  • Administer IV phosphorous when levels drop below 1 mg/dl
    
    • push slowly
  • Assess renal system before administering phosphorus
  • Instruct client to increase intake of phosphorus-containing foods while decreasing intake of calcium-containing foods

Question 16

Hyperphosphatemia

Answer 16

• Interventions
  
  • Administer phosphate-binding medications that increase the excretion of phosphorus
  • Instruct client to avoid phosphate-containing medications including laxatives and enemas
  • Phosphate-binding medications should be taken with meals or immediately after meals