Fluids & Electrolytes Flashcards
Organs used in Fluid Balance
Kidneys
Hypothalamus
Pituitary gland
Adrenal Cortex
What is the major filtering of fluid that needs pressure to work?
Kidneys
Electrolytes are
electronically charged solutes
necessary to maintain life
Hypothalamus gives the perception of
thirst
The posterior pituitary gland releases what
releases and inhibits ADH
ADH focuses on
holding and letting go of water
Adrenal cortex regulates
Na though aldosterone
Hydrostatic pressure is increasing
artery pressure
Functions of electrolytes
neuromuscular irritability
maintain the body’s osmolality
regulate acid/base
regulate the distribution of body fluids
Increase in hydrostatic pressure caused by
venous obstruction
sodium and water retention
(Heart and renal failure)
Hypoalbuminemia
decrease in plasma oncotic pressure caused by low plasma albumin
Inflammation and immune response happen due to what abnormal fluid movement?
increase in capillary permeability
Obstruction of lymph channels caused by
tumors
inflammation
surgical removal
Complications of edema
pressure injuries
infections
life-threatening to the brain, lungs, and larynx
What are the 4 abnormal fluid movements?
Increase in hydrostatic pressure
decrease in plasma oncotic pressure
Increase in capillary permeability
obstruction of lymph channels
Assessing electrolyte balance includes
-Assess overall fluid balance by monitoring daily weight, I&O
-Assess neurological status; LOC
-Evaluate sensor and motor function; neuromuscular irritability
- (LAB AND V/STRENDS)
-Look at EKF to detect changes
-Assess nutritional status (electrolytes are obtained through the food we eat)
-Evaluate health hx for medical conditions
-Evaluate medication hx for prescription or OTC drugs that can interfere
Daily wts and I&Os show what
retaining
contains PO/IV
What electrolyte affects an EKG?
Potassium
Homeostasis functions of electrolytes
Promote neuromuscular irritability
Maintain body fluid osmolality
Regulate acid-base balance
Regulate the distribution of body fluid amount of body fluid compartments
The ECF used what electrolytes
Sodium
Cloride
ICF
fluid inside the cell 2/3rd (28L)
Factors that influence body fluid
age
gender
body fat
skeleton vs muscle, bone, and skin
What is the percentage of total body water as proportion to body weight?
Neonate -
Infant (6 months) -
Child (5 yo) -
Adult male -
Elderly male -
Adult female -
80%
70%
65%
60%
50%
50%
What gender has more body fluid? except when?
men
women are pregnant
What age has more body fluid?
infants
How does weight affect body fluid?
obese people have less body fluid than thin
ECF
fluid outside the cell 1/3
Intracellular fluid has what electrolytes
potassium and magnesium
Proteins
ECF has what electrolytes
sodium
chloride
What type of fluids are in ECF
Intravascular (plasma)
Interstitial ( surround cells)
Transcellular
Transcellular
works in individual way different from circulatory
(pleural, spinal fluid, sweat, and digestive)
What fluid shifting is abnormal?
3rd spacing
Spacing 1 through 3
1st - normal
2nd - edema
3rd - ascites, burn edema
3rd spacing s/s
decreased urine output (shifted toward interstitial space)
increase heart rate (compensate)
decreased BP and CVP
edema
increase body weight
I&O not balanced
What is a form of 3rd spacing?
ascites
burn edema
Electrolyte Cations
sodium
potassium
calcium
Electrolyte Anions
bicarbonate
chloride
phosphate
What are the different types of fluid regulators?
osmosis and osmolarity
diffusion
filtration
sodium-potassium pump
Osmosis
spontaneous passage of water or other solvents through a permeable membrane
Diffusion
from higher to lower concentration
Filtration
high pressure to lower pressure
Sodium-Potassium Pump
maintains normal sodium levels by active transport
Output
kidney
Skin(1L an hour)
Lungs
GI Tract (100-200mL)
Sodium does what
SUCKS
What is the primary regulator of body fluid?
sodium
Where sodium goes
water flows
What is the major electrolyte in ECF?
sodium
If sodium is low, then serum osmolality is
low
visa versa
Lab Value of NA
135-145
If you have a decrease in serum Na, the ECF becomes
dilutes
H2O drawn into cells
If you have an increase in serum Na, the ECF becomes
concentrated ECF
H2O pulled out of the cells
When NA moves into cells, it kicks what out
K
When serum sodium increases and ECF becomes concentrated, what is stimulated?
Thirst by hypothalamus
Thirst stimulates ________ released from the pituitary gland.
ADH
What does ADH do to the kidneys?
conserve water
The adrenal gland releases
aldosterone
in which the kidneys conserve water and sodium
Increases ECF
Sodium is followed by
chloride and water
Chloride functions
maintains electrical neutrality
osmotic gradient
I&O OF Na
Intake = diet
Outtake = kidneys
Function of Na
-electrochemical state of muscle contraction and nerve impulses
BP (ECF vol and encloses water distribution with chloride - affects the concentration and absorption of K and Cl)
Blood volume
PH balance
Na is regulated by
ADH
Thirst
Aldosterone (RAAS)
Sodium Potassium Pump
ADH is also known as what drug
vasopressin
ADH does what
controls water retention
Aldosterone
hold Na inside the body by blocking it at the kidney
- causes kidneys to maintain water and sodium to keep BP up
- releases if sodium is low and K is high (to excretion K)
Sodium and Potassium Pump
moves NA out of the cells via ATP
-provides energy through muscle and energy and removes acid
Sodium and Potassium Pump uses what to move Na out
ATP
HYPONATREMIA Causes (NO Na)
-Na excretion with renal problems, NG suction, vomiting, diuretics, sweating, diarrhea,
- a decrease of aldosterone secretion (fluid stays)
-Overload of fluid (Congestive Heart Failure, renal failure, hypotonic fluid infusion)
-Na intake is low (low salt diet, NPO)
-Antidiuretic hormone (SIADH)
Hyponatremia s/s depend on the _____, ______,and _____ at which deficit occurs
cause
magneitude
speed
What mnemonic is used as Hyponatremia S/S?
SALT LOSS
Hyponatremia S/S
SALT LOSS
Seizures and stupor
Abdominal cramping, attitude confusion
Lethargic
Tendon reflexes diminished, and trouble concentrating
Low urine and appetite
Orthostatic hypotension, overactive bs
Shallow respirations (late due to skeletal weakness)
Spasms of muscles
Is your hyponatremic pt a fall risk
yes, confusion = fall risk
Hyponatremia lab values
Low Labs
Serum Na+ < 135 mEq/L
Serum osmolality < 280 mOsm/kg
Urinary Na+ < 20 mEq/L
Urine specific gravity < 1.010
Treatment of Hyponatremia
- watch for?
Na replacement (PO, NGT, IV)
Depends on the rate of loss (LR, NS)
- Watch for fluid overload/pulmonary edema
If a nurse is giving sodium to a hyponatremic pt too quickly, what should you watch out for?
neurological damage
-cerebral edema
Rule of Thumb for NA replacement
serum Na must not be increased greater than 12 mEq/L in 24 hours
What solutions are used to tx as Hyponatremia?
Lactate Ringers
Normal Saline
Medical Tx for hyponatremia due to water gain
GOAL: slowly elevate Na until seizures, lethargic, stupor are gone
restrict fluids safer than giving Na
hypertonic solution 3-5% NaCl (if neuro problem - give small amounts)
edema only - restrict Na
edema and Na - restrict both
Loop Diuretics (Lasix) with IV fluids
Loop diuretics induce isotonic diuresis w/o further
hyponatremia
Nursing Interventions for Hyponatremia
Identify pt. at risk (Lithium pts)
Monitor labs, I&O, daily weight
Review medications
GI manifestations
Monitor for S/S of hyponatremia
Monitor for neurological changes
Oral hygiene (restrict fluids)
If a pt is at risk of a seizure, what are some precautions that need to be taken?
fall precaution
mats
Suction
Lithium patients with low Na can cause them to go into
lithium toxicity with urinary sodium loss
HYPERnatremia lab values
greater than 145
Hypernatremia ____ fluid _____ of the cells
pulls fluid out
Primary protection of Hypernatremia
Thirst
HYPERnatremia mnemonic
HIGH SALT
HIGH SALT
HYPERnatremia Causes
Hypercortisolism (Cushing’s, hyperventilation)
Increased intake of sodium
GI feeding w/o adequate water supplements
Hypertonic solutions (Na is more than isotonic
Sodium excretion decreased and corticosteroids
Aldosteronism
Loss of fluids (infection, sweating, diarrhea, DI)
Thirst impairment
Hypernatremia S/S
mnemonic
No FRIED foods for you!
Hypernatremia S/S
-Neuro-
Fever, flushed skin
Restless, really agitated
Increased fluid retention
Edema, extremely confused
Decreased urine output, dry mouth/skin
Hypernatremia lab value
High Numbers
Serum Na+ > 145 mEq/L
Serum osmolality > 300 mOsm/L
Urine specific gravity > 1.015
Hypernatremia Treatment
decrease Na gradually
decrease 0.5-1 L/ hr over 48 hours
Monitor for neuro changes and cerebral edema
Hypotonic solutions (D5W or 1/2 NS)
Desmopressin for DI
What medication would you use to treat hypernatremia if the underlying factor is DI?
Desmopressin
Nursing Interventions for Hypernatremia
Identify pt at risk (ELDERLY and INFANTS, confused, trauma, post-op, burn, immobile)
Monitor fluid loss/gain
Daily wt
Labs
ORAL Na Intake(processed, canned, frozen)
Neuro precautions and behavior changes
Offer fluids
Note medication with high Na+ content
What medications have high Na content?
Alka-seltzer
Pathway of Potassium
Intake: diet
Absorbed: Kidneys
Excreted: kidneys/bowels
Normal lab values Potassium
3.5-5
Potassium functions
skeletal and cardiac muscle activity
Sodium/Potassium Pump
What is the major electrolyte of intracellular fluid?
Potassium
- it can be found in ECF
How is K obtained? absorbed? and excreted?
diet
intestines
kidneys/bowels
What meds could affect K?
diuretics
laxatives
antibiotics
parental nutrition
chemo
Potassium enriched foods
Bananas
Watermelon
White beans
Spinach
Avocado
Sweet potatoes
What percentage of K is excreted by the kidneys?
80
Does the body conserve K?
no even with a deficit
What system is important in keeping balanced potassium?
renal
body does not conserve potassium
Hypokalemia Causes mnemonic
Body is going to DITCH potassium
Hypokalemia Causes
Drugs (diuretics, laxatives, insulin, corticosteroids)
Inadequate consumption of K
Too much water intake (IV fluids w/o K)
Cushing’s syndrome
Heady fluid loss (GI, V/D, SUCTION)
What is the number 1 reason of hyperkalemia?
renal failure
Cushing’s disease
tumor on the pituitary gland makes too much ACTH. In response, adrenal glands produce too much cortisol. This causes problems with your body’s hormone balance.
What drugs cause hypokalemia?
diuretics
laxatives
insulin
corticosteroids
Hypokalemia S/S mnemonic
SLOW
LOW
Hypokalemia S/S
SLOW/LOW
Weak, irregular pulses
Orthostatic hypotension
Arrhythmias
Shallow respirations
Confusion, weak
Deep tendon reflexes decreased
Decreased bowel sounds
Lethargy (confusion)
Low, shallow respirations
Lethal cardiac dysrhythmias
Lots of urine
Leg** cramps**
Limp muscles
Low BP & Heart
Renal loss of K
loop diuretics with potassium
hyperaldosteronism
high dose of sodium PCNs
large dose corticosteroids
Digoxin does what to the heart
contracts
Hypokalemia at risk pts
elderly
Hypokalemia
-Cardiac Changes-
low strength of contraction
Myocardium irritability extra beats
ST segment depression
K+ < 2.7 mEq/L may result in PACs, PVC’s, V-fib or cardiac arrest
K+ < 3.5 assoc. with met. alkalosis, high pH & high HCO3
Digoxin toxicity
Digoxin and low K do together
potentiate
so best not to usually give buth meds
Hypokalemia lab values
K+ deficit < 3.5 mEq/L
K+ < 3.5mEq/L often assoc. with metabolic alkalosis, high pH, & high HCO3
K+ < 2.7 may result in dangerous dysrhythmias
high pH & HCO3
Hypokalemia Treatment
K replacement (PO/IV)
Increase on a daily basis (40-80 a day)
at-risk pt (50-100 a day)
potassium-rich foods
treat underlying cause
Oral K Supplements
minimize GI irritation
- dilute liquid and effervescent supplement
- give tabs and caps q/ 8 oz water
- give K with food
Adverse reactions of K oral supplements
N/V/D
GI bleed
IV K supplements
Must be diluted
Check K before giving K
NOT Direct IVP
Max. dose is 60 mEq at a time
Must use IV pump
Monitor renal output, site
Telemtery
Nursing Interventions of Hypokalemia
Identify pt at risk – esp. if on Digoxin
Monitor ECG & BP (LETHAL DYSRRHYTHMIAS)
Monitor serum K+
Pt education – diuretics & laxatives
Administer K+ supplements PO or IV
increase dietary K+
Monitor urine output
Digoxin __________ K
potentiates
Hyperkalemia Causes mnemonic
CARED (treatment induced)
When looking at fluid in our body, what are we looking to measure with?
Daily weight
Which potassium disorder is the most dangerous? Why?
Hyperkalemia
- cardiac arrest
Hyperkalemia Causes
Cellular mvmt
Adrenal insufficiency with Addison’s disease
Renal failure
Excessive potassium intake
Drugs
What part of the body does sodium affect the most?
brain (swelling)
How can cellular mvmt cause Hyperkalemia
burns, chemo
the cells die and K are released
Addison’s disease
adrenal insufficiency
Na lost and K released
What drugs can cause Hyperkalemia?
ACE inhibitors
NSAIDs
Beta-blockers
- increase aldosterone
Hyperkalemia S/S mnemonic
Muscle weakness
Urine production is little/none
Respiratory failure
Decrease cardiac contractibility
Early signs of muscle twitches/cramps
Rhythm changes
-telemetry
Hyperkalemia cardiac changes
Slows heart rate
ECG changes
Risk for Heart Block, A-fib, or, V-fib
Severe high K+
Decreased heart contraction strength
Dilated & flaccid heart
Hyperkalemia lab value
Serum potassium > 5.3 mEq/L
ECG abnormalities
ABG – low pH indicating acidosis
Hyperkalemia treatment
restrict diet
stop k containing meds
monitor for digitalis toxicity
cation exchanging resins
dialysis (if absolutely needed)
Meds containing K
ACE inhibitors
NSAIDS
Beta Blockers
Kayexalate aka
Polystyrene sulfonate
Kayexalate is a
laxative binding to K and releases in the stool
If a patient has a digestive issue, would they be able to take Kayexalate?
no
Emergency med tx Hyperkalemia
Ca Gluconate - IV
Hypertonic Glucose and Insulin
Sodium Bicarbonate
Ca Gluconate - IV
not lower K
protects the heart allowing others to work
monitor ECG and telemetry
How long do you give Ca Gluconate?
over 3 mins
If the pt has bradycardia, do you stop Ca Gluconate?
Yes
Hypertonic Glucose and Insulin
Insulin - puts K into cells
Glucose - high insulin release from the pancreas
not for diabetics
What med do you give with glucose and insulin?
albuterol (shifts K into the cells)
- they won’t feel good and fall risk
- fast hr and shakes
Sodium Bicarbonate moves
into the cells temporarily
Nursing Interventions of Hyperkalemia
Be aware of pt at risk
Monitor for:
-Generalized weakness & dysrhythmias
-Irritability & GI symptoms
-Nausea & intestinal colic
ECG or lab abnormalities
Prevention of hyperkalemia
Educate pt: medication & diet
Do NOT draw blood above K+ infusion
When should you check K after giving it?
2 hours
During dialysis, what happens to the BP?
BP lowers
-so don’t give BP lowering meds
Why should aldactone (potassium-sparing diuretics) not be given to renal pts?
potassium in sodium substitutes
Magnesium is absorbed and excreted by
GI Tract
Kidneys
Mg Normal values
1.5-2.5 mg/dL
Mg critical values
<1.2 or > 4.9
Potassium and Magnesium are
best friends
Mg functions
Regulating Muscle and nerve function
Blood Sugar levels
Immune System
Mg is needed for what system
cardiac (arrhythmias)
Mg stimulates what hormone to regulate what
parathyroid hormone
regulates Ca
Hypomagnesemia is often associated with
hypokalemia
Low Mg makes low K resistant to treatment
Keep cardiac pt at 2.0
Hypomagnesemia S/S
Tight airway
–Stridor, laryngospasm, difficulty swallowing–
Hyperflexion-Muscle twitching
N/V/D
(increased brain activity)
Irritability, insomnia, confusion, seizure
Increased BP and HR
Hypomagnesemia Causes
Mg absorbed in the intestine*
Renal loss
Chronic alcoholism (Most common)
Antibiotics
GI Loss (N/V/D)
Malabsorption (Crohn’s, celiac disease)
Nursing Interventions for Mg
Safety with swallowing
-THICK LIQUIDS, sit up and awake, tuck chin down
IV Mg sulfate (give slowly)
monitor respiratory status and reflexes
Food Rich in Mg
DARK Chocolate
Avocados
Milk
Peas
Peanut butter
Oranges
Nuts
Bananas
Hypermagnesemia Causes
Antiacids
Renal Failure
Potassium Excess
Hypermagnesemia Nursing Interventions
Hemodialysis
IV Calcium Gluconate
Monitor Labs
Hypermagnesemia S/S
Heart- calm and quiet
-Low and shallow Respirations
-Bradycardia
-Hypotension
Lung
-Low and shallow Respirations
GI
-Hypoactive Bowel Sounds
Neuro
-Drowsiness, lethargy
MS
-Weakness
Calcium (total) lab normal value
8.4-11
What percentage of Calcium is stored in bones and teeth?
99%
What are the 3 functions of Calcium in the body?
Bones and teeth- forms
Blood - clots blood
Beats - squeezing and relaxing for muscles (keep normal beats)
What are the 3 forms of Calcium?
Bound
Ionized
Complexed
Bounded Calcium is bounded to
proteins - albumin (less than 50%)
Ionized Calcium is found in
serum
What type of Calcium is most important?
ionized
What percentage of calcium is ionized?
50
Children have _____ level of serum Ca than elderly.
higher
bc of bone growth
Complexed Calcium is combined with
nonprotein anions
-Phosphate
-Citrate
-Carbonate
Ionized Calcium functions
activate body chemical reaction
muscle contractions and relaxations
promote transmission of nerve impulse
cardiac contractility and automaticity
formulation of prothrombin
Ionized Ca carries out
most of the functions
What relationship do albumin and Calcium have?
same
low = low
high = high
Calcium and Phosphorus relationship
inverse
Low Cal = High P
High Cal = Low P
Parathyroid Hormone does what to Calcium
pulls Calcium out of the bones and into blood plasma for absorption through GI and renal
When Calcium is low, this regulator “pulls” Ca and phosphorus from the bone.
Parathyroid Hormone
What are the Calcium regulators?
Parathyroid Hormone
Calcitonin
Phosphate
Vitamin D
Calcitonin is secreted by the
thyroid
Calcitonin has a ________ relationship with PTH
ANTAGONIST
When Calcium is too high, this hormone is secreted from the thyroid to “keep” Ca.
Calcitonin
-tones down Ca-
When is Calcitonin secreted?
high serum Ca
What is the function of Calcitonin?
inhibits Ca reabsorption from bone
“keeps” Ca in the bone
Phosphate has what relationship with Calcium?
inverse
high Calcium = low Phosphate
What does Phosphate do as a Ca regulator?
inhibits Ca reabsorption in the intestines
Vitamin D is necessary for what in relation to Calcium?
absorption and utilization of Ca
What foods are rich in Vitamin D?
mushrooms
egg yolk
fatty fish
tuna
spinach
safe sun exposure
Hypocalcemia Causes mnemonic
LOW CAL
Hypocalcemia Causes
Low PTH (no regulation from surgery)
Oral intake inadequate (alcoholism and bulimia)
Wound drainage (low absorption)
Celiac, Crohn’s (malabsorption)
and corticosteroids (increase the bone breakdown and body unable to absorb)
Acute pancreatitis (low PTH secretion)
Low Vitamin D (no absorption)
High doses of steroids cause
osteoporosis
Hypocalcemia S/S mnemonic
CRAMPS
Hypocalcemia S/S
Confusion
Reflexes hyperactive
Arrhythmias (cardiac floor)
Muscle spasms (tetany, seizures)
- mouth and fingertips
Positive Trousseau’s
Signs of Chvosteks (facial)
Trousseau’s
hand spasm when BP is taken due to the low blood supply and pressure on nerve
-increase in systolic BP
Chvostek’s
facial nerve spasm
tap facial nerve anterior to ear lobe below zygomatic process
Hypocalcemia - Cardiac effects
dysrhythmias
torsades de pointe
decrease cardiac contractibility
decrease sensitivity to Digoxin
Torsades de pointe
ventricular tachycardia by hypocalcemia
arrhythmias
Low serum calcium (hypocalcemia) = _______ albumin
low
What hormone levels can affect Ca?
Parathyroid Hormone
What levels should be obtained along with Calcium?
Mg
Phosphorus
What is the purpose of IV Therapy?
Provide
-H2O
-Electrolyte
-Nutrients
Replace deficits
Administer meds and blood
TPN, dysphagia
Emergency situations
TPN can only go through
Central line
Advantage of IV Therapy
emergency access
administration route when PO is not available
continuous fluids
control over rate
Disadvantages of IV Therapy
damage
fluid overload
overdose
infections
immobility
incompatibility
adverse reactions
electrolyte imbalance
If a pt has an allergic reaction to an IV medication, what should you do?
Stop infusion
Call infusion
Get help
When assessing an IV, what do you do?
check patency, wear gloves
signs of infection
check rate and med, allergies and compatibility
What are the signs of an infection?
fever
tenderness
redness
respirations increase
swelling
Hypovolemia AKA
dehydration
deficient in fluid
When do you change an IV?
48 hours
PRN
Hypovolemia leads to
hypovolemic shock
Hypovolemia Causes
loss of fluid from anywhere
-Thoracentesis/Paracentesis
-hemorrhage/bleeding
-NG Tube
-Trauma
-n/v
-severe dehydration
-conditions causing polyuria
-diuretics
-3rd spacing (burns and ascites)
Hypovolemia via polyuria diseases
Diabetes
Diabetes Insipidus
Diuretics
3rd Spacing is when
fluid shifts from intravascular to the interstitial
Hypovolemia S/S
DECREASE WT
increase hr (thready)
Low BP, urine output, and CVP
dark concentrated urine
increase respiration rate
Tenting skin
Thirst and dry mouth**
flat neck veins
What is a severe symptom of hypovolemia?
HR increases by compensating
When remembering BP and Volemia (hypo and hyper), what do you need to know?
Low volume = low pressure
High volume = High pressure
Hypovolemia Labs
concentrated
= higher numbers of serum osmolality, specific gravity, hematocrit, serum sodium, and BUN
Hypovolemia Treatment
Replace fluid (PO or IV)
- Monitor for Fluid overload
Orthostatic hypotension safety precautions
- rise slowly when standing
Daily wt and I&Os
Hypervolemia AKA
OVERHYDRATION
excess
Hypervolemia Causes
Heart failure
kidney dysfunction
cirrhosis
increase sodium intake
Hypervolemia is more common in
elderly pts
Hypervolemia S/S
daily wt gain
increase HR (BOUNDING)
increase BP, CVP, URINE (polyuria)
wet lung sounds
edema
distended neck veins JVD
When should a pt be concerned with gaining weight and contact a doctor?
increase of 2 lbs a day
5 lbs a week
Hypervolemia Labs
diluted
low values
Hypervolemia Tx
low sodium diet
Daily I&O and Wt
Monitor V/S and assess respiratory rate
Diuretics
High-Semi-Fowler’s position (relieve lungs)
What are the different crystalloids in IV Solutions?
isotonic
hypotonic
hypertonic
What 3 things determine the type of IV solution given to the pt?
condition
diagnosis
lab values
Aquaporin channels
allow water molecules to pass through cell membranes without using energy
Diffusion
movement of particles from higher to lower concentration
Hypertonic
higher concentration of salt
water rushes out of the cell
cell shrinks - plasmolysis
Hypotonic
very watery
water goes into the cell and attaches to NaCl
cell swells and possible cytolysis
Isotonic
stays the same dynamic equilibrium
The osmolality of the blood
the concentration of all chemical particles found in the intravascular/fluid part of the blood
Osmolality primarily reflects concentration of:
sodium
BUN
glucose
What relationship does sodium have with osmolality?
direct (low = low)
What is the normal value of osmolality?
280-300
Factors Increasing Osmolality
dehydration (concentration of Na)
free water loss
DI (polyuria)
Hypernatremia
Hyperglycemia
Stroke from a head injury
Renal Tubular necrosis (kidney’s dead)
Factors Decreasing Osmolality
fluid vol excess
SIADH
Renal failure
Hyponatremia
Overhydration
Isotonic Solutions are given to
replace fluid loss
Isotonic Solutions osmolality
similar to ECF
280-300
T/F: Isotonic Solutions DO cause RBCs to shrink or swell.
False, they do not.
Isotonic Solutions are given through IV where does it go?
stays in the intravascular system
Isotonic Solutions
D5W (changes to hypotonic)
NS
LR
D5W contains
water and glucose
How does D5W change from isotonic to hypotonic?
isotonic outside the body but once infused dextrose is rapidly metabolized, then the water becomes hypotonic
What isotonic solution do we need to use caution with for diabetics, hypernatremia, and head trauma pts?
D5W
cause hyperglycemia bc dextrose
cause hypotonic after sugar is used and cause cells to swell (cerebral edema)
Can you reverse cerebral edema?
no
D5W is primarily used to treat
hypernatremia
BUT use it with caution
If too much D5W goes into the cells, then what is your first sign of swelling?
decrease LOC
NS is used to correct
correct extracellular volume deficit
- hypovolemia
- resuscitative efforts
- shock
-metabolic alkalosis
- hypercalcemia
- hyponatremia
Does NS have calories?
no
What is the only solution that can be given with NS?
blood
NS replaces large amounts of sodium ___________
losses
NS is not used/cautioned for what pts?
CHF
Pulmonary edema
renal impairment
trauma
If at-risk pts, start having crackles in the lungs, dyspnea, and anxiety, then what should the nurse do?
stop infusion
sit up
O2
dr notification
- let pt know and try to decrease anxiety
possible diuretics given
LR contains what electrolytes?
potassium
calcium
sodium chloride
LR is used to correct
dehydration
sodium loss
GI loss (vomiting, diarrhea)
LR should be used with caution with what pts
CHF
Renal insufficiency
edema
sodium retention
hyperkalemia
Hypotonic Solutions osmolairty
less than 280
-depletes ECF
Hypotonic _________ ECF
DILUTES
lowering serum osmolality
Hypotonic solutions are used for
hypernatremia
(not for fluid replacement)
If hypotonic solutions are given for too long,
cells swell to a cerebral edema
Hypotonic solutions _______ BP
lower
Hypotonic solutions types
lower amounts or fractions
Hypotonic fluid shifts such as
intravascular fluid depletion
low BP
cerebral edema
What patients are at risk of worsening hypotension if given hypotonic fluid? Select all that apply.
ICP
CVA
Head trauma
Burns
Malnutrition
Liver disease
All of the above.
ICP
CVA
Head trauma
Burns
Malnutrition
Liver disease
Hypertonic solutions osmolality
greater than 300
- water to move out of the cells
Hypertonic solutions are given to
decrease risk of edema
stabilize BP
regulate urine output
-repair electrolytes and acid/base imbalances
-TPN
Hypertonic solutions are usually given through a
Central line
Hypertonic solutions are used to with caution in patients with
diabetes
impaired heart and kidney function
What should be closely monitored for hypertonic solutions?
circulatory overload
Hypertonic solution types are
high numbers
Colloids are
large molecules not dissolved and can’t pass through membrane
- volume expansion
Primary reason for colloids
pull fluid into the bloodstream
What is given after dialysis to stabilize BP?
albumin
What is the most common colloid given?
albumin
Dextran
plasma vol expander
Hetastarch
synthetic vol expander
Mannitol
alcohol sugar (usually neuro)
Albumin pulls what into the blood vessels
salt and water
- to not leak out fluid from intravascular to maintain BP
If you have a pt who came back from a Paracentesis, which they drained 3L of fluid from, what is their expected BP going to be? What would the nurse expect to be given or prescribed to the pt?
low
-Albumin (to stabilize BP)
Albumin carries what throughout the body
hormones
vitamins
enzymes
What should be monitored when giving patients an infusion of colloids?
increase in BP
Dyspnea
bounding pulse
fluid overload (JVD, high BP, resp distress)
anaphylaxis
I&O, wt, v/s
What electrolytes need to be monitored on albumin?
potassium
sodium
Phlebitis
inflammation of vein
Causes of phlebitis
poor asepsis
high osmolality infusion
improperly diluted meds
incorrect gauge
too rapid infusion
S/S of phlebitis and thrombophlebitis
tenderness
redness
heat
edema
Prevention of phlebitis and thrombophlebitis
rotate site
dilute properly
slow infusion
aseptic
Intervention of phlebitis and thrombophlebitis
stop infusion
remove
apply warm compress
How long can an IV stay in place
48 hours
PRN
Thrombophlebitis
formation of clots and inflammation in the vein
- occurs after phlebitis
Causes of thrombophlebitis
injury to vein
infection
chemical irritation
prolonged use of the same vein
Infection
pathogen in surrounding tissue of IV site
Causes of infection
lack of aseptic
loose or contaminated dressing
prolonged use of vein
S/S of infection
redness
tenderness
swelling
edema
Air embolism
air entering the vein becomes trapped in the blood as it flows
- rate of entry very important
Causes of air embolism
solution runs dry
improper priming
loose connections
poor technique in dressing, tubing, and removal of central lines
How do you remove Central lines?
left reverse Trendelenburg
hold for 5 mins
S/S of air embolism
dyspnea, unequal breath sounds
cyanosis
hypotension
weak, rapid pulse
LOC
chest, shoulder, low back pain
shock
death
Air embolism Tx
stop infusion and clamp
call for help
left Trendelenburg
O2
V/S
emergency equipment ready
Speed shock
systemic reaction when med is rapidly introduced into circulation
-caused by too rapid infusion
S/S of speed shock
dizzy
face flushing
HA
hypotension
chest tightness
irregular pulse
shock progress
Prevention of speed shock
correct rate
pump
close monitor
What fluid shifting is abnormal?
3rd spacing
K lower than 2.7 may result in what happens to the heart
V-fib
cardiac arrest
Hypocalcemia Tx
10% Ca Gluconate (severe symptoms)
Ca-Chloride (never IM)
Oral Ca (antacids and dairy and vit D)
With acute symptomatic hypocalcemia, what should the nurse do?
EMERGENCY
-requires prompt admin. of IV Calcium
With IV Calcium, what needs to be watched closely and why?
IV site
Infiltration
- cause necrosis and sloughing
Rapid infusion of Calcium can cause what complications?
bradycardia leading to cardiac arrest
Calcium does what to the BP of a patient and what risk might they be placed on?
Posterior hypotension
- Fall risk - stay in bed
Nursing Interventions of Hypocalcemia?
At risk?
- At risk = parathyroid surgery/injury
seizure precautions if severe low
monitor airway and telemetry
Educate- Calcium rich diet
HYPERcalcemia Causes mnemonic
HIGHCAL
HYPERcalcemia Causes
Hyperparathyroidism and cancer
Increased Ca intake
Glucocorticoid usage (increase CA excretion = increase PTH and increase bone reabsorption)
Hyperthyroidism
Calcium excretion** w/ thiazide diuretics** (potentiates and raises PTH)
Adrenal insufficiency (Addison’s)
Lithium (affects parathyroid)
-prolonged immobilization
HYPERcalcemia S/S mnemonic
WEAAAK
HYPERcalcemia S/S
Weakness of muscles
EKG changes (slows heart rate)
Absent reflexes, mind (disoriented)
Abdominal distension (constipation)
Kidney stones
HYPERcalcemia - Cardiac
stimulates contractibility and lowers heart rate
Arrthymias lead to cardiac arrest
potentiate digoxin toxicity
Digoxin and Calcium do what with each other?
potentiate
- worry about K in the blood with these
Digoxin toxicity
confused
vision changes
irregular hr
loss of appetite
Hypercalcemia Labs
greater than 11
dysrrthymias
PTH high
Xray osteoporosis
Urine
Hypercalcemia Tx
treat underlying cause
Dilute serum Ca with NS
Loop Diuretics - Lasix
IV Phosphate - inverse relations
Calcitonin
Glucocorticoids - inhibit reabsorb
Hemodialysis
What drug is safe to give HYpercalcemia pts with heart or renal issues too?
Calcitronin
Hypercalcemia Nursing Interventions
-at risk
- AT risk =
Increase activity and fluids
lower Ca intake
Confusion safety
Monitor EKG, I&O, breath sounds
Dig toxicity
Prevent kidney stones
Phosphorus lab normal
2.5-4.5
High Calcium =
low phosphate
-cardiac and neuromuscular problems
Phosphorus is mainly found in the
teeth and bones like Ca
Functions of Phosphorus
bone and teeth form
repair cell tissues and energy
nervous system
muscle function
Phosphorus is regulated by
parathyroid
and calcitriol
Phosphorus is high in foods
dairy
meats and beans
Hypophosphatemia Causes
Malnutrition/starvation - most common
Increased Phosphorous excretion
Hyperparathyroidism (Calcium increases: Phos drops)
Malignancy
Diuretics/Diarrhea
Use of magnesium/aluminum antacids (Increases Ca, depletes phos)
Hypophosphatemia S/S
SAME AS HYPERCALCEMIA
Cardio: Decreased BP/HR**
GI: hypoactive Bowel sounds**
GU: Kidney stones**
NEURO: Altered LOC**
MUSC: Severe muscle weakness**
Bone pain/fractures
Hypophosphatemia Interventions
replace Phosphorus IV/PO
give slow
PO with Vitamin D
Fracture precautions
Hyperphosphatemia Causes
Increased Phosphorus intake
Overuse of laxatives-elderly
Renal insufficiency= Decreased excretion
Hyperparathyroidism
Hypocalcemia
Hyperphosphatemia
Diarrhea
Hyperactive bowel sounds
Positive Trousseau’s/Chvostek’s
Painful muscle spasms
Hyperactive Deep tendon reflexes
Irritable skeletal muscles –twitches, tetany, seizures
Osteoporosis
Hyperphosphatemia Interventions
Replace Calcium (IV/PO)
IV Calcium gluconate 10% (Monitor BP, HR)
Vitamin D when giving PO
Aluminum Hydroxide (Tums)*
Initiate seizure precautions
Move pt carefully
Educate on calcium-rich foods
dairy
Thyroid inflammation is known as a
goiter
SIADH
retain too much water
leads to hyponatremia
DI
BODY MAKES TOO MUCH URINE (20qts/day)
-polyuria
hypernatremia
Potassium can go through ________ __ but you prefer a central line
peripheral IV (slowly - 10 mEq)
