Nutritional support and Fluid& electrolyte imbalance

Question 1

Nutrition labs

Answer 1

albumin levels of < 3.35 indicate protein malnutrition: edema can be expected if albumin level is < 2.7

hgb < 12 for women and < 13 for men can indicate lack of iron or protein resulting in inadequate oxygen profusion

Question 2

earliest indication of malnutrition

Answer 2

prealbumin

Question 3

when do you transfuse?

Answer 3

8 and 24

Question 4

when a person gets 2 units how does it affect hgb and htc

Answer 4

1:3 is the ration of hgb to htc

1 unit of pRBC: hgb goe sup 1 then hematocrit goes up 3

Question 5

IF cannot use the GI tract

diverticulitis, perf diverticula etc

Answer 5

Parenteral Nutrition

support greater than 2 weeks or using dextrose solution > 10% then need central vein

otherwise can use peripheral

Question 6

IF can use GI tract and need support greater than 6 weeks (brain injury, closed head injury)

Answer 6

Enterostomal tube (PEG tube)

Question 7

If cannot use GI tract and need support less than 6 weeks then use:

Answer 7

nasoenteric tube (ND- duotube)

risk for aspiration: duodenal tube
not risk for aspiration: NG tube

Question 8

Complications of enteral nutrtional support

enteral is the solution

Answer 8

Aspiration
diarrhea
emesis
gi bleeding
mechanical obstruction of tube
hypernatremia**
dehydration**

Question 9

complications of parenteral nutritional support

parenteral is mode of delivery

Answer 9

pneumothorax
hemothorax
arterial laceration
air emboli
catheter thrombosis
catheter sepsis
hyperglycemia**
HHNK**

Question 10

evaluation of hyponatremia

Answer 10

• urine Na (10-20)
• serum osmolality (usually 2x Na)
• clinical status

Question 11

what does measuring urine Na help distinguish?

Answer 11

renal from non-renal causes.

Question 12

what does a urine Na > 20 suggest?

Answer 12

renal salt waisting (problem with the kidneys)

Question 13

what does a urine Na < 10 suggest?

Answer 13

renal retention of Na to compensate for extrarenal fluid loss (problem other than the kidneys)

Question 14

Isotonic hyponatremia

Answer 14

• occurs with extreme hyperlipidemia or hyperproteinemia
• body water is normal and the patients are asymptomatic
• tx: cut down fat (no fluid restriction***)

pseudeohyponatremia: serum osmo 284-292

Question 15

what does isotonic mean

Answer 15

• of equal tension
• having the same tonicity as another solution
• a solution that causes no change in cell volume (don’t swell or shrink)

Question 16

hypotonic

Answer 16

a fluid in which cells would swell

• having a lesser osmotic pressure than a reference solution
• low tonicity

Question 17

hypotonic Hyponatremia

Answer 17

-serum osmo < 280: state of body water excess diluting all body fluids; clinical signs rise from water excess

Question 18

what do you need to do in a patient with hypotonic hyponatremia?

Answer 18

need to assess if the patients is hypovolemic or hypervolemic
-if hypovolemic, assess whether hyponatremia is due to extrarenal salt losses or renal salt wasting

Question 19

how does someone end up hypovolemic with urine Na < 10

Answer 19

• dehydration
• diarrhea
• vomiting (NG tube suctioning-prolonged)

Question 20

what are causes of hypovolmia with urine Na > 20

Answer 20

• low volume and kidneys cannot conserve Na
• diuretics**
• ace inhibitors
• mineralcorticoid deficiency (adrenal insuficiency)

Question 21

What are causes of hypervolemic, hypotonic hyponatremia

Answer 21

-edematous states
chf
liver dz
advanced renal failure

Question 22

what do you do with Hypervolemic, hypotonic (serum osmo < 280) hyponatremia

Answer 22

restrict water

Question 23

Hypertonic solution examples

Answer 23

D10
saline 3%-5% NS or NaCl
D5
D5 0.9%
D5 0.45%
5% dextrose in lactated Ringer's

Question 24

Isotonic solutions

Answer 24

D5W
0.9%NS
D5 1/4 NS
Lactated Ringer’s

Question 25

Hypotonic solutions

Answer 25

0. 45% NS | 0. 33% NS

Question 26

how do hypertonic solutions work

Answer 26

-pull solution into vascular space by osmosis that can result in increased vascular volume that can result in pulmonary edema, particularly in patients who have cardiac or renal dz -

Question 27

How do isotonic solutions work

Answer 27

used to replace fluid losses, usually extracellular lossses and to expand the intravascular volume. Most isotonic solutions do not provide calories or free water 0.9% NS and lactated ringers

Question 28

how do hypotonic solutions work

Answer 28

administered to expand intracellular space - commonly used to infused to dilute extracellular fluid and rehydrate cells of pts who have hypertonic fluid imbalances and to tx gastric fluid loss and dehydration from excessive diuresis. - provides free water, Na, Cl 0. 45% NS or 1/2 NS

Question 29

when are hypertonic solutions used?

Answer 29

tx pts who have severe hyponatremia

Question 30

Hypertonic hyponatremia

Answer 30

(serum osmo > 290) - hyperglycemia: usually fron HHNK*** - Osmolality is high and the Na is low

Question 31

Management of hyponatremia

Answer 31

tx based on cause - if hypovolemic give NS IV - if urine Na > 20, treat cause - if hypervolemic implement water restriction - if symptomatic give NS with a loop diuretic - if CNS symptoms consider 3% NS with loop diuretics

Question 32

Hypernatremia

Answer 32

usually d/t excess water loss; always indicates hyperosmolality (ie., deficit of water)

Question 33

Management of Hypernatremia | with hypovolemia

Answer 33

-severe hypermatremia with hypovolemia should be treated with NS followed by 1/2 NS

Question 34

Management of hypernatremia with euvolemia

Answer 34

free water (D5W-isotonic)

Question 35

Management of hypernatremia with hypervolemia

Answer 35

- free water and loop diuretics | - may need dialysis

Question 36

Hypokalemia causes

Answer 36

``` -diuretics*** GI loss excess renal loss alkalosis laxative abuse trauma (via epi) insulin excess hyperaldosteronism Cushing's renin-producing tumor ```

Question 37

S&S Hypokalmeia

Answer 37

- muscular weakness, fatigue and -muscle cramps*** - constipation or ileus due to smooth muscle involvement - if severe (< 2.5) flaccid paralysis, tetany, hyporeflexia and rhabdo

Question 38

Labs and diagnostics hypokalemia

Answer 38

- decreased amplitude on ecg - broad T waves - prominent U waves - PVCs, V-tach, V-fib

Question 39

management of hypokalemia

Answer 39

oral replacement if > 2.5 and no ecg abnormalities - IV replacement at 10 if cannot take PO - if < 2.5 or severe S/S may give 40 meq/hr IV- check 3 hours and institute continuous ecg monitoring

Question 40

Hyperkalemia

Answer 40

-excess intake -renal failure -drugs (NSAIDS) hypoaldosteronism -shifts of intracellular K to extracellular space occur with acidosis. K increases 0.7 meq/L with each 0.1 drop in pH

Question 41

Hyperkalemia S/S

Answer 41

- weakness, flaccid paralysis - abd distention - diarrhea

Question 42

Hyperkalemia mngt

Answer 42

``` exchange resins (kayexelate) - if> 6.5 or cardiac toxicity or muscle paralysis consider: insulin 10 u with 1 amp D50 ```

Question 43

Calcium

Answer 43

a major cellular ion and impt as a mediator of neuromuscular and cardiac function. normal total calcium of 2.2-2.6mmol/L (8.5-10.5 mg/dl) normal ionized calcium of 1.1-1.4 mmol/L

Question 44

what is calcium maintained by?

Answer 44

Vitamin D, parathyroid hormone and calcitonin

Question 45

what increases and decreases ionized calcium

Answer 45

acidemia increases | alkalemia decreases

Question 46

what is the role of albumin in calcium levels?

Answer 46

-50% of calcium is bound to albumin, a normal caclium level in presence of low albumin suggests that the patient is hypercalcemic

Question 47

how to calculate corrected calcium?

Answer 47

corrected calcium = measured total Ca _ 0.8 or 4- serum albumin where 4 represents the average albumin level

Question 48

Causes of hypocalcemia

Answer 48

``` hypothyroid hypomagnesemia pancreatitis renal failure severe trauma multiple blood transfusions ```

Question 49

S/S of hypocalcemia

Answer 49

``` increased DTRs muscle/abd cramps trousseau's sign convulsions chvostek's sign prolonged QT ```

Question 50

Management of hypocalcemia

Answer 50

- check blood pH (alkalosis) - if acute, IV calcium gluconate chronic: oral supplements, vit d, aluminum hydroxide

Question 51

hypercalcemia causes

Answer 51

- hyperparathyroidism - hyperthyroid - vit d toxicity - prolonged immobilization** - thiazide diuretics**

Question 52

S/S hyperkalemia

Answer 52

- fatigue - muscle weakness - depression - anorexia - N/V - constipation - severe hypercalcemia can cause coma and death - serum ca > 12 considered emergency

Question 53

Management of hypercalcemia

Answer 53

- may need calcitonin if impaired cardiovascular or renal function - dialysis - if > 12 begin NS infusion with loop diuretics

Question 54

Hypocalcemia

Answer 54

S/S high

Question 55

Hypercalcemia

Answer 55

S/S low