TLO 2.3 Nutrition, Fluid Balance Adult Flashcards
Fluid compartments: 2 types
Intracellular fluid (ICF) Extracellular fluid (ECF)
Volume regulation
Osmosis
Diffusion
Filtration
Active Transport
Fluid and electrolyte balance
Maintenance
Nursing role
Maintenance of homeostasis:
Requires fluid and electrolyte balance within a vary small range in a healthy body
Diseases and treatment may alter fluid and electrolyte balance
Nursing role:
Anticipate the potential for alterations in fluid and electrolyte balance
Recognize the signs and symptoms of imbalances
Intervene with appropriate actions
Evaluate interventions
Adults: 1500 mL/day of fluid intake
Distribution of body fluids
Calculation of fluids
1 liter of water weighs 2.2 lbs (1kg)
Sudden body weight changes is an indicator of fluid gain
Body fluids
Intracellular fluids?
Inside the cells
K+, Mg++, phosphate, glucose, O2
About 2/3 of total body water
Body fluids
Extracellular fluids?
Outside of cell
Na+, Chloride, Bicarbonate
About 1/2 of total body water
Positive imbalance?
More input than output
Negative imbalance?
More output than input
Extracellular fluids: 2 major divisions
Two major divisions:
Intravascular: plasma (20% of ECF)
Interstitial: fluid btw cells including lymph (80% of ECF)
Extracellular fluids: 1 minor division
One minor division:
Transcellular fluids: specialized compartments
CSF, synovial, pleural, pericardia, peritoneal fluids
Movement of body fluids
Osmosis: fluid moves passively from areas with more fluid to areas with less fluid
Diffusion: solutes move from areas of higher concentration to areas of lower concentration until the concentration is equal in both areas
Filtration: movement of fluids through capillaries resulting from blood pushing against the walls of the capillary. Hydrostatic pressure forces fluids and solutes through capillary wall
Active transport: energy from ATP moves solutes from an area of lower concentration to an area of higher concentration. i.e. sodium-potassium pump
Example: 70 kg man
42 L water
28 L intracellular
Water: 42 L
Intracellular: 28 L
Extracellular: 14 L of water
- Interstitial: 10 L
- Intravascular: 3 L
- Transcellular: 1 L at a given time
**3-6 L of fluid is secreted into and reabsorbed from the GI tract
Fluid spacing
Distribution of body water
First spacing: normal distribution of fluid in the ICF and ECF compartments
Second spacing: abnormal accumulation of interstitial fluid (edema)
Third spacing: Fluid accumulates in a portion of the body (transcellular fluid) that is not easily exchanged
Trapped and unavailable for functional use
-ascites
-abdominal cavity with peritonitis
-edema with burns, trauma, sepsis
Fluid balance: NI
I/O: provides valuable data regarding fluid and electrolyte problems. Excessive intake or output losses can be identified
Daily weight
Assess for:
- cardiovascular changes
- respiratory changes
- neurologic changes
- skin turgor
- monitor rates of IV infusions
- no oral fluids with NG suction (unless ordered), increases electrolyte loss
Urine output
Adult: 30 mL/hr
Children: 1 g of west diaper = 1 mL urine
Skin assessment:
Skin turgor and color: tenting, poor skin tented for 20-30 sec Weight Edema Abnormal assessment Assessment of mouth and mucus membranes Anterior fontanel in children
Skin care, NI
Protect edematous tissue
Intake includes:
Oral
IV
Tube feeding
Retained irrigates
Output includes:
Urine (adult 30mL/hr) Excess perspiration Wound drainage (est) Perspiration (est) Vomitus Diarrhea
Urine specific gravity
> 0.125 concentrated urine (dehydration)
<1.010 diluted urine (fluid overload)
Fluid balance
Daily weights
Easiest measurement of volume status Required standardized conditions -same clothes -bed weight: same linens, pillows, drainage bags off bed Same time of day Same calibrated scale
- *an increase of 1 kg is = to 1000mL of fluid retention
- *on normal diet, NOT NPO
Skin care NI
protect edematous tissue Changes in position Elevate edematous extremities Frequent skin care Application of moisturizing creams
Fluid imbalances
Sodium: hyper/hypo natremia
Potassium: hyper/hypo kalemia
Calcium: hyper/hypo calcemia
Magnesium: hyper/hypo magnesium
Sodium Na++
Normal serum sodium levels Major cation found in ECF Role Works with K+ and Ca++ to conduct nerve impulses Comes Kidneys regulate sodium balance in body
Sodium Na++
Normal serum sodium levels 135-145 mEq/L Major cation found in ECF Role is to maintain fluid volume in body Regulates osmolality and BP Works with K+ and Ca++ to conduct nerve impulses Comes from dietary intake Kidneys regulate sodium balance in body
Hyponatremia (sodium) causes?
Fluid gain:
IV fluid overload
Fluid overload after drinking water
Dilutional states (hyperglycemia, SIADH (symptom of the inappropriate diuretic hormone), heart failure)
Sodium loss:
Diuretic therapy
GI Tract (vomiting, diarrhea, GI suction, fistulas)
Excessive sweating
Hyponatremia (sodium) s/s
Decreased serum osmolality Muscle cramps, weakness HA Lethargy, stupor, coma Anorexia, nausea, vomiting Hypotension, shock
Hyponatremia (sodium) diagnostic
Serum sodium <135 mEq/L
Urine specific gravity <1.010
Serum sodium critical level <110 mEq/L
**do not correct level too fast or cerebral edema
Hyponatremia (sodium) nursing management
monitor neurological signs daily weights I/O, VS Urine color consistency and amount Maintain fluid restriction Admin 3% NaCl solution as ordered, if critically low to prevent seizures
Hypernatremia (sodium) causes
Fluid volume deficit:
not drinking enough fluids
eating high sodium diet
excessive water loss (high fever, heatstroke, diarrhea)
Interruption of body's regulatory mechanism: diabetes insipidus renal failure hyperaldosteronism Cushing syndrome uncontrolled DM
Hypernatremia (sodium) s/s
increased thirst, oliguria increased urine specific gravity dry skin and mucous membranes, decreased skin turgor, furrowed tongue, dry mouth HA, restlessness seizures, coma trachy, hypotension, vascular collapse decrease urine output
Hypernatremia (sodium) diagnosis
Serum sodium >145
Serum osmolality >300
Specific gravity >1.030
Hypernatremia (sodium) nursing management
VS
I/O
Daily weight
Edema- peripheral extremities, sacrum, face
Risk for seizures
Correction need to be provided slowly to avoid a shift of water into the cerebral cells
Potassium (kalemia)
Normal serum levels 3.5-5 mEq/L Maintains fluid balance in cells Contracts skeletal, cardiac and smoot muscle Maintains acid base balance Kidneys are the primary regulators
Hypokalemia (potassium) causes
Diuretics
Inadequate intake
GI losses: diarrhea, vomiting, GI suction, ostomy fluids
Major surgery/hemorrhage
Hypokalemia (potassium) s/s
Early signs: fatigue and muscle weakness, leg cramps Weak, irregular pulse Bradycardia Decrease GI motility EKG changes
Hypokalemia (potassium) diagnosis normal
Serum potassium <3.5 mEq/L
Hyperkalemia (potassium) causes
Excessive intake of potassium containing foods, oral or IV potassium
Potassium sparing diuretics
Renal failure
Addison disease
Increased K+ intake and absorption: rapid IV blood, salt substitute, IV K+)
Shift of K+ from cells into the ECF: trauma, chemo, diabetic ketoacidosis
Hyperkalemia (potassium) s/s
muscle cramping muscle weakness, bilateral in quadriceps increased GI motility transient ab cramps and diarrhea slow, irregular HR hypotension cardiac dysrhythmias EKG changes
Hyperkalemia (potassium) diagnostic
Serum potassium >5.0 mEq/L
Hyperkalemia (potassium) treatment
Eliminate oral and IV K+
Increase elimination of K+: diuretics, dialysis, Kayexalate
IV glucose and insulin: force K+ to ICF
Admin calcium gluconate to reverse membrane excitability
Hyper and Hypo kalemia (potassium) nursing management
Admin oral potassium supplement as ordered Pt education Monitor levels Avoid high potassium foods Avoid salt substitutes with potassium S/S of hypokalemia Telemetry
Calcium
what is it
Normal serum calcium is 8.9-10 mg/dl
Necessary for development of strong teeth and bones
Helps maintain muscle tone
Nerve transmission and contraction of skeletal and cardiac muscles
Inverse relationship with Phosphorus
Hypocalcemia causes
Chronic disease: alcoholism, ESRD Poor intake Inadequate absorption: Crohn's disease Surgical removal of thyroid or parathyroid Inadequate V D
Hypocalcemia s/s
Numbness/tingling of nose, ears, fingertips Positive Chvostek sign Positive Trousseau sign Hyperactive deep tendon reflexes EKG changes Seizures
Hypocalcemia diagnosic
Serum Ca++ <8.5-9 mg/dl
Increased Parathyroid hormones
Hypercalcemia causes
Excessive intake of C++ or V D Renal failure Hyperparathyroidism Invasive/metastatic cancers Diuretics (thiazides) Prolonged immobilization
Hypercalcemia s/s
Anorexia, N/V, constipation Lethargy, fatigue Decreased LOC Diminished reflexes Confusion Severe: cardiac arrest EKG changes
Hypercalcemia diagnosic
Serum calcium levels >11 mg/dl
Magnesium
Normal range 1.5-2.5 mEq/L or 1.8-3 mg/dL
A coenzyme in metabolism of carbs and protein
Maintains strong healthy bones
Influences contractility of cardiac muscles
Helps sodium and potassium ions cross the cell membrane
Regulates muscle contractions
Hypomagnesium causes
Occurs along with decreased potassium and calcium
Malabsorption disorders: IBD, bowel resection, gastric bypass surgery
Deficient Mg intake and absorption
Alcoholism
Diuretics (loop and osmotic)
Some chemotherapeutic agents
Hypomagnesium s/s
Positive Chvostek's and Trousseau's sign Hyperactive deep tendon relaxes Muscle cramps and twitching, grimacing, dysphagia Hypertension, tetany, seizures Cardiac dysrhythmia, tachy
Hypomagnesium diagnostic
Magnesium <1.5 mEq/L
Calcium and potassium may be low
Hypermagnesium s/s
muscle weakness lethargy diaphoresis decreased deep tendon reflexes bradycardia severe: resp failure, dysrhythmias, cardiac arrest
Hypermagnesium diagnostic
Magnesium level >2.5 mEq/L
Monitor BUN and Creatinine
Hypermagnesium causes
Renal failure
DM or DKA
Leukemia
Thyroid gland
Secretes two hormones: thyroxine (T4) and triiodothyronine (T3)
They affect metabolic rate, caloric requirements, oxygen consumption, carbohydrate and lipid metabolism and growth and development, brain function
Thyroid diagnostic test
Triiodothyronine (T3)
Purpose:
To diagnose hyperthyroidism and to compare with T3 and T4 for diagnosis of thyroid disorder
Thyroid diagnostic test
Thyroxine (T4)
Purpose:
To determine thyroid function and aid in the diagnosis of hyperthyroidism and hypothyroidism
Thyroid diagnostic test
Thyroid-Stimulating hormone (TSH)
Purpose:
Blood test done to measure levels of T4 to identify circulating TSH
-decreased T4 and a normal increased TSH can indicate a thyroid disorder
-decreased T4 and a decreased TSH level can indicate pituitary disorder
Thyroid diagnostic test NI
Tell patient to avoid shellfish for several days prior to testing
Hypothyroidism cause
Insufficient thyroid hormone production
-atrophy of thyroid
Hypothyroidism manifestations and s/s
fluid retention, edema decreased appetite weight gain constipation dry skin dyspnea pallor hoarseness muscle stiffness cold intolerance mask like appearance to face
Hypothyroidism diagnostic and treatment
Diagnosis:
Increased TSH
Decreased T4 and T3
Treatment:
Levothyroxine
Med admin r/t thyroid preparations
Hyperthyroidism causes
Hyperactivity of thyroid gland, excessive delivery of TH to tissues
Graves disease
Toxic multinodular goiter
Hyperthyroidism manifestations
Increased appetite Weight loss Nervousness Restlessness Excitability Tachy N/V/D
Hyperthyroidism diagnosis
Diagnostic: TSH decreased, T4 and T3 increased
Hyperthyroidism treatment
Antithyroid meds
Surgical treatment: Thyroidectomy
Hypoparathyroid
Damage or inadvertent removal
Causes hypocalcemia and elevated blood phosphate
S/S Numbness/tingling of mouth/finger tips Muscle spasms hands/feet Convulsions Laryngeal spasms tetany
Treatment:
Supplemental calcium
Increase calcium diet
Vit D
Hyperparathyroid
Hyperplasia or adenoma of glands
Secondary to chronic hypocalcemia
R/t chronic renal failure
S/S Hypercalcemia Musculoskeletal Renal GI Cardiovascular
Treatment:
Mild: fluids, increase activity, avoid calcium
Severe: hospitalization, meds
Surgical removal
Hypopituitarism
Pituitary tumors
Surgical removal
Radiation of gland
Infection/trauma of gland
S/S
Will vary related to deficient hormone
Treatment:
Hormone replacement
Hyperpituitarism
Benign adenoma
S/S
Visual changes
Gigantism
Acromegaly
Treatment:
Gigantism: most often r/t tumor, very rare
Acromegaly: surgical removal or irradiation of pituitary tumor
Nasogastric suction
Salem sump
Salem sump (16f):
Double lumen
Radiopaque
1st lumen suction of gastric contents
2nd lumen blue extension (pig tail) open to room air to maintain a continuous flow of atmospheric air
Controls the amount of suction pressure placed on stomach wall
Prevents injury, ulcer
Complications of NG suction
Metabolic alkalosis occurs with loss of acid from stomach
Electrolyte imbalance: hyponatremia, hypokalemia, hypomagnesemia
Enteral feeding
Used to meet calorie and protein requirements
Enteral feeding indications
Indications for tube feeding: diff swallowing, unresponsive, oral/neck surgery/trauma
Methods of administration enteral feeding
Bolus feeding
Continuous feeding (reduces risk of aspiration)
Cyclic
Enteral Tube feeding Nasogastric Nasoduodenal Gastrostomy (G tube, PEG tube) Jejunostomy (J tube)
Nasogastric: 8-12 f, placed through nose, into stomach, attached to nose
Nasoduodenal: weighted tip, <4 wk, placed through nose to small intestine, attached to nose
Gastrostomy (G tube, PEG tube): >4 wk, placed directly through skin into stomach, attached to abdominal wall and secured with bumper/balloon
Jejunostomy (J tube): preferred with reflux, >4 wk, placed directly through skin to small intestine
Nasogastric tube
Levine Tube
Levin tube (14-16f)
Single lumen, holes near tip
Prevent accumulation of intestinal liquids and gas during and following surgery.
Prevents N/V and distention due to reduced peristaltic action
Nasogastric suction nursing responsibilities
Assess condition of patients nares
Mouth care q 2 hr
NPO, unless ice chips ordered by provider
Flush tube with NS if needed
Verify placement: x-ray, pH, aspirate stomach contents, air bonus
Turn patient regularly to promote emptying of stomach
Accurate I/O
Document gastric characteristics, amounts
Parenteral nutrition (IV nutrition)
Parenteral nutrition: Nutrition is provided through IV
Crystalline amino acids, hypertonic dextrose, electrolytes, vitamins and trace elements
TPN: admin through a central line, protein and dextrose, fats
Purposes: patients unable to ingest or absorb nutrients
Collaborative care for parenteral nutrition
Clinical and lab monitoring Goal: to use the GI tract asap Xray confirmation Maintain securement of device, sterile dressing Always uses infusion pump Assess for infection, I/O, daily weight
What is PPN?
Peripheral parental nutrition
Difference between TPN and PPN is the concentration of dextrose, at least 20% dextrose need TPN
Diet types
Consistency: 5 food types, depend on level
Food type: clear, full, diabetic, renal, dysphagia, reg
Antiemetics
Zofran (ondansetron): serotonin receptor antagonist, most effective for N/V
NI: admin 30-60 min prior, oral/IV, monitor liver function and clotting
Reglan: (metoclopramide): dopamine antagonist
Increases lower esophageal sphincter pressure and enhances the rate of gastric emptying
Side effects: drowsiness, sedation, hypotension, akathisia (uncontrolled motor restlessness) and dystonic (facial muscle spams, neck, back) extrapyramidal effects
**older adults more sensitive
Gastrointestinal diagnostic test
X-ray: ab flat plate
No prep
Shows gas and stool pattern, patency of GI, inflammation.
Used to congenital anomalies in children, ab pain, appendicitis
Upper GI barium swallow
NPO
Drink medium or contrast given per NG tube
Various x-rays in different position
Flush body with fluids to prevent impaction
Sometimes laxative needed
Stool will be white
Upper GI Endoscopy
Fiberoptic camera goes down esophagus, views esophagus, stomach, duodenum, biopsy can be obtained
NPO several hr prior
Conscious sedation
For adults: medication may be used to subdue gag reflex (NPO until gag returns)
Signed consent: risk for bleeding/trauma
Diagnostic test: Gastric analysis
Evaluate gastric contents of fasting, acidity, appearance, volume
Determines proper functioning of stomach
Educate patient, no smoking, eating, drinking 8-12 hr prior
Diagnostic test: Ultrasonography
Used to identify ab masses, ascites, disorders of appendix with high sound waves
No food, drink, smoke, gum 6 hr prior
Diagnostic test: cholecystogram
X-ray, evaluate gallbladder
Gallbladder cancer, decreased or blocked bile flow in the biliary duct system of liver
Diagnostic test: Cholangiogram
Primarily used to look at larger bile ducts within the liver and outside the liver
Used to locate gallstones
Biliary tract problems
Gallstones and inflammation of the gallbladder
Most common symptom is pain: biliary colic after ingesting a fatty meal
Other symptoms: N/V, fever if infection, jaundice if obstruction
Cholelithiasis
Gallstones
Risk factors: age, family history, obesity, hyperlipidemia, rapid weight loss, female, hormonal, contraceptives, sickle cell
Pain, N/V
Cholecystitis
Inflammation of the gallbladder
Anorexia, N/V, RUQ tenderness, chills, fever
Endoscopic retrograde cholangiopancreatography (ERCP)
Used primarily for adults. Endoscope that travels from mouth down to common bile duct and pancreatic ducts
Preprocedural: NPO, signed consent, admin sedation, antibiotics
Postprocedural: V/S, check for signs of perforation or infection. Pancreatitis main problem. Check for return gag
Nursing management of surgical patient: laparoscopic cholecystectomy
Patient experience N/V, shoulder pain from gas infusion into ab
Position with head and torso elevated
Ambulate to rid gases
Possibility of bile leakage causing chemical peritonitis = RUQ pain, tachy, hypotension
Nursing management of the patient with an open cholecystectomy
Same care as for an ab incision (issuers with decreased peristalsis, pain, infection, lung infection, DVT)
May divert bile using T tube: do not clamp tube, provides external drainage of bile
May need Vit K shots if bile diverted
GERD treatment
Medications:
Antacids- neutralize HCL
Anti-secretory agents- decrease secretions of HCL acid by stomach. Zantac, Pepcid
Proton pump inhibitors- inhibit pump mechanism responsible for secretion of H+ ions. Prilosec, Protonix
Sucralfate
Reglan
GERD Nursing care: adult
Teach about diet, meds, lifestyle changes Stop smoking Reduce alcohol consumption Elevate HOB Patient teaching Follow up with PCP Watch for cancer
GERD: surgical
Fundoplication: Fundus of stomach is wrapped around distal esophagus and sutured Postop care: NPO until peristalsis IV fluids Prevent infection Monitor respiratory
Hiatal Hernia
Part of the stomach protrudes through the esophageal hiatus of the diaphragm into the thoracic cavity
Causes:
weakened anchors of the esophageal hiatus
shortening of the esophagus
increased intra ab pressure
Diagnosis:
barium swallow
upper endoscopy
Symptoms:
heartburn
Treatment:
medication, if ineffective, Nissen fundoplication is done laparoscopically
prevents the gastroesophageal junction from slipping into the thoracic cavity
Peptic Ulcer Disease (PUD)
Main cause:
presence of helicobacter pylori bacteria
breakdown in gastric mucosal barrier
acid in stomach injures tissue
Risk:
use of NSAIDs, stress, alcohol
smoking
H. Pylori
PUD and H. Pylori
H. Pylori
Bacteria spread person to person by oral/oral-fecal/oral
Produces enzymes that break down the mucous gel that protects the gastric mucosa
-testing: biopsy, fecal antigen, breath test
-treatment: triple therapy (PPI and 2 antibiotics)
**PPI= proton pump inhibitor
Peptic ulcer disease
Main assessment
Main assessment: Pain, gnawing, burning, caching, hunger like Epigastric region May have heart burn or regurgitation Pain is 1-2 hours after eating
Duodenal ulcers:
Pain on empty stomach
Relieved by food and antacids
Peptic ulcer
Complication - Perforation
Perforation can lead to chemical peritonitis.
Occurs with duodenal ulcers
Sudden sharp and severe pain in mid epigastrium, pain spreads to entire abdomen, becomes rigid, hard and tender
Nursing care: insert NG tube to empty gastric contents admin IV fluids collaborate with provider prepare for endoscopic or surgery
Peptic ulcer diagnostic
Endoscopy, Upper GI Urea breath test Barium swallow CBC Liver enzymes Stool sample to check for blood
Peptic ulcer meds, treatment
Diet: Teach patient to avoid food that cause discomfort Maintain good nutrition Smoking discourage Mild alcohol intake permitted
Medications:
Two antibiotics for two weeks
Proton pump inhibitor
Peptic ulcer surgical treatment criteria
Criteria: Disease has resulted in hemorrhage, perforation, obstruction or disease cannot be controlled by medical management Subtotal gastrectomy (Billroth I and Billroth II), partial removal of the stomach
Peptic ulcer surgical
Vagotomy (surgical operation in which one or more branches of the vagus nerve are cut, typically to reduce the rate of gastric secretion):
Performed when acid production in the stomach can not be reduced by other means. Purpose is to disable the acid producing capacity of stomach
Subtotal gastrectomy:
Partial removal of portion of the stomach, distal third
Total gastrectomy:
Removal of entire stomach for diffuse cancer that has spread into mucosa
Peptic ulcer post surgical complications
Malabsorption:
vitamin B12, folic acid, calcium, Vit D
Dumping syndrome: most common problem Food bolus pulls water into intestines. Peristalsis is stimulated and motility increased Rapid dumping of gastric contents Managed by small or more frequent meals Decrease carbs with meals
Peptic ulcer postsurgical care
Rest the surgical area to prevent pain, bleeding and infection
Maintain NG tube
Surgical care for any ab surgery
Liberal use of pain med to prevent immobility and atelectasis
Bariatric surgery criteria
BMI >40 kg/m or >35 kg/m with one or more serious complications
Psychiatric and social stability ad willingness to cooperate with long term follow up
Bariatric post op care
Similar to ab surgery
More chance of all complications
On a specific diet that involves taking a small quantities of food with a progression to larger quantities
May need Vit supplement in the beginning
Gastric bypass
Roux-en-Y gastric bypass
Small stomach pouch is created to restrict food intake
Y shaped section of the jejunum is then attached to the pouch to allow food to bypass the lower stomach and duodenum
Calorie and nutrient absorption is limited
Deficiencies are common: iron, calcium, Vit B12, fat soluble vit
Risk for dumping syndrome
Gastric by pass
Biliopancreatic bypass with duodenal switch
More complex procedure and higher risk of nutritional deficiencies
Performed in 2 stages, sleeve created during first stage. Duodenum and jejunum are bypassed by connecting ileum to stomach pouch
Restricts nutrient intake and absorption for rapid weight loss
Deficiencies are common: iron, calcium, Vit B12, fatty soluble vit
Gastric bypass
Vertical sleeve gastrectomy
Only the first stage of procedure (sleeve only), becoming more popular
Restricts intake, slows digestions
Gastric bypass postop complication
Anastomosis leak with peritonitis Abdominal wall hernia Gallstones Wound infections DVT/PE Nutritional deficiencies Dumping syndrome
Gastric bypass
Adjustable gastric banding
Safer but less effective in long term
Hollow band of silicone is placed under the upper portion of the stomach and inflated
Few nutritional deficiencies
vomiting is common risk for restrictive procedures
Band can clip or break leading to further surgery
Few keep weigh toff >10 years
