Week 2 Flashcards
Intracellular
2/3 of body fluid; most in skeletal muscle mass; most water here
Extracellular
⅓ body fluid
Intravascular space, plasma and blood cells
Extracellular contains what body fluid compartments?
- Intravascular
- Plasma 3.5L
- 2.5L erythrocytes, leukocytes and thrombocytes - Interstitial
- Space between cells, tissues, organs and blood vessels
- 10L adult - Transcelluar
- CBS, pericardial sac, intraocular space, pleura space, peritoneal cavity
What body compartment do we lose water from first?
vascular space first, then interstitial space, then intracellular space
When we replace water, we replace intravascular, interstitial and intracellular
Third spacing
the movement of bodily fluid from the blood, into the spaces between the cells. The term “third spacing” also describes the accumulation of fluid from the blood within body cavities, intestinal areas, or areas of the body that normally contain little fluid.
Early evidence of third spacing
Decrease in UOP (first sign)
Other signs: increase HR, decrease BP, decrease CVP, edema, increase body weight, imbalance I&O, peripheral and dependent edema
When might 3rd spacing occur?
ascites, burns, peritonitis, bowel obstruction, massive bleeding into joint or cavity, sepsis
When we are referring to normal levels of electrolytes, what fluid compartment are we referring to?
EXTRACELLULAR Sodium 142 Potassium 5 Calcium 5 Magnesium 2 Chloride 103 Bicarbonate 26
normal electrolyte values in intracellular space
Potassium 150 Magnesium 40 Sodium 10 Phosphate 150 Bicarbonate 10
osmosis and osmality
movement of water in relation to the number of dissolved particles
HIGH to LOW concentration
Diffusion
movement of substance from high to lower concentration
Filteration
kidneys filter 180 L/day
hydrostatic pressure and capillaries filter fluid out of intravascular into the interstitial space
Hydrostatic pressure
the pressure that is exerted by a fluid at equilibrium at a given point within the fluid, due to the force of gravity.
Plasma oncotic
Plasma proteins
Sodium potassium pump
Active transport, requires E
a protein that has been identified in many cells that maintains the internal concentration of potassium ions [K+] higher than that in the surrounding medium (blood, body fluid, water) and maintains the internal concentration of sodium ions [Na+] lower than that of the surrounding medium.
What can lack of albumin lead to?
Albumin (plasma proteins) line vessel walls so fluid stays inside vessel → when we don’t have this, fluid can go out into interstitial space (increased permeability) → create fluid/volume deficit and edema
Why does replacing plasma proteins decrease peripheral edema?
keeps fluid inside cells
What happens when we have edema because of too much intravascular volume?
blood vessels get larger, and there are not enough plasma protein levels (hypervolemic), even if plasma proteins are normal → causes peripheral edema. If we increase protein intake we see a decrease in peripheral edema (high protein diet important)
Routes of gains and losses: kidneys
- 5L/24 hour average adult (lose)
0. 5-1mL/kg/hour
Routes of gains and losses: skin
~600mL/day (sweat)
Routes of gains and losses: lungs
Insensible loss → no way to measure how much fluid we lose through lungs
Lose about 400mL/day
Routes of gains and losses
100 mL/day (lose); increase with diarrhea, decrease with constipation
Lab tests for evaluating fluid status: osmolality
the concentration of fluid that affects the movement of water between fluid compartments by osmosis
275-300 = normal blood osmolality
Lab tests for evaluating fluid status: Urine specific gravity
Measures ability of kidneys to concentrate urine and save water
Goes up w dehydration
Does down with fluid volume overload
Dependent upon normal kidney function
normal is 1.010 to 1.025
Lab tests for evaluating fluid status: BUN
Breakdown of nitrogen product in proteins
Decrease kidney function, dehydration, increase protein intake increases BUN
Malnutrition decreases BUN
BUN is dependent on hydration status
normal is 10-20 mg/dL
Lab tests for evaluating fluid status: Creatinine
In-product of muscle metabolism
NOT affected by hydration status
Most reliable lab test for kidney function
normal is 0.6-1.4 mg/d
Lab tests for evaluating fluid status: hematocrit
Percent of RBC in whole blood
Dependent upon volume
Rule of 3’s → hematocrit should be 3x hemoglobin if the patient has adequate fluid volume status. If you have fluid volume deficit, hemoglobin takes up more than the plasma (higher than 3x hemoglobin)
normal is 42%-52% for males and 36%-48% for females
Fluid volume excess, fluid volume deficit and dehydration/polycythemia impact on hematocrit
Fluid volume excess → decrease in hematocrit
Fluid volume deficit → excess hematocrit
Dehydration, polycythemia → increase hematocrit
Atrial natriuretic peptide (ANP)
Decreases BP and volume
a. Synthesized, stored and released by muscle cells of the atria
b. Excretion is enhanced by increases in atrial pressure, endothelin (powerful peptide vasoconstrictor-released from damaged endothelial cells in kidneys or other tissues) and sympathetic stimulation
c. Also conditions that lead to volume expansion - hypoxia, increased cardiac filling pressures
d. Expect increased levels in PAT, hyperthyroidism, subarachnoid hemorrhage and small cell lung cancer
ANP normal value
20/77ng/L
brain natriuretic peptide (BNP)
Stored in ventricles
Released when diastolic pressure in ventricles rises
normal = less than 100 (values over 100 indicate CHF)
NOT an emergency lab value
Hemostatic mechanisms: Kidneys
Regulate ECF volume and osmolality by selective retention and excretion of body fluids
Regulation of electrolyte levels in ECF - selective retention and excretion
Regulation of pH of the ECF by excretion or retention of hydrogen ion and/or bicarbonate ions (HCO3)
Hemostatic mechanisms: kidney failure
Can result in multiple fluids and electrolyte abnormalities
Hemostatic mechanisms: Heart
Trying to maintain adequate pumping
Fluid volume deficit → increase HR because not getting enough 02 and nutrients out to tissues
Hemostatic mechanisms: lungs
400 mL removed daily
Increase RR when hypoxic, fluid volume overload
Hemostatic mechanisms: Pituitary function
release AHD
Hemostatic mechanisms: ADH
Holds onto fluid volume
Fluid volume deficit and hypernatremia cause ADH to be released because we want to dilute sodium
Hemostatic mechanisms: Adrenal function
Releases aldosterone
Hemostatic mechanisms: Aldosterone
Increased secretion = Na retention (water retention), potassium loss
Decreased secretion = Na and water loss and potassium retention
Part of RAAS system; happens in kidneys
Medicines that work to block aldosterone
K+ SPARING diuretics (Spironolactone), ACE inhibitors → when we give these, we can develop hypovolemia (getting rid of h20 and Na+) → hypotension; hyperkalemia ACE inhibitors (-pril) and spironolactone SHOULD NOT BE USED TOGETHER
Hemostatic mechanisms: Cortisol
Large quantities can produce Na and H2O retention
Hemostatic mechanisms: parathyroid hormone (PTH)
Regulate serum calcium
Hemostatic mechanisms: Baroreceptors
Located in blood vessels; pick up changes in BP and send that to nervous system
Hemostatic mechanisms: Chemoreceptors
Located in atrium; pick up change in pH of blood
Hemostatic mechanisms: RAAS
Renin-Angiotensin-Aldosterone System (RAAS) is a hormone system within the body that is essential for the regulation of blood pressure and fluid balance. The system is mainly comprised of the three hormones renin, angiotensin II and aldosterone. Primarily it is regulated by the rate of renal blood flow.
Hemostatic mechanisms: Osmoreceptors
Located in hypothalamus and sense change in Na levels and trigger release of ADH
Isotonic IV solution
Has a total osmolality close to that of the ECF and do not cause RBCs to shrink or swell
Almost equal in the crystalloid concentration that is in your blood
We put isotonic fluid in vascular space, it stays there until its full, then interstitial fluid, then intercellular fluid
Expand volume of ECF (1 liter of Isotonic fluid increases ECF by 1 liter) 1:1 ratio
Only increases plasma volume by 0.25 liter as diffuses quickly into the ECF compartments
Total electrolyte concentration is approximately 310 mEq/L
Plasma Osmolarity is 300 mOsm/L
Expands ECF volume
What are examples of isotonic solutions?
0.9% normal saline
Lactated Ringers
D5W
Hypotonic solutions
Replace cellular fluid (ex. dehydration)
Makes cells swell like HIPPO –> can cause hypervolemia within cell
Leave intravascular space and goes to cells
ex. 0.45% normal saline
Hypernatremia risk for these solutions
Hypertonic solution and ex.
ICF to ECF
a. 3% normal saline
b. 5% normal saline
c. D10W
d. TPN
Typically given in critical care settings
Examples of colloid solution
Dextran, Albumin, blood
What should the nurse assess when administering fluids to patients with cardiovascular disease?
Signs for circulatory overload e.g., cough, dyspnea, puffy eyelids, dependent edema, weight gain in 24 hours). The lungs are auscultated for crackles. Extreme care is taken when administering highly hypertonic sodium fluids (e.g., 3% or 5% sodium chloride) because these fluids can be lethal if infused carelessly
What should one consider when selecting a venipuncture site?
Condition of the vein Type of fluid/medication to be infused Duration of therapy Age and size Dominant hand Medical hx and health status atm Skill of the person performing the venipuncture
Central Venous access device locations
PICC
Subclavian
Internal jugular
What are signs and symptoms of air embolism and what can be done to prevent damage?
Signs: chest pain, tachycardia, short of breath (same as pulmonary embolism)
Put head down and lay on left side with left side up to get air to absorb through right atrium before it reaches pulmonary circulation
Systemic complications of venipuncture
Circulatory overload, air embolism, febrile reaction, infection
Infiltration of venipuncture
fluid leaking into interstitial tissue
extravasation
When medications (vesicants) have leaked into interstitial tissue causing blisters and necrosis
Chemo., vancomycin, gentamicin, potassium, vasopressors
Call provider and ask for antidote
antidote for extravasation
hyaluronic acid –> increases vascular flow to area so it can absorb and dilute that medicine
Regitine (same MOA as above)
phlebitis
red, warm, swollen around venipuncture sute
thrombophlebitis
Clot in IV site
Hematoma (venipuncture)
Clotting of needle
Take out IV, restart IV ABOVE that site
Purpose of parenteral fluid therapy
provide electrolytes and nutrients to meet daily requirements
To replace water and correct electrolyte deficits
To administer medications and blood products
Normal saline
Used for trauma situations because it is the only fluid that you can give blood with
Cold effects – when we have to transfuse a lot of volume quickly, if we dont warm the solution we can harm our patient
What can happen to pt. if IV liquid is too cold (cold effects)
Patient can develop acute respiratory distress syndrome (ARD), disseminated intravascular coagulation (DIC)
Lactated Ringers
Isotonic Extra electrolytes (K, Na, Cl) -- does not have any more of these electrolytes than what blood has
Used for…
a. GI losses and dehydration (fluid replacement)
CI: should never be used in someone with renal issues due to the added K+ (risk for hyperkalemia)
D5W
Isotonic - 5% dextrose and water
As it is hanging in the bag, it is isotonic. Becomes hypotonic as soon as it gets into patient.
– quickly becomes hypotonic and only contributes to 1/3 ECF
CI: Do not use if client at risk for ICP (leaves vascular space, goes to cells, will increase cerebral edema)
Not good for long term use
0.45% sodium chloride (1.2 strength sodium chloride) can lead to what?
Intravascular fluid depletion
- shift from blood vessels to cells –> decrease BP –> cellular edema and cell damage
Dextrose 50%
Must be administered via central vein so it can rapidly dilute and not cause vascular necrosis
3% or 5% sodium chloride
Hypertonic solution
Cause interstitial fluid to suck into intravascular space (sucks fluid out of cells)
— Can cause extracellular volume excess and cause overload (can be given with diuretic to prevent)
Only use when serum osmolality is dangerously slow ONLY administered in ICU settings Administer low and slow Frequent electrolyte checks Relieves cerebral edema
Monitor for signs of hypervolemia, especially pulmonary edema (listen to lungs upon assessment)
Dextran and Albumin
Colloids
Used as a volume expander because it increases colloid pressure to keep intravascular volume where it belongs
Used to decrease third spacing to maintain normal volume status
Affects clotting by coating platelets and decreasing ability to clot
Increase pulse pressure, cardiac output and arterial blood pressure
Stays in circulatory system for up to 24 hours; stays where we put it
More expensive, difficult to obtain, obtain from blood bank or pharmacy
Choosing an IV site: peripheral
Distal first
Condition of vein, type of fluid, duration of therapy, patients age and size, dominant hand, medication history and current status, skill of person doing the venipunctures
1st: nondominant hand and most distal site
Lymphedema, lymph node resection, bilateral mastectomy can make choosing a site harder (choose other arm)
Why do we use 18g needle to transfuse blood?
18G IV site to transfuse blood because cell lysis can occur with smaller catheter
PICC and peripheral midline cath - why might we use this and what is one thing that must be done
Longer therapy
Limited peripheral access
Require consent
How should nurses prepare IV site?
Assess allergies, do not shave site (can clip), clean area, maintain sterile technique
What contributes to IV flow?
Gravity
Monitor at least hourly
Electronic pumps
Occlusion
Types of central venous access devices
Peripherally inserted central catheter (PICC)
Central line
Implanted infusion port
Why do we use central lines?
Long-term therapy, chemotherapy, home infusion, limited peripheral access due to disease condition, IV therapy or tissue damage, frequent blood collection needed, Total parenteral Nutrition (TPN)
How long can a PICC, central line and implanted ports be left in?
PICC up to 6 weeks Central line (depending on type and placement) several months imported plans several years
PICC
May be used for blood draws if ordered by physician or a stated per Hospital policy
often inserted if the patient will need therapy for longer than 7 days or if the patient has fragile veins
change transparent dressing every seven days or when moist, soiled, or not adhering (sterile procedure)
Blush every Lumen before and after use with 10 mL of sterile normal saline using the push-pause technique. per Mercy policy this must be done at least every 12 hours to remain patent
Central lines
Tunneled or non-tunneled placed in chest, neck, groin
Flush with 10 mL of normal saline before and after each use; this should be done every 12 hours at Mercy Hospital
Antimicrobial cuff that helps to prevent infection
Change transparent dressing every 7 days or when it is moist soiled not adhering (sterile)
MUST be placed by physician or surgically implanted
examples: Hickman, broviac, and Groshong
Implanted fusion ports
Surgically implanted under skin
less likely to clot
may be accessed using Huber needle
Flush with 10 mL of sterile normal saline before each use; flush with 0 normal saline daily when not in use in Port is accessed with Huber needle
Mercy policy, must be flush with 3 ml of Heparin monthly in prior to discharge
Both Huber needle and dressing are changed every seven days; dressing may also be changed if moist, soiled, or not adhering (sterile)
Complications of central lines
Occlusion, infection, phlebitis, infiltration or extravasation, air embolism, thrombosis formation, catheter migration, catheter damage
Infection control of central lines
strict sterile procedure
proper hand hygiene prior to working with any central line
vigorously scrub needleless connector a minimum of 30 seconds with alcohol swab prior to access
change tubing and dressing as scheduled
