Acute and Chronic Test fluid and electrolytes with MSK ppt questions
What electrolytes act as companions?
Mg and Ca Mg and K
How would you treat HYPOmagnesemia?
Mild HYPOmagnesium - Diet: Best sources are unprocessed cereal grins, nuts, legumes, green leafy vegetables, dairy products, dried fruits, meat fish - magnesium salts - More severe --> 1) MgSO4 IM 2) MgSO4 IV slowly
A 72 year old man presents to the ER with n/v/d for 2 days. He states that he babysat his 4 year old grandchild the other day when she had a GI bug. How will you fix this?
NS, lactated Ringer
What electrolytes are competitors against each other?
Na and K Ca and PO4 K and H+
What are the normal levels for calcium?
Normal is 4.5-5.5 mEq/L OR 8.7-10.4 mg/dL
How would you treat HYPERmagnesemia?
- Withhold Mg-containing products especially in patients with renal failure - calcium chloride or gluconate IV for acute symptoms - IV hydration and diuretics - Monitor VS, LOC - Check patellar reflexes
What are the causes of HYPERphosphatemia?
- chronic renal failure (most common) - hyperthyroidism, hypoparathyroidism - severe catabolic states - conditions causing hypocalcemia
What would be the treatment for hyperkalemia?
- 10% calcium glutinate or calcium chloride slowly IV over 5-10 minutes - insulin/ glucose drip - sodium bicarb -albuterol - stop K supplements and avoid K in foods, fluid, and salt substitutes
What are the causes of HYPOmagnesemia?
- < 1.5 mEq/L - Decreased intake or decreased absorption or excessive loss through urinary or bowel elimination - acute pancreatitis, starvation, malabsorption syndrome, chronic alcoholism, burns, prolonged hyperalimentation without adequate Mg - Hypoparathyroidism with hypocalcemia - diuretic therapy
What are the s/sx of HYPERphosphatemia?
- >4.5 phosphate (<3.0 for calcium ) 1. Trousseau's sign 2. Chvostek's signs 3. Diarrhea 4. Weak B's - Strong bones? - WEAK --> fractures - Strong blood clotting?- Weak!! risk for bleeding - strong heart beats? WEAK --> cardiac dysrhythmias
A 72 year old man presents to the ER with n/v/d for 2 days. He states that he babysat his 4 year old grandchild the other day when she had a GI bug. What diagnostic tests do you want?
- CBC: will tell us about WBC and if elevated or viral - chemistry: if they are out of whack then can call for EKG - urine analysis: good indicator of hydration, protein
What is HYPERcalcemic crisis?
- Emergency: level of 8-9 mEq/L - intractable nausea, dehydration, stupor, coma, azotemia, hypokalemia, hypomagnesemia, hypernatremia - high mortality rate from cardiac arrest
What does magnesium do for the body?
- Ensures K and Na transport across cell membrane - important in CHO and protein metabolism - Plays significant role in nerve cell conduction - important in transmitting CNS messages and maintaining neuromuscular activity - Factors that affect Ca will affect Mg. - causes vasodilation - DEC peripheral vascular resistance - intracellular compartment electrolyte
What are the causes of HYPERmagnesemia?
- Most common cause is renal failure, especially if taking large amounts of Mg-containing antacids or cathartics; DKA with severe water loss
What is the treatment for HYPERcalcemic crisis levels?
- NS IV: match infusion rate to amount of UOP - I&O hourly - Loop diuretics and adequate IV hydration w/ isotonic fluids (promote renal excretion) - Pamidronate in malignant cancer clients (inhibits bone resorption without affecting bone mineralization) - Phosphorus and/or synthetic calcitonin - Encourage fluids
How would one treat moderate to severe phosphate deficiency?
- Oral or IV phosphate (do not exceed rate of 10 mEq/h) - identify clients at risk for disorder and monitor - prevent infections - monitor levels during treatment
What is calcium used for?
- Required for blood coagulation, neuromuscular contraction, enzymatic activity, and strength and durability of bones and teeth - Nerve cell membranes less excitable with enough calcium - Ca absorption and concentration influenced by Vitamin D, calcitriol (active form of Vitamin D), inc PTH (inc Ca), calcitonin (dec Ca), phosphorous.
How would you treat HYPOphosphatemia?
- closely monitor and correct imbalances - adequate amounts of Phos-foods (dairy products) - Recommended dietary allowance for formula- fed infants 300 mg Phos/day for 1st 6 months and 500 mg per day for latter 1/2 first year - 1:1 ratio phos and Ca recommended dietary allowance. Exception is infants, whose Ca requirements is 400 mg/day for 1st 6 months and 500 mg/day for next 6 months - Watch for hypocalcemia when treating low phos
describe calcium balance
- controlled by parathyroid hormone (inc Ca++) - inc gi absorption and renal reabsorption - calcitonin (DEC Ca++) - dec GI absorption - Vitamin D (low Vis D= low Ca++) - PTH and calcitonin levels respond to fluctuations in total body Ca++ to move Ca++ stores in and out of bone
What are the causes of HYPERkalemia? (serum potassium level above 5.0)
- excessive K intake (IV or PO especially in renal failure - tissue traume - acidosis
How do we treat hypocalcemia?
- high calcium diet or oral calcium salts (mild)- (square root sign) formulas for calcium content - IV calcium as 10% calcium chloride or 10% calcium gluconate-- give with caution!! - Close monitoring of serum Ca - Dec phosphorus levels INC magnesium levels - Vitamin D therapy
How do we treat HypoKalemia?
- hydrate if low UOP - oral replacement through high K+ diet - IV supplementation (done in boluses with acute replacement) --> this is good because it will bypass liver! ** remember not to push K+ you could dilute it,
what are the causes of hypokalemia? (serum < 3.5)
- loss of GI secretions - Excessive renal exertion of K - Movement of K into the cells (DKA treatment) - Prolonged fluid administration without K supplementation - Diuretics (some)- Lasix
What are the causes of HYPOphophatemia?
- malnutrition - hyperparathyroidism - certain renal tubular defects - metabolic acidosis (esp. DKA) - disorders causing hypercalcemia - phosphorous is needed to form ATP and 2,3-DPG- can severely affect cell viability if levels too low
What are the causes of HYPERcalcemia?
- mobilization of Ca from bone - malignancy -hyperparathyroidism - immobilization- causes bone loss - thiazide diuretics - thyrotoxicosis - excessive ingestion of Ca or Vitamin D
What are the causes of hypocalcemia?
- most common: depressed function or surgical removal of the parathyroid gland - hypomagnesemia - hyperphophatemia - administration of large quantities of stored blood (preserved with citrate) - Renal Insufficiency - DEC absorption of Vitamin D from intestines
What does potassium do in the body?
- normal cardiac and neuromuscular function - influences nerve impulse conduction - important in CHO metabolism - helps maintain acid-base balance - controls fluid movement in and out of cells by osmosis
How would one treat HYPERphosphatemia?
- prevention is the goal - restrict phosphate- containing foods - administer phosphate- binding agents - diuretics - treat cause - treatment may need to focus on correcting calcium levels
What are the three functions of sodium?
1. Blood pressure 2. Blood volume 3. pH balance
Assessment signs and symptoms for hypocalcemia are:
1. Trousseau's sign- arm twerk with BP cuff on 2. Chvostek's signs- smile when stroking cheek 3. Diarrhea 4. Circus oral tingling Risk for the three B's: bone fracture, weak heart beats, bleeding
What are normal levels for Magnesium?
1.5-2.5 mEq/L
What are the normal levels for sodium?
135-145 mEq/L
What are the functions of phosphate and its normal numbers?
2.5-4.5 - Calcium's worst enemy: they work inversely - bone and teeth formation - Helps regulate calcium - Essential to tissue oxygenation, normal CNS function and movement of glucose into cells, assists in regulation of Ca and maintenance of acid- base balance .
What is the normal level for Potassium?
3.5-5.0 mEq/L
What are the s/sx of HYPOphosphatemia?
<2.5 (a high calcium level >5.5) Swollen and slow- moans, groans, and stones 1. constipation 2. Dec DTR and severe muscle weakness 3. Dec HR, RR 4. INC BP
What are the signs and symptoms of HYPERmagnesemia? **(think there is a sheriff in town and he's keeping Law and Order in Muscle Town )
Low because sheriff is in town (>2.5) 1. Cardiac: Calm and quiet - hypotension, drowsiness, absent DTRs, respiratory depression, coma, cardiac arrest - bradycardia, CHB, cardiac arrest, tall T waves 2. GI - hypoactive bowel/ slows motility
HYPERkalemia Causes (MACHINE)
M- medication, ACE inhibitors, NSAIDs A- acidosis- metabolic and respiratory C- cellular destruction- Burns, traumatic injury H- hyperaldosterone, hemolysis I- intake- excessive N- nephrons, renal failure E-excretion impaired
A nurse is caring for a client being treated for fat embolus after multiple fractures. Which of the following data would the nurse evaluate as the most favorable indication of resolution of the fat embolus A. minimal dyspnea B. Clear mentation C. oxygen saturation of 85% D. arterial oxygen level of 78 mmHg
B. clear mentation An altered mental status is an early indicator of fat emboli therefore clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea is a normal sign. Arterial oxygen levers should be 80 to 100. Oxygen saturation should be higher that 95%
What are the signs of HYPERnatremic?
Big and Bloated 1. Skin - flush "red and rosy" - edema " waterbed skin" - low grade fever 2. Polydipsia - excessive thirst 3. Late serious sign SERIOUS - Swollen dry tongue - GI: nausea and vomiting - INC muscle tone
When screening patients at a community center, the nurse will plan to teach ways to reduce risk factors for osteoarthritis to a A. 24 year old man who participates in a summer softball team B. 36 year old woman who is newly diagnosed with diabetes mellitus C. 49 year old woman who works on an automotive assembly D. 56 year old man who is a member of a construction crew
C 49 year old woman who works on a n automotive assembly line Rationale: OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals who's work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces risk for OA. Diabetes is not a risk factor for OA. Working on a construction crew would involve non repetitive work and thus would not be risky.
HYPOcalcemia s/sx (CATS go numb)
C-convulsions A- arrhythmia T- tetany S- spasms, seizures, and stridor numbness of hands, feet, and lips
In the patient with arthritis, what is the name of these nodes (MCP joints) A. Nodes of Ranv B. finger nodes C. bouchard's nodes D. Herbedon's nodes
C. Bouchard's nodes - calcific spurs on middle joints of the finger - Herbedons nodes occur on the distal joint (joint closest to finger tip) - Node of Ranv is a gap in myelin sheath of a nerve that facilitates conduction of nerve impulses
A 60- year-old patient has osteoarthritis (OA) of the left nee. A finding that the nurse would expect to be present on examination of the patient's knee is A. Heberden's nodules B. redness and swelling of the knee joint C. Pain upon join movement D. stiffness that increases with movement
C. Pain upon joint movement Rationale: initial symptoms of OA include pain with joint movement. Redness of the joint is more strongly associated with rheumatoid arthritis (RA), and stiffness in OA is worse right after the patient rests and decreases with joint movement
A nurse is assessing the casted extremity of a client. The nurse would assess for which of the following signs and symptoms indicative of infection? A. dependent edema B. diminished distal pulse C. presence of a "hot spot" on the cast D. Coolness and pallor of the extremity
C. Presence of a hot spot Signs and symptoms of infection under a cast area include odor or purulent drainage from the cast or the presence of "hot spots" which are area of the cast that are warmer than others. The physician should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallow of the skin, diminished arterial pulse, and edema. NOTE: process of elimination (expected to see with infection)
HYPERkalemia s/sx (MURDER)
M- muscle weakness U- urine (oliguria, anuria) R- respiratory distress D- decreased cardiac contractility (cardiac arrest) E- ECG changes R-reflexes, hyperflexia, or areflexia
The health care provider prescribes methotrexate for a 28 year old woman with stage II rheumatoid arthritis. When obtaining a health history form the patient, the most important for the nurse to communicate to the health care provider is that the patient has A. history of infectious mononucleosis as a teenager. B. family history of age-related macular degeneration of the retina C. been trying to have a baby before her disease becomes more severe. D. been using large doses of vitamins and health foods to treat the RA.
C. been trying to have a baby before her disease becomes more severe. Rationale: Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.
A nurse is assessing the casted extremity of a client. The nurse would assess for which of the following signs and symptoms indicative of infection? A. dependent edema B. diminished distal pulse C. presence of a "hot spot" on the cast D. Coolness and pallor of the extremity
C. presence of a "hot spot" on the cast Rationale: signs and symptoms of infection under a casted area include odor or purulent drainage from the cast of the presence of "hot spots" which are area of the cast that are warmer than others. The physician should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished arterial pulse, and edema
A patient with a herniated intravertebral disk undergoes a laminectomy and a discectomy. Following the surgery, the nurse should position the patient on the side by A. Elevating the head of the bed 30 degrees and having the patient extend the legs wile turning to the side. B. Turning the patient's head and shoulders and then the hips, keeping the patient centered in the bed C. having the patient turn by grasping the side rails and pulling the shoulders over D. Placing a pillow between the patient's legs and turning the entire body as a unit
D. Placing a pillow between the patient's legs and turning the entire body as a unit Rationale: logrolling is used to maintain correct body alignment after laminectomy. The other positions will create misalignment of the spine
A client with a hip fracture asks the nurse why Buck's (extension) traction is being applied before surgery. The nurse's response is based on the understanding that Buck's (extension) traction primarily: A. allows bony ealing to being before surgery B. provides rigid immobilization of the fracture site C. lengthens the fractured leg to prevent severing of blood vessels D. Provides comfort by reducing muscle spasms and provides fracture immobilization
D. Provides comfort by reducing muscle spasms and provides fracture immobilization Rationale: Buck's (extension ) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps immobilize the fracture. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. Traction also does not allow for bony healing to begin.
Following a laminectomy with a spinal fusion, a patient reports numbness and tingling of the right lower leg. The first action indicated by the nurse is to A. report the patients's complaint to the surgeon. B. check the vital signs for indications of hemorrhage C. Turn the patient to the side to relieve pressure on the operative area D. check the chart for preoperative neuromuscular assessment data
D. check the chart for preoperative neuromuscular assessment data Rationale; the postoperative movement and sensation of the extremities should be unchanged (or improved) from the preoperative assessment. If the numbness and tingling are new, this information should be immediately reported to the surgeon. Numbness and tingling are not symptoms associated with hemorrhage at the site. Turning the patient will not relieve the numbness
What are the signs of HYPOnatremia?
Depressed and Deflated 1. Neuro= seizures and comas 2. Heart= tachycardia and weak thready pulses 3. Respiratory Arrest (patient will not be breathing)
HYPERnatremia s/sx (you are FRIED)
F-fever(low), flushed skin R- restlessness (irritable) I-increased fluid retention and increased BP E-edema (peripheral) D-decreased urine output, dry mouth
What is seen in Hypokalemia?
Heart 1. Flat T waves, ST depression, and prominent U wave Muscular- Low and Slow 1. Dec DTR 2. muscle cramping 3. Flaccid paralysis (paralyzed limbs) GI: Low and Slow 1. Decreased motility, hypoactive to absent bowl sounds 2. Constipation 3. Abdominal Distention. 4. Paralytic ileum of intestines
S/SX of HYPERkalemia are:
Heart: tight and contracted! 1. ST elevation and peaked T waves 2. Severe= V fib or cardiac stand still 3. HYPOtension, Bradycardia GI Tract: Tight and Contracted! 1. Diarrhea 2. Hyperactive bowel Neuromuscular: tight and contracted 1. paralysis in extremities 2. Increased Deep tendon reflexes 3. Profound weakness (general feeling of heaviness)
HYPERnatremia s/sx ( SALT)
S- skin flushed A- agitation L- low grade fever T- thirst
A nurse is caring for a client who has had a spinal fusion with insertion of hardware. The nurse would be concerned especially with which of the following assessment findings? A. Temperature of 101.6 orally B. complains of discomfort during repositioning C. Old bloody drainage outlined on the surgical dressing D. Discomfort during coughing and deep breathing exercises
The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temp is expected after insertion of hardware, but a temperature of 101.6 F should be reported.
A 72 year old man presents to the ER with n/v/d for 2 days. He states that he babysat his 4 year old grandchild the other day when she had a GI bug. What are your first steps?
VS taken to see if he is volume depleted, ask if he has been able to keep anything down, along with any abdominal pain
A 72 year old man presents to the ER with n/v/d for 2 days. He states that he babysat his 4 year old grandchild the other day when she had a GI bug. What type of loss is this?
isotonic
You are caring for a patient with a bowel obstruction who has an Ng in place to low intermittent suction, she is NPO and has an IV of D5NS at 150ml/hr. Labs are as followed: glucose: 80 Na: 128 K: 2.8 BUN: 31 Cr: 1.5
sodium is low, Low K (hypokalemic), BUN and CR elevated ---> Based on lab the patient is NOT getting enough sodium. Fluid --> based on kidney function not enough K+ bc suctioning
What are the manifestations (s/sx) of HYPERcalcemia?
swollen and slow: moans, groans, and stones 1. Constipation 2. Bone Pain 3. Stones: renal calculi (kidney stones) 4. Deep tendon reflexes (DEC DTR and severe muscle weakness) - EKG: short ST, short QT, Vfib/asystole
You are caring for a patient with a bowel obstruction who has an Ng in place to low intermittent suction, she is NPO and has an IV of D5NS at 150ml/hr. Labs are as followed: glucose: 80 Na: 128 K: 2.8 BUN: 31 Cr: 1.5 Do you want to change her fluid?/ How
yes, if she is not having CNS symptoms- more NS maybe some hypertonic (if given, not for long) But if this patient is dehydrated she needs fluids so maybe saline bolus, D5NS too to help with blood sugar.
