Fluid and Electrolytes
Hyperchloremia S/S
** S/S of metabolic acidosis! Primarily this is going to be all ↓CNS activity... slowing down of functions! ** S/S of hypernatremia (Increased Na) • Acidosis: • Weakness, lethargy, unconsciousness • Kussmauls respirations (deep, rapid, vigorous breathing) • Anorexia, N/V & abdominal pain • ↓CNS activity • Hypernatremia: • ↓cardiac contractility, ↓cardiac output • Dry, flakey skin • Pulmonary edema → excess BP with holding all that fluid can lead to excess fluid in lungs
Manifestations of hyperkalemia (>5.0 mEq/l)
*Cardiac changes and dysrhythmias* *muscle weakness* paresthesia anxiety GI manifestations *Peak T Wave arrest*
Hypomagnesemia manifestations
*Chvostek and Trousseau signs* Apathy Depressed mood Psychosis *Neuromuscular irritability* *Muscle weakness* Tremors ECG changes Dysrhythmias
Hypernatremia causes
*Decreased water intake* *Fever* *Excessive* perspiration *Dehydration* *Hyperventilation* *Watery* diarrhea Enteral nutrition and parenteral nutrition deplete the cells of water *Diabetes insipidus* Cushing's syndrome *Impaired* renal function Use of corticosteroids *Excessive administration of sodium bicarbonate*
sodium polystyrene sulfonate (Kayexalate)
*Exchanges sodium ions for potassium ions in the large intestine.* *2. Used in the treatment of severe hyperkalemia (antidote)*. 3. Can be given PO or by 6 hour retention enema B. Side effects / nursing care 1. Needs to be in contact with GI tract for 6 hours to be most effective. 3. Monitor for hypokalemia and loss of magnesium and calcium 4. Monitor for sodium overload. 1/3 of sodium is retained. 5. Rectal administration helps to prevent constipation. 6. Stop resin administration when serum potassium is 4 - 5 mEq.
Causes of hyperkalemia (>5.0 mEq/L)
*Impaired renal function* Rapid administration of potassium Hypoaldosteronism Medications Tissue trauma Acidosis Burns
Hypocalcemia causes
*Inadequate dietary intake of calcium* *Inhibited absorption of calcium from the intestinal tract* *Inadequate vitamin D consumption* Diarrhea Long-term immobilization and *bone demineralization* Excessive gastrointestinal losses from diarrhea or wound draining *End-stage* renal disease *Calcium-excreting medications* such as diuretics, caffeine, anticonvulsants, heparin, laxatives, and nicotine *Decrease secretion of parathyroid hormone* Acute pancreatitis Crohn's disease *Excessive administration of blood*
Management of Hypomagnesemia:
*Magnesium sulfate IV* is administered with an infusion pump, monitor vital signs and urine output Oral magnesium Monitor for dysphagia *Seizure precautions* Dietary teaching foods- Nuts, grains, and green veggies
Causes of hypomagnesemia (<1.3)
*alcoholism* GI losses from suctioning Enteral or parenteral feeding deficient in magnesium rapid administration of citrated blood DKA (diabetic ketoacidosis)
Manifestations of hypokalemia:
*dysrhythmias* *muscle weakness* *paresthesia* *ECG changes-flatten T wave, prolonged QRS* dilute urine, excessive thirst fatigue anorexia decreased bowel motility
Manifestations of hypermagnesemia:
*hypoactive reflexes, drowsiness, muscle weakness, depressed respirations* ECG changes, dysrhythmias, and cardiac arrest
•A 79-year-old female client is admitted to the hospital with a diagnosis of bacterial pneumonia. Which of the following would most likely be a predisposing factor for the diagnosis of pneumonia? 1. Age 2. Osteoarthritis 3. Vegetarian Diet 4. Daily Bathing
1. Age •#1- The client's age is a predisposing factor for pneumonia; pneumonia is more common in elderly or debilitated clients. Other predisposing factors include smoking, URTIs, malnutrition, immunosuppression, and the presence of chronic illness. OA, vegetarian diets, and frequent bathing are not predisposing factors.
•A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first? 1. Elevate the head of the bed 30-45 degrees 2. Encourage the client to cough and deep breathe 3. Auscultate the lungs to detect abnormal breath sounds 4. Contact the physician
1. Elevate the head of the bed 30-45 degrees •#1: Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The physicians must be kept informed of changes in a client's status, but the priority in this case is alleviating the symptoms
The nurse is caring for a pt who is anxious & dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, & HCO3 24. The nurse would anticipate which initial intervention to correct this problem? 1. Encourage the pt to breathe in & out slowly into a paper bag. 2. Immediately administer oxygen via a mask & monitor oxygen saturation. 3. Prepare to start an intravenous fluid bolus using isotonic fluids. 4. Anticipate the administration of intravenous sodium bicarbonate.
1. Encourage the pt to breathe in & out slowly into a paper bag. This pt is exhibiting signs of hyperventilation that is confirmed with the blood gas results of respiratory alkalosis. Breathing into a paper bag will help the pt to retain carbon dioxide & lower oxygen levels to normal, correcting the cause of the problem. Rationales: Rationale 2: The oxygen levels are high, so oxygen is not indicated, & would exacerbate the problem if given. Intravenous fluids would not be the initial intervention. Rationale 3: Not enough information is given to determine the need for intravenous fluids. Rationale 4: Bicarbonate would be contraindicated as the pH is already high.
The body's electrolytes are regulated by which body systems? (Hint- there are 4)
1. Endocrine system (hormones, remember ADH is an important hormone that is involved in fluid and electrolytes) 2. Vascular system- The blood vessels aid in transportation of water and fluids to the body's cells and systems, as well as for maintaining blood volume and transporting waste products to the lungs and kidneys for removal. 3. GI System- Recall that excessive vomiting and diarrhea can cause electrolyte imbalance. The body absorbs water and nutrients in the small and large intestines. 4. Kidneys- The kidneys help maintain electrolyte concentrations by filtering electrolytes and water from blood, returning some to the blood, and excreting any excess into the urine.
Name the hypotonic solutions:
1/2 Normal Saline (1/2 NS or 0.45% NaCl) 0.33% NaCl 0.225% NaCl 2.5% dextrose in water (D2.5W)
Furosemide treats (list 5)
1: Edema from CHF 2: Pulmonary edema 3: Hepatic disease 4: Renal disease 5: May be used to treat HTN
•A client with bacterial pneumonia is to be started on I.V. antibiotics. Which of the following diagnostic tests must be completed before antibiotic therapy begins? 1. Urinalysis 2. Sputum culture 3. Chest radiograph 4. Red blood cell count
2. Sputum culture #2- A sputum specimen is obtained for culture to determine the causative organism. After the organism is identified, an appropriate antibiotic can be prescribed. Beginning antibiotic therapy before obtaining the sputum specimen may alter the results of the test. Neither a UA or chest radiograph nor a RBC count needs to be obtained before initiation of antibx therapy for pna.
One liter of water weighs
2.2 lbs (1 kg)
•The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). •pH 7.35; PC02 62; PO2 70; HCO3 34 •The nurse should: 1.Apply a 100% nonrebreather mask 2.Assess the vital signs 3.Reposition the client 4.Prepare for intubation
2.Assess the vital signs •#2- Clients with COPD have Co2 retention and respiratory drive is stimulated when the PO2 decreases. The HR, RR, and BP should be evaluated to determine if the client is hemodynamically stable. Symptoms, such as dyspnea, should also be assessed. Oxygen supplementation, if indicated, should be titrated upward in small increments. There is no indication that the client is experiencing respiratory distress requiring intubation.
A client with COPD is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which of the following statements is true concerning oxygen administration to a client with COPD? 1.High oxygen concentrations will cause coughing and dyspnea 2.High oxygen concentrations may inhibit the hypoxic stimulus to breathe 3.Increased oxygen use will cause the client to become dependent on oxygen 4.Administration of oxygen is contraindicated in client who are using bronchodilators
2.High oxygen concentrations may inhibit the hypoxic stimulus to breathe •#2-Clients who have a long history of COPD may retain CO2. Gradually the body adjusts to higher CO2 concentration, and the high levels of CO2 no longer stimulate the respiratory center. The major respiratory stimulant then become hypoxemia. Administration of high concentrations of O2 eliminates this respiratory stimulus and leads to hypoventilation. O2 can be drying if it is not humidified, but it does not cause coughing and dyspnea. Increased O2 use will not create an oxygen dependency; clients should receive O2 as needed. O2 is not contraindicated with the use of bronchodilators.
A pt's blood gases show a pH greater of 7.53 & bicarbonate level of 36 mEq/L. The nurse realizes that the acid-base disorder this pt is demonstrating is which of the following? 1. respiratory acidosis 2. metabolic acidosis 3. respiratory alkalosis 4. metabolic alkalosis
4. metabolic alkalosis Arterial blood gases (ABGs) show a pH greater than 7.45 & bicarbonate level greater than 26 mEq/L when the pt is in metabolic alkalosis. Rationale 1& 2: Respiratory acidosis & metabolic acidosis are both consistent with pH less than 7.35. Rationale 3: Respiratory alkalosis is associated with a pH greater than 7.45 & a PaCO2 of less than 35 mmHG. It is caused by respiratory related conditions.
Name the hypertonic solutions:
5% dextrose in normal saline (D5NS) 5% in 1/2 normal saline (D5 1/2NS) dextrose in 10% water (D10W)
The human body is approximately _______ % water.
60% But this also depends on the amount of adipose tissue, age, and gender
What are BUN levels used for?
A BUN test is done to see how well your kidneys are working. High levels indicate: kidney disease/damage or hypovolemia Low levels indicate: hypervolemia
A 22-yr-old man is admitted to the emergency department with a stab wound to the abdomen. The patient's vital signs are blood pressure 82/56 mm Hg, pulse 132/beats/min, respirations 28 breaths/min, and temperature 97.9' F (36.6' C). Which fluid, if ordered by the health care provider, should the nurse question? A) 0.45% saline B) 0.9% saline C) Packed red blood cells D) Lactated Ringer's solution
A) 0.45% saline IV administration of 0.45% saline is hypotonic and is used for maintenance fluid replacement and dilutes the extracellular fluid. IV solutions used for volume expansion for hypovolemic shock include lactated ringer's solution and 0.9% saline. If hypovolemia is due to blood loss, blood may be adminstered.
Which serum potassium result best supports the rationale for administering a stat dose of IV potassium chloride 20 mEq/L in 200 mL of normal saline over 2 hours? A) 3.1 mEq/L B) 3.5 mEq/L C) 4.6 mEq/L D) 5.3 mEq/L
A) 3.1 mEq/L The normal range for serum potassium is 3.5 to 5.0 mEq/L. This IV order provides a substantial amount of potassium. Thus, the patient's potassium level must be low. The only low value shown is 3.1 mEq/L.
When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is respiratory distress and the vital signs show hypotension and tachycardia. The nurse suspects that the patient may be experiencing what complication? A) Air embolism B) Catheter occlusion C) Insertion site trauma D) Precipitate build up in lumen
A) Air embolism The cap off the central line could allow entry of air into the circulation, causing an air embolus. Catheter occlusion, precipitate build in lumen manifest with sluggish infusions. Insertion site trauma manifests with edema near the insertion site and dysrhythmias.
A patient with dehydration is receiving a hypertonic solution. Which assessments must be done to avoid adverse risks associated with these solutions? (Select all that apply) A) Lung sounds B) Bowel sounds C) Blood pressure D) Serum sodium level E) Serum potassium level
A) Lung sounds C) Blood pressure D) Serum sodium level Blood pressure, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions.
Body fluids contain water and 2/3 of intracellular fluid (ICF). What is the most prevalent cation and anion in the ICF? Choose the correct answer. A) Potassium and Phosphate B) Sodium and Chloride C) Hydrogen and Sulfate D) Potassium and Sodium
A) Potassium and Phosphate The most prevalent cation and anion in the ICF is Potassium (+) and Phosphate (-). Remember a cation is a positively charged ion and an anion is a negatively charged ion. Refer to Queen's powerpoint.
A patient is admitted with metabolic acidosis. Which system is not functioning normally? A) Renal system B) Buffer system C) Endocrine system D) Respiratory system
A) Renal system When the patient has metabolic acidosis, the kidneys are not combining H+ with ammonia to form ammonium or eliminating acid with secretion of free hydrogen into the renal tubule. The buffer system neutralizes HCl acid by forming a weak acid. The hormone system is not directly related to acid-base balance. The respiratory system releases CO2 that combines with water to form hydrogen ions and bicarbonate. The hydrogen is then buffered by the hemoglobin.
You are caring for a patient admitted with diabetes, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient? (Select all that apply) A) The potassium level may be increased if the patient has nephropathy. B) The patient has been eating excessive amounts of foods that increase potassium levels. C) The patient may be excreting extra sodium and retaining potassium secondary to malnutrition. D) There may be excess potassium being released into the blood as a result of massive blood transfusion. E) The potassium level may be increased because of dehydration that accompanies high blood glucose levels.
A) The potassium level may be increased if the patient has nephropathy. D) There may be excess potassium being released into the blood as a result of massive blood transfusion. E) The potassium level may be increased because of dehydration that accompanies high blood glucose levels. Hyperkalemia may result from hyperglycemia, renal insufficiency, or cell death. Diabetes, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Because malnutrition does not cause sodium excretion accompanied by potassium retention, it is not a contributing factor to this patient's potassium level. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. The patient with a massive GI bleed would have a nasogastric tube and not be eating.
When caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient? (Select all that apply) A) Weakness B) Paresthesia C) Facial spasms D) Muscle tremors E) Depressed reflexes
A) Weakness E) Depressed reflexes Signs of hypercalcemia are lethary, fatigue, weakness, depressed reflexes, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms or hypocalcemia.
Arterial blood gas (ABG) values provide information about:
Acid-base status Underlying cause of imbalance Body's ability to regulate pH Overall oxygen status
Causes of hypochloremia (<97):
Addison disease, reduced chloride intake, GI loss, diabetic ketoacidosis, excessive sweating, fever, burns, medications, metabolic alkalosis. Loss of chloride occurs with loss of other electrolytes, potassium, sodium
What IV meds should be administered during a hyperkalemia emergency?
Administer IV Calcium Gluconate and Sodium Bicarbonate **Administering IV regular insulin and dextrose shifts potassium into the cells, worsening hyperkalemia**
Manifestations of hypchloremia:
Agitation, irritability, weakness, hyperexcitability of muscles, dysrhythmias, seizures, coma
What is albumin? When is it usually given?
Albumin is a product known as a volume expander that can be administered to increase volume in the patient's circulation. It may be given in cases of shock or severe bleeding when the patient needs more fluid in circulation.
Causes of hypophosphatemia (<2.5):
Alcoholism, refeeding of patients after starvation, pain, heat, stroke, respiratory alkalosis, hyperventilation, diabetic ketoacidosis, hepatic encephalopathy, major burns, hyperparathyroidism, low magnesium, low potassium, diarrhea, vitamin D deficiency, use of diuretic and antacids
What are the clinical manifestations of hypovolemia: A) Thirst B) Hypotension C) Tachycardia D) Flattened neck veins E) Poor skin turgor F) Decreased urine output G) Dry mucous membranes E) Shock, if severe H) BUN, H&H, and Cr or all of the above?
All of the above.
Fluid and electrolyte imbalances can occur due to various causes. Imbalances can be caused by: (Select All that Apply) A) Nausea + Vomiting B) Dehydration C) Surgery D) Trauma E) Burn injuries F) Bleeding G) Liver and Kidney problems or all of the above?
All of the above: A) Nausea + Vomiting B) Dehydration C) Surgery D) Trauma E) Burn injuries F) Bleeding G) Liver and Kidney problems
Nursing management for hypochloremia:
Assessment, avoid free water, encourage high-chloride foods, patient teaching related to high-chloride foods
Nursing management for hyperphosphatemia:
Assessment, avoid high-phosphorous foods, patient teaching related to diet, phosphate-containing substances, signs of hypocalcemia
Nursing management for hyperchloremia:
Assessment, patient teaching related to diet and hydration
A patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. Which IV solution may be used to pull fluid into the intravascular space after the paracentesis? A) 0.9% sodium chloride B) 25% albumin solution C) Lactated' Ringer's solution D) 5% dextrose in 0.45% saline
B) 25% albumin solution After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used a volume expander. Normal saline, lactated Ringer's solution, and 5% dextrose in 0.45% saline will not be effective for this action.
The nurse is caring for a patient admitted to the medical unit with hypokalemia. The best foods to offer the patient are? (Select all that apply) A) Apple B) Banana C) Orange juice D) Chocolate milk E) Cooked broccoli
B) Banana C) Orange juice D) Chocolate milk E) Cooked broccoli Milk products, oranges, and bananas are all high in potassium. Cooked broccoli is high in potassium. Apples are low in potassium.
You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. You should a medication from which classification until you consul with the health care provider? A) Antibiotics B) Loop diuretics C) Bronchodilators D) Antihypertensives
B) Loop diuretics Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus, administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing physician should be consulted for potassium replacement therapy, and the drug should should be withheld until the potassium has returned to normal range.
You are admitting a patient who reports abdominal pain, nausea, and vomiting. A proximal bowel obstruction is suspected. Which acid-base imbalance do you anticipate in this patient? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis
B) Metabolic alkalosis Because gastric secretions are rich in HCl acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis.
Which clinical manifestations would alert the nurse to the possibility of hypocalcemia in a patient? A) Weakness B) Paresthesia C) Facial spasms D) Muscle tremors E) Depressed reflexes
B) Paresthesia C) Facial spasms D) Muscle tremors Weakness and depressed reflexes are signs of hypercalcemia. Remember: Cocky calcium goes down (hypo) to Mexico! He learns two new dance moves: Chvostek's (The smile when stroking the facial nerve on the cheek) and Trousseu signs (The hand posture when BP cuff is inflated over the systolic pressure). Diarrhea (bad tacos) and circumoral tingling (tingling around the mouth)
You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results? A) Fully compensated respiratory alkalosis B) Partially compensated respiratory acidosis C) Normal acid-base balance with hypoxemia D) Normal acid-base balance with hypercapnia
B) Partially compensated respiratory acidosis A low pH (normal, 7.35 to 7.45) indicates acidosis. In a patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal, 35 to 45 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for elevated CO2.
Which statements are appropriate to include when teaching a patient about hypercalcemia? (Select all that apply) A) Have patient restrict fluid intake to less than 2000 mL/day B) Renal calculi may occur as a complication of hypercalcemia C) Weight-bearing exercises can help keep calcium in the bones D) The patient should increase daily fluid intake of 3000 to 4000 mL E) Any heartburn can be managed with an as needed calcium-containing antacid
B) Renal calculi may occur as a complication of hypercalcemia C) Weight-bearing exercises can help keep calcium in the bones D) The patient should increase daily fluid intake of 3000 to 4000 mL A daily fluid intake of 3000 to 4000 mL is necessary to enhance calcium excretion and prevent the formation of renal calculi, a potential complication of hypercalcemia. Turns are a calcium-based antacid that should not be used in patients with hypercalcemia. Weight-bearing exercise does enhance bone mineralization.
Body fluids contain water and 1/3 of extracellular fluid (ECF). What is the most prevalent cation and anion in the ECF? Choose the correct answer. A) Potassium and Phosphate B) Sodium and Chloride C) Hydrogen and Sulfate D) Potassium and Sodium
B) Sodium and Chloride The most prevalent cation and anion in the ECF is Sodium (+) and Chloride (-). Remember a cation is a positively charged ion and an anion is a negatively charged ion. Refer to Queen's ppt.
The renal system conserves ________ and excretes _______.
Bicarbonate, acid
What is the effect of potassium-sparing diuretics? (Ex: Spironolactone)
Blocks effect of aldosterone on renal tubules, causing loss of sodium and water while retaining potassium.
Define hydrostatic pressure.
Blood pressure generated by heart contraction.
When planning care for stable adult patients, the oral intake that is adequate to meet daily fluid needs is: A) 500 to 1500mL B) 1200 to 2200mL C) 2000 to 3000mL D) 3000 to 4000mL
C) 2000 to 3000mL Daily fluid intake and output is usually 2000 to 3000mL. This is sufficient to meet the needs of the body and replace both sensible and insensible fluid losses. These would include urine output and fluids lost through the respiratory system, skin, and GI tract.
Which action is most important for the nurse to take when caring for a patient with a subclavian triple-lumen catheter? A) Change in the injection cap after the administration of IV medications. B) Use a 5-mL syringe to flush the catheter between medications and after use. C) During removal of the catheter, have the patient perform the Valsalva maneuver. D) If resistance is met when flushing, use the push-pause technique to dislodge the clot.
C) During removal of the catheter, have the patient perform the Valsalva maneuver. The nurse should withdraw the catheter while the patient performs the Valsalva maneuver to prevent an air embolism. Injection caps should be changed at regular intervals but not routinely after medications. Flushing should be performed with at at least a 10-mL syringe to avoid excess pressure on the catheter. If resistance is encountered during flushing, force should not be applied. The push-pause method is preferred for flushing catheters but not used if resistance is encountered during flushing.
When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? A) Fluid movement from the blood vessels into the cells B) Fluid movement from the interstitial space into the cells C) Fluid movement from the interstitial spaces into the plasma D) Fluid movement from the blood vessels into interstitial spaces
C) Fluid movement from the interstitial spaces into the plasma In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.
A 50-yr-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should the nurse question? A) Limit foods high in potassium B) Calcium gluconate IV piggyback C) Give a potassium-sparing diuretic daily D) Administer intravenous insulin and glucose
C) Give a potassium-sparing diuretic daily Potassium-sparing diuretics inhibit the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss. A potassium-sparing diuretic is contraindicated in a patient with hyperkalemia. Management of patients with hyperkalemia may include limiting foods high in potassium, administering IV insulin and glucose, administering IV calcium gluconate, changing to potassium-wasting diuretics (e.g. furosemide [Lasix], hemodialysis, administering sodium polystyrene sulfonate (Kayexalate), and IV fluid administration.
You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00am assessment of this patient, you note that the IV solution, which was ordered to infuse at 125mL/hr, has infused 950 mL since it was hung at 4:00am. What is the priority nursing intervention? A) Slow the rate to keep vein open until next bag is due at noon. B) Notify the health care provider and complete an incident report. C) Listen to the patient's lung sounds and assess respiratory status D) Assess the patient's cardiovascular status by checking pulse and blood pressure
C) Listen to the patient's lung sounds and assess respiratory status After 4 hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for fluid volume excess, and you should assess the patient's respiratory status and lung sounds as the priority action and the notify the health care provider for further orders.
Which nursing intervention is most appropriate when caring for a patient with dehydration? A) Monitor skin turgor every shift B) Auscultate lung sounds every 2 hours C) Monitor daily weight and intake and output D) Encourage the patient to reduce sodium intake.
C) Monitor daily weight and intake and output Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume.
When assessing a patient admitted with nausea and vomiting, which finding best supports the nursing diagnosis of deficient fluid volume? A) Polyuria B) Bradycardia C) Restlessness D) Difficulty breathing
C) Restlessness Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occuring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma.
You receive a provider's prescription to change a patient's IV from 5% dextrose in 0.45% saline with 0.45% saline with 40 mEq KCl/L to 5% dextrose in 0.9% saline with 20 mEq KCl/L. Which serum laboratory values best support the rationale for this IV order change? A) Sodium, 136 mEq/L; potassium, 3.6 mEq/L B) Sodium, 145 mEq/L; potassium, 4.8 mEq/L C) Sodium, 135 mEq/L; potassium, 4.5 mEq/L D) Sodium, 144 mEq/L; potassium, 3.7 mEq/L
C) Sodium, 135 mEq/L; potassium, 4.5 mEq/L The normal range for serum sodium is 136 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV order decreases the amount of potassium and increases the amount of sodium. Therefore, for this order to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.
Hypocalcemia S/S
C.A.T.S. C - Convulsions A- Arrhythmias T - Tetany (involuntary contraction of muscles) S - Spasms and stridor
Decreased respirations leads to _________ retention.
CO2
Increased respirations lead to increased _______ elimination and decreased _______ in the blood.
CO2
What meds are used to treat hypocalcemia? (<8.6)
Calcium Gluconate or Calcium Chloride (orally) administer with orange juice to maximize absorption. Calcium Gluconate (parenterally) Use with caution if patient is taking digoxin (both are cardiac depressants) It can also cause vein irritation and should be administered through central line Can cause tissue necrosis if IV infiltrates
What is an excellent indicator of overall fluid volume loss or gain?
Changes in body weight. As the nurse, daily weight measurements are vital in the treatment of patients with hyper or hypo-volemia.
What are the clinical manifestations of hypervolemia?
Clinical manifestations of hypervolemia due to intravenous therapy are related to the respiratory and cardiac system. They include dyspnea, hypertension, tachycardia, coughing, pulmonary edema, cyanosis, rales, and distended jugular veins.
What are some gerontologic considerations of fluid imbalances?
Clinical manifestations of imbalance may be subtle Fluid deficit may cause delirium Decreased cardiac reserve Reduced renal function Dehydration is common Age-related thinning of the skin and loss of strength and elasticity
Osmolality is another word for?
Concentration. Higher osmolality means you have more particles in your serum. Lower osmolality means the particles are more diluted.
When planning the care of a patient with dehydration, what urine output would the nurse instruct the unlicensed assistive personnel to report? A) 60mL in 90 minutes B) 1200mL in 24 hours C) 300mL per 8-hour shift D) 20mL for 2 consecutive hours
D) 20mL for 2 consecutive hours The minimal urine output necessary to maintain kidney function is 30mL/hr. If the output is less than this for 2 consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.
The nurse on a medical-surgical unit identifies which patient as having the highest risk for metabolic alkalosis? A) A patient with a traumatic brain injury B) A patient with type 1 diabetes mellitus C) A patient with acute respiratory failure D) A patient with nasogastric tube suction
D) A patient with nasogastric tube suction Excessive nasogastric tube suctioning may cause metabolic alkalosis. Brain injury may cause hyperventilation and respiratory alkalosis. Type 1 diabetes mellitus (diabetic ketoacidosis) is associated with metabolic acidosis. Acute respiratory failure may lead to respiratory acidosis.
You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? A) Sodium falling to 138 mEq/L B) Potassium rising to 4.1 mEq/L C) Magnesium rising to 2.9 mg/dL D) Phosphorous falling to 2.1 mg/dL
D) Phosphorous falling to 2.1 mg/dL Calcium has an inverse relationship with phosphorous in the body. When phosphorus levels fall, calcium rises, and vice versa. Because hypercalcemia rarely occurs because of calcium intake, the patient's phosphorus falling to 2.1 mg/dL (normal, 3.0 to 4.5 mg/dL) may be a result of the phopshate-binding effect of calcium carbonate.
You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO2 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as: A) metabolic acidosis B) respiratory acidosis C) respiratory alkalosis D) within normal limits
D) within normal limits The normal pH is: 7.35 to 7.45 Normal PaCO2 levels are: 35 to 45 mm Hg HCO3 is 22 to 26 mEq/L PaO2 is greater than 80 Oxygen saturation is greater than 95% Because the patient's results all fall within these normal ranges, the nurse can conclude that the patient's blood gas results are within normal limits.
metabolic acidosis causes
DKA, severe diarrhea, renal failure, shock
What are some health problems that lead to acid-base imbalances?
Diabetes mellitus COPD Kidney disease
Hypocalcemia S/S
Diarrhea, Numbness, Tingling of extremities and around mouth, Convulsions, Positive Chvostek sign, Positive Trousseau sign, *Pt at risk for tetany.
What does digoxin do to potassium levels?
Digoxin increases potassium levels
What are causes of fluid volume excess? (hypervolemia)
Due to fluid overload or diminished homestatic mechanisms Heart failure, kidney injury, and cirrhosis of the liver Contributing factors: Consumption of excessive amounts of table salt or other sodium salts. Excessive administration of sodium-containing fluids- overhydrate
What are the clinical manifestations of hypervolemia?
Edema Distended neck veins Lungs- Crackles Increased B/P or low if third space shift Low or urine output- 1 mL/kg/hr or min 30 mL/hr I&O- more in than out Labs? BUN, H&H, Electrolytes
What happens when interstitial fluid is drawn into plasma?
Edema decreases. Think of interstitial fluid as TISSUE fluid compartments. When there is too much fluid going into the interstitial space, this will cause the tissues to FILL or SWELL causing edema. When the fluid in the interstitial place is drawn into plasma (drawn into the vascular space/blood vessels) the edema will decrease as the tissues are no longer filled with excess fluid.
When plasma enters interstitial fluid space causing a shift, this results in what manifestation?
Edema. When plasma enters the tissue's fluid compartments causing a shift/ imbalance in the blood vessels (vascular space), this results in edema.
Causes of hyperchloremia (>107)
Excess sodium chloride infusions with water loss, head injury, hypernatremia, dehydration, severe diarrhea, respiratory alkalosis, metabolic acidosis, hyperparathyroidism, medications
Hyperphosphatemia causes
Excessive dietary intake of phosphorus Overuse of *phosphate-containing laxatives or enemas* *Vitamin D intoxication* *Hypoparathyroidism* Renal insufficiency Chemotherapy
What diuretic is most commonly used to promote rapid diuresis?
First line diuretic choice is loop diuretics, (Lasix, aka Furosemide). If a client has low renal function and rapid diuresis is desired, loop diuretics will allow the kidneys to regain the ability to reabsorb sodium
What are the causes of hypernatremia (>145)?
Fluid deprivation, excess sodium intake/administration, diabetes insipidus, heat stroke, hypertonic IV solutions, low water enteral feedings
What are causes of fluid volume deficit? (hypovolemia)
Fluid loss related to: hemorrhage, frequent urination, vomiting, diarrhea, fistulas, fever, excessive nasogastric suctioning Reduced fluid intake related to: Dysphagia, unconscious states, reduced ability to sense taste, lack of fluid availability, lack of supplemental water when receiving concentrated tube feedings Fluid shift out of the vascular space related to: Burns, pancreatitis, acute intestinal obstruction, crushing injuries, diabetes insipidus, adrenal insufficiency, third-space shifts
Isotonic fluids
Fluids close to the same osmolarity as serum 0.9 % NS Lactated Ringers
Hypermagnesemia S/S
Flushing, Hypotension, Drowsiness, Lethargy, Hypoactive reflexes, Depressed respirations, Bradycardia
Causes of hypokalemia (<3.5 mEq/L):
GI Losses, medications-diuretics, prolonged intestinal suctioning, recent ileostomy, tumor of the intestine, alterations of acid-base balance, poor dietary intake, hyperaldosteronism
Management of hypernatremia:
Gradual lowering serum sodium level via infusion of hypotonic electrolyte solution Diuretics Assessment for abnormal loss of water and low water intake Assess for over-the-counter sources of sodium Monitor for CNS changes
What are the clinical indications for diuretic use? (What clinical findings indicate a need for diuretic use?)
Heart Failure Edema (fluid volume excess) Hypertension Diabetes Inspidus
Aldosterone
Hormone that stimulates the kidney to retain sodium ions and water, increases potassium secretion
Movement of fluid through capillary walls depends on:
Hydrostatic pressure: exerted on walls of blood vessels Osmotic pressure: exerted by protein in plasma
What are the side effects of potassium-sparing diuretics?
Hyperkalemia Hyponatremia Hepatic and renal damage Remember potassium sparing diuretics RETAIN potassium, therefore the serum potassium levels will increase. Since the diuretic inhibits sodium reabsorption promoting diuresis, the serum sodium level will be LOW. Of course, with any electrolyte imbalance, liver and kidney damage can occur.
A deficit of sodium in the blood is called ______. (<135 mEq/L)
Hyponatremia
Causes of hypocalcemia <8.6):
Hypoparathyroidism, malabsorption, osteoporosis, pancreatitis, alkalosis, transfusion of citrated blood, kidney injury, medications, thyroid cancers
What are nursing interventions for fluid volume excess (hypervolemia)?
I&O and daily weight; assess lung sounds, edema-3+, other symptoms Monitor responses to medications- *diuretics* and *parenteral fluids* Promote adherence to fluid restrictions, patient teaching related to sodium and fluid restrictions (250mg). Read food can Monitor, avoid sources of excessive sodium, including medications Promote rest, HOB^, turn
What med is used to treat hypermagnesemia (>2.5)
IV Calcium Gluconate
Management of Hypermagnesemia:
IV Calcium gluconate Hemodialysis Administration of loop diuretics, sodium chloride, and LR Avoid medications containing magnesium Patient teaching regarding magnesium- containing over-the-counter medications Observe for DTRs and changes in LOC (pregnancy for preclampsia)
What meds treat hypomagnesemia? (<1.5)
IV Magnesium Sulfate. Monitor cardiac rhythm and reflexes Assess renal function Monitor digitalis toxicity Calcium may need to be given to counteract magnesium if given too rapidly Potential danger of heart dysfunction and respiratory complications. Keep crash cart nearby.
What meds are used to treat hypercalcemia? (>10.2)
IV administration of 0.45% NaCl or 0.9% NaCl Furosemide (loop diuretic) Calcitonin (decreases calcium level)
What IV solutions are used to treat hypernatremia (>145)
IV administration of hypotonic solutions (0.3% NaCl, or 0.45% NaCl, or 5% dextrose in water)
How do you treat hyponatremia (<135)?
IV of LR or 3% NS Note: Water restriction and encouraging sodium-rich foods is a safer method for correcting the imbalance.
Management of hypocalcemia:
IV of calcium gluconate for emergent situations *Seizure precautions* Oral calcium and vitamin D supplements Exercises to decrease bone calcium loss Patient teaching related to diet and medications- laxatives and anti-acids can bind with Ca
Causes of hyponatremia (<135 mEq/L):
Imbalances of water, losses by vomiting, diarrhea, sweating, diuretics, adrenal insufficiency, certain medications and SIADH- brain swells
What is a special consideration in the older population and diuretic use?
In older adults, start low, go slow, monitor renal function, watch for dehydration
Hypertonic fluids
Increase in serum osmolarity. Pulls fluid into the blood vessels. Reduces risk of edema. Hypertonic solutions contain #'s 3,5, and 10: 3% NS 5% NS D10W D51/2NS D5LR D50W
What are the respiratory signs and symptoms of fluid volume excess? (3)
Increased respiratory rate (shallow respirations) Dyspnea Moist crackles on auscultation
What routes is potassium chloride available in?
It is available in oral and IV supplements. Assess renal function prior to adminstration. ****IV supplement ALERT: the usual concentration is between 10-40mEq/L and MUST be given at 10 mEq/100mL**** Stop the infusion if the pt complains of burning. Depending on the concentration, you may need to put the pt on a cardiac monitor and they may also require a central line.
Causes of hypermagensemia (>3.0)
Kidney injury, ketoacidosis, excessive administration of magnesium, extensive soft tissue injury
What action does Loop diuretics have? (Ex: Furosemide)
Loop diuretics are potassium wasting diuretics. They inhibit reabsorption of sodium and chloride in the loop of Henle and distal renal tubules
Hyperkalemia S/S
M.U.R.D.E.R. M - Muscle weakness U - Urine, oliguria, anuria R- Respiratory distress D - Decreased cardiac contractility E - ECG changes R - Reflexes, hyperreflexia, or areflexia (flaccid)
Causes of hypercalcemia (>10.2):
Malignancy and hyperparathyroidism, bone loss related to *immobility* and *diuretics*
What is Mannitol?
Mannitol is an IV diuretic used to rapidly induce diuresis by increasing the osmotic pressure (of the glomuler filtrate) causing fluid to be drawn out of the tissues and into the bloodstream. Used in mobilizing excess fluid in oliguric renal failure and edema. Also is used to reduce intraocular and intracranial pressure. With any diuretic, monitor I&Os, vital signs, and electrolyte imbalance.
What are ways electrolytes can be affected?
Medications, hyperalimentation (parenteral overfeeding), blood administration, IV fluids
What imbalance is this? pH 7.58 PaCO2 35 mm Hg PaO2 75 mm Hg HCO3- 50 mEq/L
Metabolic alkalosis
Management of hyperkalemia:
Monitor ECG, assess labs, monitor I&O, obtain apical pulse Limitation of dietary potassium and dietary teaching Administration of cation exchange resins (Kayexalate) Emergent care: IV calcium gluconate, IV sodium bicarbonate, IV regular insulin, and hypertonic dextrose IV, beta-2 agonists, dialysis Administer IV slowly and with an infusion pump
What are important nursing considerations when caring for a patient who is prescribed diuretics?
Monitor weight (important to use same scale, weight daily, wearing the same clothing) Monitor electrolytes Monitor for hypotension (change positions slowly) Consume a high potassium diet for loop and thiazide diuretics Limit potassium intake for potassium-sparing diuretics
What is Osmosis?
Movement of water from from an area of low concentration to high concentration across a semipermeable membrane.
Hypercalcemia S/S
Muscle weakness, Constipation, Anorexia, N/V, Polyuria, Polydipsia, Neurosis, Dysrhythmias,
Hypernatremia (>145 mEq/L)
Occurs in patients with normal fluid volume, FVD, FVE. Those who are most affected are very old, very young, and cognitively impaired-cells shrink.
Medical management for Hypophosphatemia:
Oral of IV phosphorous replacement
Passive transport includes:
Osmosis, diffusion, and filtration
What are osmotic diuretics? Ex: Mannitol
Osmotic diuretics pull fluid from tissues due to a hypertonic effect.
What is Cushing's syndrome?
Overproduction of aldosterone, leading to sodium retention, and secretion of potassium. This causes an increase in blood pressure.
Clinical manifestations of hypercalcemia (>10.2):
Polyuria, thirst, *muscle weakness*, intractable nausea, abdominal cramps, *severe constipation*, diarrhea, peptic ulcer, bone pain, *ECG changes*, dysrhythmias, *kidney stones*
Manifestations of hyponatremia (<135 mEq/L):
Poor skin turgor, dry mucosa, headache, decreased salivation, *decreased blood pressure*, nausea, abdominal cramping, neurologic changes (seizures or coma), respiratory arrest
What treatment is used for hypokalemia? (< 3.5)
Potassium Chloride. If a patient has low potassium levels then it only makes sense to replace the potassium. Potassium chloride is mainly used to replace and prevent potassium deficiency. Potassium loss can be due to excessive or prolonged vomiting, diarrhea, intestinal drainage, and the famous potassium wasting diuretics.
Management of hypokalemia (<3.5 mEq/L)
Potassium replacement: increase dietary potassium or IV for severe deficit Foods: OJ, spinach, broccoli, cantelope, banana Monitor ECG for changes- flattened T-wave, prolong QRS Monitor ABGs for alkalosis Monitor patients receiving *digitalis* for toxicity Monitor for early signs and symptoms Administer IV potassium only after adequate urine output has been established- renal function
Major intracellular electrolytes
Potassium, Magnesium, and Phosphate
respiratory acidosis causes
Primary Cause: Hypoventilation (causes hypercapnia); Contributing Causes: COPD, Pulmonary dz, Drugs, Obesity, Mechanical asphyxia, Sleep Apnea
respiratory alkalosis causes
Primary cause: Hyperventilation (causes hypocapnia); Contributing Causes: Overventilation on a ventilator, Response to acidosis, Bacteremia, Thyrotoxicosis, Fever, Hepatic failure, Response to hypoxia, Hysteria
What is creatinine?
Product of muscle breakdown, measurement of kidney function
What imbalance is this? pH 7.60 PaCO2- 30 mm Hg PaO2- 60 mm Hg HCO3- 22mEq/L
Respiratory alkalosis
What treatment is used for hyperkalemia? (> 5.0)
Sodium polystyrene sulfonate (Kayexalate) When there is too much potassium, we need to work on lowering the level between the expected range (3.5-5.0). Kayexalate is administered orally or rectally. It pulls potassium out from the extracellular fluid and is excreted through feces. It causes diarrhea.
Major extracellular electrolytes
Sodium, Chloride, Calcium, and Bicarbonate.
What is hemoglobin?
The amount of available O2 carrying RBCs
What is the primary regulator of acid-base balance?
The buffer system
What is Facilitated diffusion?
The diffusion of molecules across a membrane through transport protein channels.
What is Diffusion?
The movement of particles from an area of high concentration to an area of low concentration.
Define osmotic pressure.
The pressure that would have to be applied to prevent a solvent from passing into a solution by osmosis. Often used to express the concentration of the solution.
Hyperphosphatemia
The same as low calcium Weak B's: blood, bones, heartBeats Trousseau + Chvostek signs Diarrhea
What are 3 major roles of electrolytes?
They move fluids within the body Produce energy Contract muscles
What are the major classes of diuretics? (4)
Thiazides Loop Diuretics Potassium-sparing diuretics Osmotic
What action does thiazide diuretics have? (Ex: Hydrochlorothiazide)
Thiazides are potassium wasting diuretics. They block the chloride pump in the kidney and inhibits the reabsorption of sodium and chloride in the distal tubule promoting diuresis (urination)
Hypophosphatemia
Think HIGH calcium Decreased DTR Severe muscle weakness Decreased HR, RR Increased BP Kidney stones
What causes hyponatremia?
Too much water, SIADH, retaining water, psychogenic polydipsia
Management of hyponatremia:
Treat the underlying condition Sodium replacement: IV NaCl 0.9% Water restriction Medication Assessment: I&O, daily weight, lab values, CNS changes Encourage dietary sodium Monitor fluid intake Effects of medications (diuretics, lithium) if too much water is the cause
Management of hypercalcemia:
Treat underlying cause Administer IV fluids, furosemide, phosphates, calcitonin, biphosphonates *Increase mobility* *Encourage fluids* Dietary teaching, fiber for constipation Ensure safety
Medical management for hyperphosphatemia:
Treat underlying disorder, vitamin-D preparations, calcium-binding antacids, phosphate-binding gels or antacids, loop diuretics, NS IV, dialysis
What are special considerations when caring for older adults taking thiazide diuretics?
Watch for hypotension and electrolyte imbalances
Hypernatremia S/S
You are 'fried' or S.A.L.T. F - Fever (low grade), flushed skin R - Restless (irritable) I - Increased fluid retention and increased BP E - Edema (peripheral and pitting) D - Decreased urinary output, dry mouth S = Skin flushed A = Agitation L = Low-grade fever T = Thirst
The nurse is caring for a client with a history of heart disease has developed hypokalemia. An ECG is ordered and the nurse notes an elongated Q-T interval that develops into torsades de pointes. Which of the following interventions are appropriate for the nurse to perform in this situation? Select all that apply. a) Call the rapid response team b) Prepare to assist with cardiac defibrillation c) Administer intravenous procainamide d) Prepare to assist with external cardiac pacing e) Administer intravenous magnesium sulfate
a) Call the rapid response teamTorsades de pointes is a potentially life-threatening condition that can develop after a noted prolonged Q-T interval. It is considered a medical emergency that requires quick action by the nurse. A rapid response should be initiated by the nursing staff because this alerts the provider and other staff members to the situation so the best team to handle this emergency are present. b) Prepare to assist with cardiac defibrillationIf the rhythm does not correct from the magnesium sulfate, the team will prepare to defibrillate the client. e) Administer intravenous magnesium sulfateMagnesium sulfate is the first line medication given, 1-2 g over 30-60 seconds, repeated every 5-15 minutes.
A nurse must administer a dose of potassium chloride for a client with hypokalemia. 40 mEq of Potassium Chloride has been ordered IV to be given one time. The nurse understands which of the following items when administering this drug? a) Give the medication in a 500 mL bag of fluid b)Administer the medication followed by a 10 mL flush of normal saline c)Administer IV push over 5 minutes d)Avoid giving the dose just after a meal
a) Give the medication in a 500 mL bag of fluid Potassium chloride can be very irritating to the vein when given quickly as a bolus, and diluting it will reduce the likelihood of irritation. To prevent phlebitis when administering this drug, the nurse would ensure that the medication is mixed into a 500 mL bag of fluid.
A client who has been suffering from severe diarrhea has developed hypokalemia and cardiac arrhythmias as a result. Which of the following treatments would most likely be ordered for this client to correct the situation? a) IV administration of potassium b) Oral intake of potassium by electrolyte preparations c)Encouraged intake of potassium-rich foods, such as bananas d)No intervention but continue to monitor the client's hemodynamic status
a) IV administration of potassiumHypokalemia occurs when there is not enough potassium in the body. The decrease in potassium can cause life-threatening arrhythmias. Although hypokalemia may be treated in various ways by adding potassium to the diet, if the condition is severe enough that it is causing heart conduction changes, the client should receive potassium as soon as possible to correct the situation, preferably through an IV.
When analyzing an arterial blood gas report of a pt with COPD & respiratory acidosis, the nurse anticipates that compensation will develop through which of the following mechanisms? a) The kidneys retain bicarbonate. b) The kidneys excrete bicarbonate. c) The lungs will retain carbon dioxide. d) The lungs will excrete carbon dioxide.
a) The kidneys retain bicarbonate. Read the question carefully. It is NOT asking you what happens during respiratory acidosis, it is asking you what COMPENSATORY mechanism occurs when the pt is acidotic. The kidneys will retain bicarbonate which is an alkalinizing agent in order to try and maintain homeostasis. Just think, if something is acidic, how do we neutralize it? We don't add more acid, we will add more base, or in this case bicarbonate because it is basic (alkaline).
While checking a client's morning labs, the nurse notes a potassium level of 2.8 mEq/L. Which of the following clinical findings is NOT consistent with this? a) Widened T wave b)ST depression c)Prominent U wave d)Shallow, inverted T wave
a) Widened T waveA potassium level of 2.8 mEq/L indicates hypokalemia. Hypokalemia ECG changes include ST depression, shallow/flat/inverted T waves, or a prominent U wave. A widened T wave is indicative of hyperkalemia, or a potassium level >5.0 mEq/L.
The nurse is caring for 4 clients, all of whom have insulin scheduled. Which client will need insulin first? a)A client with a potassium of 6.2 b)A client with a magnesium of 1.8 c)A client with a POC glucose of 60 d)A client with a POC glucose of 145
a)A client with a potassium of 6.2 Insulin moves both glucose and potassium across the cell membrane, lowering the amount of potassium in the blood. Since hyperkalemia affects the heart, the client with a potassium level of 6.2 must be given insulin first.
The nurse is caring for a client receiving rapid fluid resuscitation. Which of the following are important for the nurse to monitor? Select all that apply. a)Breath sounds B)oxygenation saturation c)breathing effort d)pleural rub e)jugular venous distention
a)Breath sounds. These signs and symptoms include crackles in the lungs, increased breathing effort, shortness of breath, JVD, edema, and hypertension. B)oxygenation saturation c)breathing effort e)jugular venous distention JVD indicates to the nurse that the fluid is going in too fast and there is increased right heart pressure.
Which of the following types of IV fluids is an example of a hypertonic solution? a)D10W b)0.45% sodium chloride c)Lactated Ringer's d)0.9% sodium chloride
a)D10W A hypertonic solution is one that contains a higher concentration of solutes when compared to plasma. As a result, when the nurse administers a hypertonic solution, fluid will flow out of the cell and into the extracellular space. An example of a hypertonic solution is D10W.
The nurse is caring for a client who requires fluids for hydration. The client needs an isotonic solution to which potassium can be added. Which of the following solutions would the nurse expect to give? a)Dextrose 5% in Water b)0.45% NaCl solution c)Dextrose 5% in 0.45% NaCl solution d)Ringer's Lactate
a)Dextrose 5% in Water Dextrose 5% in Water (D5W) is isotonic and is a good vehicle for potassium. 0.45% NaCl is hypotonic as is dextrose in 0.45% NaCl. Ringer's lactate contains components that mimic the concentration of electrolytes in the blood, so adding potassium could cause too much potassium to be given to the client.
The provider has ordered a hypotonic IV solution to manage the client's condition. Based on the nurse's knowledge of fluid and electrolytes, hypotonic IV solutions are given in what type of situation? a)Diabetic ketoacidosis b)Hypotonic dehydration c)Blood transfusions d)Hyponatremia
a)Diabetic ketoacidosis Hypotonic IV solutions are given when there is intracellular dehydration. These situations include GI fluid losses, hypertonic dehydration, and diabetic ketoacidosis.
A client is receiving an IV infusion of lactated Ringer's solution during surgery. Which best describes a potential complication of using this type of fluid? a)Fluid overload b)Alkalosis c)Respiratory depression d)Hyponatremia
a)Fluid overload A client is at risk of fluid overload if they receive too much fluid in a short amount of time, and Lactated Ringer's (LR) is sometimes given in large amounts during surgery. It should be administered on a pump or well monitored when administered by gravity. Lactated Ringer's is a type of isotonic solution with a small amount of electrolytes added that may be administered during surgery to prevent volume loss.
A recovery room nurse is caring for a client who is recovering from anesthesia after colon surgery. The nurse is providing IV fluids of Normal Saline at a rate of 150 mL/hr to the client. In order to avoid complications associated with fluid overload, which intervention would the nurse most likely perform? a)Maintain IV administration with a fluid pump instead of gravity b)Elevate the extremity that has the IV c)Increase the rate of the IV for the first hour and then turn it down to a very low rate d)Apply a pressure support sleeve to the IV bag
a)Maintain IV administration with a fluid pump instead of gravity A client recovering from surgery can be at risk of fluid overload if the IV fluids run too fast or are not well controlled. Occasionally clients are given IV fluids by gravity, which must be watched closely to avoid giving too much fluid at once. The nurse can reduce the risk of too high volume administration by using a fluid pump instead of administering fluid by gravity.
A client who is dizzy, hypotensive, and weak has blood work confirming adrenal insufficiency. The client needs an isotonic solution to replace lost fluids. Which of the following is an isotonic solution? Select all that apply. a)Normal saline b)Lactated ringers c)D5W in the bag d)Half normal saline e)2.5% dextrose
a)Normal saline b)Lactated ringers c)D5W in the bag
A client with a history of kidney disease is being seen for symptoms of muscle weakness and fatigue. The nurse checks the client's blood chemistry levels and notes that the potassium level is 6.8 mmol/L. Which interventions would be involved in the management of this lab level? Select all that apply. a)Prepare the client for an EKG b)Administer intravenous calcium gluconate c)Administer oral digoxin d)Provide supplemental oxygen via face mask e)Prepare the client for an echocardiogram
a)Prepare the client for an EKGA client with hyperkalemia is at risk of developing potentially life-threatening cardiac arrhythmias. The nurse in this situation should prepare the patient for an EKG. When assessing the client, the nurse should monitor for an irregular apical heart rate, which indicates arrhythmia. Electrolyte-binding and electrolyte-secreting medications should be administered as prescribed, to lower the serum K level. Loop diuretics will assist with the excretion of K. The client should also be prepared for dialysis as prescribed. b)Administer intravenous calcium gluconateThe nurse in this situation should administer calcium gluconate, which reduces the irritability of the heart muscle from the elevated potassium.
A nurse in the ICU is working with a 67-year-old client with a potassium level of 2.9 mEq/L. An hour after admission to the hospital, the client develops a cardiac arrhythmia. The rhythm on the monitor shows pulseless electrical activity (PEA). Which action should the nurse perform first? a)Start CPR by using chest compressions at a rate of 100 per minute b)Charge the defibrillator to administer a shock c)Provide 2 rescue breaths and reassess the heart rhythm d)Administer adenosine and place the client in the recovery position
a)Start CPR by using chest compressions at a rate of 100 per minute When a client enters cardiac arrest and has a rhythm of PEA on the monitor, the nurse must perform chest compressions to support blood flow, as long as the client's code status is not "do not resuscitate", or DNR. PEA does not produce electrical activity and will not respond to a shock from an AED.
In which situation would a nurse most likely use a pressure sleeve when administering IV fluids? a)The client needs rapid intravascular volume repletion b)The client is receiving antibiotics c)The client has high blood pressure d)The client is obese
a)The client needs rapid intravascular volume repletion The client needs rapid intravascular volume repletionA pressure sleeve is a mechanism that can be added to the outside of an IV bag to increase the rate at which IV fluid flows into the client. A pressure sleeve may be added when a client quickly needs greater volumes of intravascular fluid. Examples include hemorrhage or severe dehydration.
The provider orders an electrolyte replacement on a client with a potassium of 2.4. The nurse knows that this potassium level could be caused by which of the following? a)Vomiting b)Diarrhea c)Loop diuretics d)Dehydration e)Excess potassium intake
a)Vomiting b)Diarrhea c)Loop diuretics Normal potassium levels in the blood are between 3.5-5.5 mEq/L, so this client is hypokalemic. Loop diuretics decrease potassium levels. Diarrhea can lead to potassium loss. Vomiting can lead to potassium loss.
A pH less than 7.35 is considered:
acidosis
A pH that is greater than 7.45 is considered:
alkaline
Nursing management for hypophosphatemia:
assessment, encourage foods high in phosphorus, gradually introduce calories for malnourished patients receiving parenteral nutrition
A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, PaCO2 of 43 mm Hg, PaO2 of 75 mm Hg, and HCO3− of 42 mEq/L. Based on these findings, the nurse documents that the patient is experiencing which type of acid-base imbalance? a) Respiratory alkalosis b) Metabolic alkalosis c) Respiratory acidosis d) Metabolic acidosis
b) Metabolic alkalosis How do we know this? Because pH is above 45 and HCO3- is greater than 26 High pH= alkalosis HCO3- = less than 22 or higher than 26 = metabolic
The nurse is reviewing lab values and notes the client's K is 6.5 mEq/L. The client complains of palpitations, and the client's EKG shows tall, peaked T waves. Which of the following is a priority intervention for the nurse? a)Continue to monitor b)Administer IV insulin as ordered c)Administer IV KCl as ordered d)Ensure the client has an airway
b)Administer IV insulin as orderedIV insulin should be given as ordered. This helps shift potassium from the extracellular space to the intracellular space, which lowers the serum potassium level.
A nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PCO2 of 30 mm Hg, and HCO3 of 22 mEq/L. The nurse analyzes these results as indicating which condition? a. Metabolic acidosis, compensated b. Respiratory alkalosis, compensated c. Metabolic alkalosis, uncompensated d. Respiratory acidosis, uncompensated
b. Respiratory alkalosis, compensated pH is 7.45 or on the higher scale, therefore is alkalosis PCO2 is 30 which is low (normal expected range is between 35-45 mm Hg). PCO2 measures respiratory changes, this is why it is respiratory. It is compensated because the pH is not abnormal. Remember if PaCO2 is abnormal and pH is normal, it indicates compensation. pH > 7.4 would be a compensated alkalosis. pH < 7.4 would be a compensated acidosis.
When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? a. PaCO2 36 b. pH 7.48 c. HCO3 21 mEq/L d. O2 sat 95%
b. pH 7.48 pH greater than 7.45 = alkalosis HCO3- less than 22 or greater than 26 mEq/L = metabolic. Even though C may be less than 22, a lower HCO3- isn't always consistent but a high pH is ALWAYS consistent. Look for key words to answer the question properly.
Sodium Bicarbonate (NaHCO3)
base that can reverse acidosis
A nurse is caring for a client with IV fluids running into a peripheral IV. Which of the following would indicate the client is experiencing IV fluid-induced hypervolemia? Select all that apply. a)Nausea and vomiting b)Headache c)Dyspnea d)Hypertension e)Tachycardia
c)Dyspnea d)Hypertension e)Tachycardia Clinical manifestations of hypervolemia due to intravenous therapy are related to the respiratory and cardiac system. They include dyspnea, hypertension, tachycardia, coughing, pulmonary edema, cyanosis, rales, and distended jugular veins.
What are the major anions:
chloride, bicarbonate, phosphate, sulfate, proteinate ions
signs of hyponatremia
confusion, seizures, lethargy
A client with a 3-day history or nausea and vomiting presents to the emergency department. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which of the following? a. A decreased pH and an increased CO2 b. An increased pH and a decreased CO2 c. A decreased pH and a decreased HCO3- d. An increased pH with an increase HCO3-d.
d. An increased pH with an increase HCO3- Nausea and vomiting REMOVES acid, therefore is BASIC (alkaline). The values consistent with alkalosis is an increased pH and increased bicarb level. (Basic bitches vomit, lol) Diarrhea REMOVES base from the body, therefore is acidotic. (If you have too much diarrhea coming out of your AZZ you're going to be AZZIDOTIC, aka acidotic, lol) These are examples of metabolic acidosis and alkalosis. Remember respiratory acidosis and alkalosis involves hypo and hyperventilation. Reflecting the respiratory measurements to fluctuate (PACO2 and PAO2)
A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, PCO2 is 90 mm Hg, and HCO3- is 22 mEq/L. The nurse interprets the results as indicating which condition? a. Metabolic acidosis with compensation b. Respiratory acidosis with compensation c. Metabolic acidosis without compensation d. Respiratory acidosis without compensation
d. Respiratory acidosis without compensation pH is low = acidosis PCO2 = HIGH (remember a high PCO2 is compatible with respiratory acidosis, and a LOW PCO2 reflects respiratory alkalosis) It is uncompensated because....
Alkalosis is caused by
decreased CO₂ or increased HCO₃
Hyperchloremia causes
excess sodium chloride infusions with water loss, head injury, hypernatremia, dehydration, severe diarrhea, respiratory alkalosis, metabolic acidosis, hyperparathyroidism, medications
Manifestations of hyperphosphatemia:
few symptoms; soft-tissue calcifications, symptoms occur due to associated hypocalcemia
Define third spacing
fluid accumulates in areas that normally have no fluid or a minimum amount of fluid. (brain, heart, lungs)
Acidosis is caused by
increased CO₂ or decreased HCO₃
What does renin do?
increases blood pressure
What does Mannitol do?
it is a diuretic; we use it when we need a lot of water removed IV mannitol is used to lower intraocular pressure and intracranial pressure. Affects water not sodium
Causes of hyperphosphatemia (4.5 mg/dL)
kidney injury, excess phosphorous, excess vitamin D, acidosis, hypoparathyroidism, chemotherapy
Furosemide (Lasix)
loop diuretic (potassium wasting)
Hypotonic fluids
lower osmotic pressure 0.45% NaCl 0.33% NaCl 0.225% NaCl 2.5% Dextrose in Water D5W Remember NS and NaCl are the same thing.
Hypercalcemia causes
malignancy and hyperparathyroidism, bone loss related to immobility
What imbalance is this? pH 7.28 PaCO2 28 mm Hg PaO2 70 mm Hg HCO3- 18 mEq/L
metabolic acidosis
What imbalance is this? pH- 7.18 PaCO2- 38 mmHg PaO2- 70 mmHg HCO3- 15 mEq/L
metabolic acidosis pH is low HCO3 is low
Manifestations of hypophosphatemia:
neurologic symptoms, confusion, muscle weakness, tissue hypoxia, muscle and bone pain, increased susceptibility to infection
Name the isotonic solutions:
normal saline (NS) Lactated Ringers (LR) 5% dextrose in water (D5W)
Mannitol
osmotic diuretic
What are the ABG ranges and what do they measure? pH range? PaCO2? HCO3? PaO2? SaO2?
pH = 7.35-7.45: measures acid-base balance-changes affect body function PaCO2 = 35-45: influenced by respiratory changes HCO3 = 22-26: influenced by metabolic changes in kidney. PaO2 = 80-100: partial pressure of oxygen in arterial blood Sa02 = 95% or greater: Oxygen saturation
What is hematocrit?
percent of blood volume that is RBCs
Spironolactone
potassium sparing diuretic
antidiuretic hormone (ADH)
promotes retention of water by kidneys
Furosemide contraindications/precautions
rapid IV push of high dose can cause ototoxicity
Medical management of hypochloremia:
replace chloride-IV NS or 0.45% NS
What imbalance is this? pH 7.33 PaCO2 67 mmHg PaO2 47 mm Hg HCO3 37 mEq/L
respiratory acidosis
Medical management of hyperchloremia:
restore electrolyte and fluid balance, LR, sodium bicarbonate, diuretics
metabolic alkalosis causes
severe vomiting, excessive GI suctioning, diuretics, excessive NaHCO3
What is an example of active transport?
sodium potassium pump
What are the major cations:
sodium, potassium, calcium, magnesium, hydrogen ions
Manifestations of hyperchloremia:
tachypnea, lethargy, weakness, rapid, deep respirations, hypertension, cognitive changes
Manifestations of hypocalcemia:
tetany, circumoral numbness, paresthesias, hyperactive DTRs, Trousseau's sign, Chovstek's sign, seizures, respiratory symptoms of dyspnea and laryngospasm, abnormal clotting, anxiety
Define fluid and electrolyte balance
the process of regulating the extracellular fluid volume, body fluid osmolality, and plasma concentrations of electrolytes
Name the manifestations of hypernatremia (>145)
thirst, elevated temperature, late serious: swollen dry (red beefy tongue), nausea and vomiting, and increased muscle tone
Hyperkalemia causes
usually treatment related, impaired renal function, hypoaldosteronism, tissue trauma, acidosis
Dehydration is not the same as FVD. Dehydration is the loss of ________ alone, with increased serum ________ levels.
water, sodium
Hypomagnesemia S/S
↑HR ↑BP Shallow Respirations Tetany/Twitches/Seizures/Paresthesias ↑DTR Irritability/Confusion + Trousseau's and Chvostek's
