NUR 310 Module 4 (Excess fluids, electrolyte balance, drug therapy)

what are ascites?

accumulation of fluid in the peritoneal cavity describe as tympany, dullness, bulging flank Moderate to severe abdominal discomfort increased abdominal grith increased weight sever sodium retention dilutional hyponatremia renal failure

A patient reports a drug allergy to sulfonamides. Which diuretic drug class should the nurse question if ordered for the patient? a. loop diuretics b. thiazides c. potassium-sparing diuretic d. sosmotic diuretics

b. thiazides

What can ascites lead to?

development of shock renal failure respiratory failure hypoperfusion

most common cause of dehydration?

diarrhea

Symptoms of hypernatremia

disorientation agitation confusion

what are diuretics?

drugs that increase urine production

Whys is a dietary sodium restriction required when taking loop diuretics?

high sodium intake can cause sodium retence and reduce the diuretics induced sodium loss.

What type of medications puts a patient at risk for intrarenal acute kidney injury (AKI)?

Antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs) are common potential contributors to intrarenal AKI.

What is dependent edema?

localized edema occurs in feet and ankles associated with prolonged sitting or standing

Protoype for osmotic diuretics

mannitol (Osmitrol)

symptoms of hyperkalemia

muscle cramps paresthesia to weakness abdominal cramping ECG changes

1Why do loop diuretics need to be pushed slowly when administered via intravenous (IV) push?

To prevent ototoxicity

A patient is ordered potassium replacement for a potassium level of 3.2 mEq/dL. What is the best way to administer this medication?

Whole pill by mouth

What does tubular component of kidney do?

necessary substance reabsorbed into blood stream and unneed materials secreted into tubular filtrate to eliminate in urine

the functional unit of kidney

nephron

what is the function of loop diuretics?

reduce absorption of sodium in loop of henle - decrease osmality in interstitial fluid of collecting ducts -Impairs ability to concentrate urine at loop

what is the function of potassium spring diuretics?

reduce sodium absorption in distal and collecting duct. effects of aldosterone inhibited promoting sodium and water excretion

hypocholermia

when levels of chloride is less than 98 mEq/L

Hypokalemia

when potassium levels are less than 3.5 mEq/L

What is pitting edema?

when pressure over edematous area forces fluid movement and leaves an indentation

colloid osmotic pressure

pressure induced by proteins in blood plasma greater on venous end of capillary bed

what is the function of thiazide diuretics?

prevent NaCl reabsorption in distal convoluted tubule -increased potassium loss in urine -uric acid retention

Contraindication of Thiazides

sulfa allergy kidney decompensation anuria

what is edema?

swelling

manifestations of edema

swelling VS changes stiff, itchy joints

What is edema?

swelling characterized by buildup of interstitial fluid

What are thiazide diuretics?

synthesized drug

what do diuretics target?

the kidneys causing decrease sodium reabsorption

what are electrolytes?

chemicals that produce ions when they dissolve in water

Hyperchloremia

chloride levels greater than 108 mEq/L

symptoms of hyperchloremia

deep rapid breathing, weakness, headache, diminished cognitive ability, cardiac arrest

Contraindication of Loop Diuretics

sensitivity to drug anuria allergies to sulfonamides may also be allergic furosemide

treatment for cirrhosis

- paracentesis- removes fluid buildup inside abdomen called ascites - diuresis - increased production of urine - IV albumin - Fluid restriction - decrease protein intake - decrease sodium intake

diagnostic criteria of dehydration

- physical exam - fluid I/Os - characteristic of urine -stools -emesis & sweat - nutrition - lab analysis

Action of potassium-sparing diuretic

-Increases diuresis -decreased edema -decreases BP -Blocks aldosterone which retains sodium and water and excretion of K+

Indications for osmotic diuretics

-Manages oliguria & anuria -Prevents acute renal failure in trauma patients or lengthy surgeries

clinical manifestation of cirrhosis

-ascites

clinical manifestation of dehydration

- decreased level of consciousness - dry mucous membranes - changes in VS (increase RR, decrease BP, weak pulse) - sunken eyes - decrease urine output

Use of potassium-sparing diuretic

- heart failure - ascites (pt with liver disease) -hypokalemia -hypertension -hyperaldosternism

adverse effects of potassium-sparing diuretic

-dizziness -headache -abdominal cramping -diarrhea -gynecomastia -drug interactions: digotoxin & lithium can lead to toxicitiy -mixed with alcohol can cause hypotension

Contraindication of potassium-sparing diuretic

-hypersensitivity - presence of abnormal kidney function -pregnancy -use reduced dose in patient w/ renal & heaptic Impairment

Adverse Effects of Thiazides

-hypersensitivity reactions -hypotension Fluid Loss -weakness -dizziness -vertigo -Nocturia GI -anorexia -nausea -vomitting glucose elevation

How long can the recovery period of AKI take?

3 to 12 months

Which intravenous (IV) solution is expected for a patient with cerebral edema?

3% saline

Which statement accurately describes acute kidney injury (AKI)?

AKI has an abrupt onset.

Which factors should be assessed prior to administering a loop diuretic? Select all that apply.

Blood pressure, Potassium level

administration of osmotic diuretics

IV

what is portal hypertension?

Increased pressure in the portal pressure of the liver caused by vascular resistance to blood flow in liver

Mrs. Conley, age 53, has had hypertension for 10 years and admits that she does not comply with her prescribed antihypertensive therapy. Recently, she has begun to experience shortness of breath and ankle swelling. A workup reveals the presence of chronic renal insufficiency. What classification of diuretic is the first drug of choice for the nurse practitioner to prescribe? a. thiazide b. loop c. osmotic d. potassium sparing

Loop diuretics

What type of diet should patients with kidney disease follow?

Low-potassium and low-sodium

Administration of thiazides

PO

What are potassium-sparing diuretics?

act by competing for aldosterone-sensitive Na+/K+ channels at the distal tubule of nephron to decrease sodium and water reabsoprtion and potassium excretion

how do osmoreceptors promote thirst?

activated by cellular dehydration resulting from increased extracellular osmolality decrease in blood volume

A nurse is instructing a patient on dietary considerations while taking spironolactone (Aldactone). Which of the following statements made by the patient indicates that further teaching is necessary? a. "I should not eat foods high in potassium while taking this medication." b. "I should use a salt substitute instead of regular salt." c. "I should call my nurse practitioner if I have any significant adverse effects from my medications." d. "I should not take large amounts of potassium chloride supplements."

b. "I should use a salt substitute instead of regular salt."

A man who is taking an oral hypoglycemic for management of his type 2 diabetes mellitus begins taking hydrochlorothiazide. The nurse should monitor for which of the following serum laboratory changes? a. hypocalcemia b. hypercalcemia c. hyperglycemia d. hypernatremia

c. hyperglycemia

hypocalcemia

calcium levels less than 8.5 mg/dL

hydrostatic forces

can promote movement of fluid bas on pressure gradient

what is dehydration?

characterized by negative fluid balance

causes of dehydration

decrease fluid intake increased fluid output fluid shift between compartments

What is hyponatremia?

decreased of levels of sodium in blood less than 135 mEq/L

what is isonatremic hydration?

equal solute and water loss maintains normal sodium concentration 130-150mEq/L No fluid shift seen

hypervolemia

excessive increase of fluid in the extracellular compartment

What is ECF?

extracellular fluid, fluid outside of cells

What do the kidneys do?

filter blood and produce urine

What is the prototype for thiazide diuretics?

hydrochlorothiazide

Action of Loop diuretics

inhibit sodium and chloride reabsorption in asceding limb of loop of Henle

What is ICF?

intracellular fluid, fluid inside a cell

What are osmotic diuretics?

produce rapid diuresis. Increase solute load of glomerular filtrate. Increased osmoitc pressure causes water to pilled from extravascular sites into bloodsteam, increasing blood volume and decreasing reabsorption of water and electrolytes in kidney tubules

Hyperkalemia

too much potassium in blood greater than 5 mEq/L

why is sodium so important in the body?

most abundant cation in extracellular compartment Primary determinant of osmolality

Uses of Loop Diuretics

-manage edema and ascites in patient with hepatic impairment -decrease pulmonary edema -Used for hypertension - peripheral edema from HF, hepatitic disease, and renal disease

Nursing implications for osmotic diuretics

-monitor I/Os, labs, vitals -monitor dehydration -access for anorexia, muscle weakness, numbness, tingling

Nursing Implications

-monitor lab levels -patient education: diet & lifestyle change -minimize adverse effects

Adverse effects of Loop Diuretics

- Dehydration -fluid and electrolyte imbalances -ototoxicity (avoid by conitunous infusion of IV doses or diving oral doses) -blood volume reduction w/ circulatory collapse -electrolyte imbalance worsen hepatic encephalopathy and coma.

Uses of Thiazides

- Hypertension -Edema -prevent/recurrence of kidney stones

Action of thiazides

-produces diuresis -increases excreation of sodium, water, chloride, and bicarbonate -increases serum cholesterol, glucose, ans uric acid levels -decrease excretion of calcium -loweres BP by circulating volume

What are diuretics?

Drugs used to treat fluid volume excess

A patient has a sodium level of 124 mEq/dL. Which assessment finding is expected?

Confusion

What is an isotonic solution?

Contains equal concentrations of solutes on both sides.

What is the difference between crystalloids and colloids?

Crystalloids are clear fluids, and colloids are thicker and more viscous.

Which condition is not an indication for a loop diuretic?

Diabetes mellitus

What kind of diet must the patient be on when taking loop diuretics?

Dietary Sodium Restrictions

symptoms assocaited with hypermagnesemia

ECG changes widened QRS Hypotension Bradycardia Drowsiness Lethargy

What are diuretics used to to treat?

Edamatous: HF, Kidney & hepatic disease Nonedematous: Hypertension, opthalmic surgery conditions * useful in preventing kidney failure by their ability to sustain urine flow*

Clinical indications for diurectics

Edema Heart failure Hypertension

what is the pathophysiology of cirrhosis?

Fibrosis interferes with blood supply and hepatocyte damage

Prototype for Loop Diuretics

Furosemide (Lasix)

Upon assessment, a patient has Trousseau and Chvostek signs. Which electrolyte abnormality does this indicate?

Hypocalcemia

A patient is ordered furosemide. What is a potential complication of this medication?

Hypotension

Nursing Implication of potassium-sparing diuretic

Monitior I/O's Lab Vitals

Nursing Considerations when administering Loop Diuretics

Monitor lab levels Patient education- diet & lifestyle changes -Minimize adverse effects

symptoms of hypochloremia

Muscle effect shallow, depressed breathing, paralysis mental confusion

A patient receives intravenous (IV) furosemide 80 mg for symptoms of severe heart failure. The nurse recognizes that administering the drug slowly by IV push reduces the likelihood of which of the following adverse effects of drug therapy? a. hyponatremia b. hypokalemia c. fluid volume deficit d. ototoxicity

Ototoxcity

Administration of Loop Diuretics

PO or IV

Administration of Prototype potassium-sparing diuretic

PO with food

diagnostic criteria of cirrhosis

Physical exam Body weight abdominal girth Lab analysis - asicitic fluids, liver & renal function, cardiac function

A patient is admitted for hypovolemic shock. Which type of acute kidney injury (AKI) is this patient at risk for?

Prerenal (Anything happening above the kidney, such as hypotension, puts the patient at risk for prerenal AKI.)

Prototype potassium-sparing diuretic

Spironolactone (Aldactone)

A patient is prescribed a loop diuretic. What will happen to the potassium level when this medication is administered?

The potassium level will decrease.

What is the action of osmotic diuretics?

Water pulled from extravascular sites into bloodstream to increae blood volume, decrease absorption and water in renal tubes.

When are LOOP DIURETICS the choice of diuretics?

When RAPID EFFECTS REQUIRED and kidney function IMPAIRED

symptoms of hypercalcemia

abdominal pain constipation bone pain hypertension thirst lethargy

pathophysiology of dehydration

alteration in fluid & electrolyte balance

symptoms of hypocalcemia

anxiety confusion fractures irritability Chvostek's sign Trousseau's sign twitching tremors

what is seen in advances state of cirrhosis?

associated with protein wasting leads to loss of albumin in circulation , altering fluid balance through loss of fluid to extravascular space

Hypercalcemia

blood calcium greater than 10.5 mg/dL

what is hyperphosphatemia?

blood phosphate levels rise above 4.5 mg/dL

what is dehydration characterized on?

blood sodium concentration

What does the glomerulus do?

filters blood

what is homeostasis dependent upon?

fluid and electrolyte balance

hyponatremic dehydration

fluid lost contain more sodium than the amount of blood. Fluid shift intravascular to extravascular Type of fluid loss is hypertonic sodium concentration is less than 130 mEq/L

symptoms of hyponatremia?

headache lethargy confusion muscle twitching and weakness

what is hypernatremia?

high sodium in body Over 145 mEq/L

Hypochloremia is associated with?

hyponatremia, hypokalemia, and metabolic alkalosis

where are osmoreceptors located?

hypothalic thirst center

hypovelemia

inadequate intake or excessive excretion

What do diuretics do?

increase urine formation and output

causes of edema

increased capillary filtration pressure decreased capillary osmotics pressure increased capillary permeability obstructed lymph flow

Where do diuretics act on?

kidneys to decrease reabsorption of sodium, chloride, water, and other substances

Pulomonary edema

life-threatening occurs with circulatory overload or acute heart failure

What is cirrhosis?

liver disease characterized bt local blood flow interference and hepatocyte damage

Subclasses of diuretics

loop diuretics Thiazides and related drugs Potassium sparing diuretics

hypernatremic dehydration

loss of more water than sodium type of fluid loss is hypotonic Fluid shift extravascular to intravascular

what is hypotonic solution?

lower osmolality than the ICF cell swells to to water coming into the cell where concentration is greater.

hypomagnesium

magnesium blood level less than 1.5 mEq/L

hypermagnesemia

magnesium levels over 2.5 mEq/L

symptoms of hypophosphatemia

occurs with hypercalcemia symptoms may occur accompanies w/ another electrolyte imbalance weakness slurred speech irritability confusion

symptoms associated with hyperphosphatemia

occurs with hypocalcemia muscle cramps parethesia weakness ECG changes

treatment for dehydration

oral (frequent, small amounts) or IV rehydration (lactated ringer's or isotonic saline solution) - correction of electrolyte imbalance

what are the receptor that control thirst?

osmoreceptors

what is tonocity?

osmotic pressure of an extracellular solution allows water to move into or out of cells

symptoms of hypomagnesemia

parathesias tetany twitching tachycardia nausea/vomitting seizure rapid heartbeart

hypophasphatemia

phosphate levels under 2.5 mg/dL

what diet do patients on loop diuretics need to be on?

potassium rich, low sodium diet

what is tonocity determined by?

solutes that cannot cross semipermeable plasma membrane, producing osmotic force that transports water

what is a hypertonic solution?

solution has greater osmolality than ICF. cell shrinks due to water going to high solute concentration.