COMBO --- 39 (Fluid and Electrolytes)

Respiratory Acidosis

-low pH <7.35 -PaCO2 >42 -always due to respiratory problem with inadequate CO2 excretion -hypoventilation related to : --drug overdose, chest trauma, pulmonary edema, airway obstruction, COPD, neuromuscular disease -hypoventilation

Arterial Oxygenation (PaO2)-from blood

-meausres O2 level in the blood-reflects body's ability to pick up O2 from lungs -80-100 mmHg=normal -60-80 mmHg=mild hypoxemia -40-60 mmHg=severe hypoxemia -SaO2-O2 sat measures level of blood in tissues (Pulse Ox) -normal 95%+

Respiratory Acidosis: Treatment:

-medical/nursing management -improve ventilation*

Acid-Base Imbalances without Compensation

-metabolic acidosis -metabolic alkalosis -respiratory acidosis -respiratory alkalosis

Osmosis

-movement of fluid from an area of lower solute concentration to an area of higher solute concentration -isotonic -hypertonic -hypotonic-take water into cell

Capillary Filtration

-movement of fluid through capillaries -hydrostatic pressure --forces fluid and solutes through cap. wall -- blood pushing against capillary walls --try to get rid of volume

Diffusion

-movement of molecules and ions --from area of higher concentration to an area of lower concentration

Hypomagnesemia

-normal range: 1.3-2.3 -often ass. with hypocalcemia -Causes: rapid administration of citrated blood, GI loss, alcoholism, medications, sepsis, burns, hypothermia, enteral/parenteral feeding deficient in mag. -Manifestations: neuromuscular & EKG changes, tetant, muscle weakness and tremors; dysphagia

Sodium (Na+)

-normal range: 135-145 -most abundant elec. in the ECF -life-threatening -<120 ->155 -causes mental status change and seizures

Arterial Blood Gases

-pH: 7.35 (7.4)- 7.45 -PaCO2: 35 (40)-45 -HCO3: 22(24)-26 -PaO2: 80 -100 -O2 sat: >94% -Base excess/deficit 2

Dehydration: Medical management

-provide fluid to meet body's needs -oral fluids/IV solutions

Heart and Blood Vessels

-pumping action -circulates blood through kidneys -sufficient pressure to allow renal perfusion

Dehyration: S&S

-rapid weight loss, dec. skin turgor, oliguria, concentrated urine, postural hypotension, rapid weak pulse, inc. temp., cool "clammy", skin due to vasoconstriction, lassitude, thirst, nausea, muscle weakness, cramps

Reabsorption

-reabsorption prevents too much fluid from leaving capillaries -despite amt. of hydrostatic pressure -kidneys: get rid of what it doesn't need and keeps what it does -when fluid filters through a capillary, the protein albumin remains behind (less vol. but can pull vol. into vascular space) -albumin is like a water magnet, pulling water into the intravascular space

Capnography & Pulse Oximetry: O2 Saturation

-reflects oxygenation -30-60 second lag in detecting apnea or hypoventilation -should be used with capnography

Parathyroid Gland's Role

-reg. and balances calcium and phosphate -parathyroid hormone (PTH) --calcium absorption from intestines --calcium reabsorption from renal tubules of the kidneys --how bones reabsorb

Renin and Angiotensin

-regulates, maintains blood pressure and blood volume --by maintaining balance of Na and water --renin released by kidneys --stimulates formation of angiotensin in blood and tissues --which stimulates release of aldosterone from adrenal cortex (of kidneys) -renin(kidneys)-angiotensin-angiotensin II(lungs)-aldosterone -clamp everything down-->bring fluid where its needed

Pituitary Glands Role

-releases ADH anti-diuretic hormone (to conserve H2O) -inc. ADH (less urine output) -dec. ADH (more urine output) -hold H2O-->bring it to intravascular space -produced by the hypothalamus; stored and released by the posterior pituitary gland

Adrenal Gland's Role

-secretes more aldosterone --causes NA retention (water retention & K loss) -secretes less aldosterone --causes NA loss (water loss & K retention)

Hypercalcemia

-serum level: >10.2 -Causes: malignancy, hyperparathyriodism, bone loss related to immobility, high calcium intake, thyroid disorders -Manifestations: muscle weakness, poor coordination, anorexia, abdominal and bone pain, constipation, nausea, and vomitting, polyuria, thirst, cardiac dysrythmias

Hyperkalemia

-serumK+: >5.0 -Causes: usually treatment related, impaired renal function, K+ sparing diuretics, hypoaldosteronism, tissue trauma, and acidosis (be aware of potential for false lab values -Manifestations: dysrhythmias, ECG changes, muscle weakness with potential respiratory impairment, paresthesia, anxiety

Active Transport

-sodium potassium pump-physiologic pump --moves fluid from an higher con. to area of lower con. --movement against con. gradient --maintain higher concentration: (extracellular sodium and intracellular potassium) *requires adenosine(ATP) for energy: ACTIVE TRANSPORT -major cation in ECF-sodium -major cation in ICF- potassium

Capnography & Pulse Oximetry:CO2

-validation of proper endotracheal tube placement -reflects ventilation -detects apnea and hypoventilation immediately -should be used with pulse oximetry

hypotonic

0.45 saline

If a patient weighs 154 lbs (70 kg) and should be having 0.5 mL/kg/hour output, how many mL per hour would you expect from their output?

0.5 mL x 70 kg = 35 mL/hr

Normal Values: Creatinine (Cr)

0.7-1.4

******ISOTONIC FLUIDS HAVE TO REMEMBER!!!******

0.9% SODIUM CHLORIDE(NORMAL SALINE)--> ONLY ONE YOU CAN USE WITH BLOOD TRANSFUSION LACTATED RINGERS RINGERS SOLUTION 5% DEXTROSE IN WATER (D5W)

Circulation of Fluid Gain or Loss

1 L of water = 1kg = 2.2lb - adult fasting may lose 1-2lb a day

Facts to remember

1 Liter of water weighs 2.2lb, equal to 1kg Weight change of 1lb=fluid volume change of about 500ml

Each Kilogram (2.2 lb) = how much fluid lost?

1 liter of fluid retained or lost

Renin-Angiotensin mechanism initiates

1) low blood volume 2)low serum Na 3) low BP 4)high serum K 5) low cardiac output

I. Concepts of Fluid and Electrolyte Balance I. Maintaining electrolyte and fluid balance 1. Description, goal of clinical care 2. Adrenal gland 3. Pituitary gland

1. homeostasis of fluids must be constant. If fluid/electrolyte is deficient, goal is to replace through normal intake or IV therapy. If fluid/electrolyte excess, goal is assisting body to eliminate. 2. Adrenal glands secrete aldosterone, aid in controlling ECF by regulating Na reabsorption by kidneys. 3. Pituitary gland secretes antidiuretic hormone, regulating osmotic pressure of ECF by controlling water reabsorption in kidneys.

IV. HYPONATREMIA A. Description

1. hyponatremia is serum sodium level lower than 135 mEq/L 2. sodium imbalances are typically associated with fluid volume imbalances

What are the two major fluid compartments in the body?

1. intracellular fluid (ICF), or inside the cells, and 2. extracellular fluid (ECF), or outside the cells. ECF is composed of interstitial fluid, plasma, and transcellular fluids.

III. Fluid Volume Excess E. Interventions

1. monitor body systems 2. prevent further excess and restore normal balance 3. (NCLEX) give diuretics, osmotic diuretic typically given first to prevent severe electrolyte imbalances 4. Restrict fluid and sodium intake 5. Monitor I&O and daily weight 6. Monitor electrolytes, prepare to give med to treat any imbalances !! Patient with acute kidney injury or chronic kidney disease is at risk for fluid volume excess !!

II. Fluid Volume Deficit E. Interventions

1. monitor cardio, respiratory, neuro, renal, integumentary and GI status. 2. Prevent further fluid loss and increase fluid levels to normal ranges 3. Provide oral rehydration therapy or IV fluid replacement, monitor I&O 4. (NCLEX) Generally isotonic dehydration is treated with isotonic fluid, hypotonic with hypertonic, and hypertonic with hypotonic 5. Administer meds as Rx'd to treat cause, like antidiarrheal, antimicrobial, antiemetic, antipyretic. 6. Administer O2 as Rx'd 7. Monitor electrolyte values and prepare to give med to treat imbalances

Hyponatremia occurs when serum sodium levels fall below _____ mEq/L, and critical values occur at levels below _____ mEq/L.

125 mEq/L; 115 mEq/L although new studies suggest 124 mEq/L should be the lowest point

Blood - Bicarbonate

1st line of defense of acid base balance. (immediate response, only small fluctuations)

Normal Values: HCO3

22-29

Body Fluid Regulation

2600cc/day Hypothalamus regulates thirst drive

The minimum daily requirement of sodium for an average adult is:

2g

Respiratory system (lungs)

2nd line of defense for acid base balance.

17%

% of body weight of extracellular fluid

42%

% of body weight of intercellular fluid

What are the four pressures acting on body fluids?

(1) capillary hydrostatic pressure, (2) plasma oncotic pressure, (3) interstitial hydrostatic pressure, and (4) interstitial oncotic pressure.

pH Normal, increased, and decreased

(7.35 - 7.45)- measures hydrogen ion, increased= acidic, decreased=alkaline

Hypovolemia

(Fluid volume deficit) body's fluid intake isnt sufficient to meet body's fluid needs

II. Fluid Volume Deficit C. Causes of Fluid Volume Deficit 2. Hypertonic dehydration

(NCLEX) a. conditions that increase fluid loss, excessive perspiration, hyperventilation, diarrhea, prolonged fevers, diabetes insipidus, early stage kidney disease

II. Fluid Volume Deficit C. Causes of Fluid Volume Deficit 1. Isotonic dehydration

(NCLEX) a. inadequate intake of fluids and solutes b. Fluid shift between compartments c. Excessive loss of isotonic fluid

Anions

(Negative) Bicarbonate Chloride Phosphorous

Cations

(Positive) Calcium Magnesium Potassium Sodium

Isotonic IV Fluids

- Expands only ECF -No net loss or gain in ICF - Ideal fluid replacement for a patient with an ECF volume deficit - Stays in the same space you put it in- stays in ECF - Examples: Lactated Ringer's Solution, 0.9% NaCL, kind of dextrose 5% technically

Inverse Relationship between sodium and potassoum

- Factors that cause sodium retention- low blood volume, increased aldosterone level, cause potassium loss in the urine - Large urine volumes are associated with excess loss of potassium in the urine - if kidney function is sig impaired, retained potassium --> toxic

Fluid Volume Deficit: Causes

- Fever ( --> sweat, metabolism inc, RR inc --> insensible water losses) - Vomiting - Diarrhea or ostomy losses- patients with ostomies have fluid and electrolyte imbalances frequently - Increased urine output - Increased RR - Medical use of diuretics- get rid of fluid in urine - Poor IV fluid replacement - Draining wounds or fistulas- burns drains or decuptitis ulcers - means that they are breaking down - 3rd spacing: burns or ascites

Hypovolemia- Clinical Presentation

- First organ that suffers from decreased volume is brain- dizzy second is muscles- weakness 1. Dizziness 2. Weakness - confusion - fatigue - syncope - anorexia - nausea - vomiting - thirst - constipation- body pulling fluid out of feces

Sources of Potassium and regulated by

- Fruits and veggies- bananas and oranges - Salt substitues - Potassium medications- PO, IV - Stored blood - and regulated by the kidneys

Normal Saline (NS or NSS)

- Isotonic - Slihgtly more NaCl than ECF - Expands IV volume- preferred fluid for immediate response, risk for fluid overload higher - also monitor for hyperchloremic acidosis - no free water - no calories - no additional electrolytes - blood products - compatible with most medications - the only electrolytes are sodium and chloride- but more sodium and chloride than in your blood (if chloride goes up can get acidosis) - may be used when a patient has experienced both fluid and sodium losses or vascular fluid replacement in hypovolemic shock

D5W

- Isotonic (but quickly turns hypotonic- can't just give water has dextrose (sugar) in it and is metabolized super quickly and winds up as free water- great way to treat high sodium levels) - Provides 170 cal/ L - Prevents ketosis associated with starvation - Free water: moves into ICF-- increases renal solute excretion - Used to replace water losses and treat hypernatremia (high sodium) - Does NOT provide electrolytes

ECF Volume Deficit Caused by Dehdyration

- Isotonic Dehydration (Iso is equal- blood and urine become concentrated because lost their fluid): water and electrolytes lost in same proportion- blood and urine become concentrated- most common - Hypertonic dehydration- plasma osmolality increases: water loss excessdes electrolyte loss- excessive presipration, ketaacidosos, prolonged fevers, diarrhea - Hypotonic Dehydration- plasma osmolality decreases: electrolyte loss exceeds water loss from chronic illness, excessive hypotonic fluid replacement, kidney disease

FVE- Fluid Volume Excess Fluid Overload

- Isotonic Fluid Overload- hypervolemia: excessive IV fluid in ECF and does not shift --> interstitial edema - Hypotonic Fluid Overload- water intoxication: decreased kidney function right CHT or cirrhosis- excessive fluid moves into intracellular space and all fluid comparments expand example- take upper in club and drink tons of water - Hypertonic Fluid overload- rare caused by excessive sodium intake

Fluid Tonicity

- Isotonic: fluids with the same osmolality as the cell's interior - normally ICF and ECF are isotonic so NO net movement of water occurs - Hypotonic: solutions in which the solutes are less concentrated than the cells- hypoosmolar- if cell is surrounded by hypotonic fluid than water moves into the cell --> swelling and cell can burst - Hypertonic: fluids with solutes more concentrated than in cells- increased osmolality- hyperosmolar- cell water leaves cell to dilute ECF -- cell shrink and can die

Hypokalemia Causes

- K+ <3.5 mEq/L - can result from increased loss of potassium from an increase shift of potassium from ECF to ICF or rarely from deficient dietary potassium intake -Diuretics and other mediations - Prolonged NPO status - Diarrhea - Anorexia nervosa or bulimia - Vomiting or NG suction - Factors causing potassium to move from ECF to ICF: insulin therapy, alkalosis

Potassium: Hyperkalemia

- K+ greater than 5.0 mEq/L (normal value 3.5-5.0)

Hypokalemia Nursing Implementation

- KCL supplements orally or IV - KCL is never given unless urine output of at least 0.5mL/kg of body weight per hour + must be diluted in IV and never given in bolus - Always dilute IV KCL - NEVER give KCL via IV push or as a bolus - Should NOT exceed 10 mEq/hr- to prevent hyperkalemia and cardiac arrest preferred dose is 40 mEq/L - best way is oral can do IV but never BOLUS - note KCL is irritating to the vein therefore assess IV sites at least hourly for phlebitis and infiltration - should also have cardiac monitoring

Normal Physiology

- Maintenance of homeostasis: the stable internal environment of the body- disease afffect fluid and electrolyte imbalances - Composition of fluids and electrolytes (can be dissociated in water) kept within narrow limits of normal - Water content varies with age, gender, and fat content

IV Fluids Purposes

- Maintenance: when oral intake is not adequate - Replacement: when losses have occurred - Types of fluids categorized by tonicity

ICF most prevalent cation and anion

- Prevalent cation is K+ - Prevalent anion is PO43- (phosphorus or phosphate connected to oxygen giving it the negative charge)

ECF most prevalent cation and anion

- Prevalent cation is Na+ - Prevalent anion is Cl-

Renal Regulation of Water Balance and Key Lab Values

- Primary organs for regulating fluid and electrolyte balance by adjusting urine volume and the urinary excretio of electrolytes - Adjusting urine volume --> selective reabsorption of water and electrolytes --> renal tubules are sites of action of ADH and aldosterone 30 cc (mL) an hour = good - average kidney retains 99% - As the filtriate moves through renal tubules, selective reabsorption of water and electrolytes and secretion of electrolytes result in production of urine that is different in composition and concentration from plasma - renal tubules = sitee for action of ADH and aldosterone - Key lab values include 1. BUN- Blood Urea Nitrogen (10-20) 2. Creatinine (0.5-1.5) 3. Osmolality (275-295)

Hypernatremia: Manifestations

- Primary the result of water shifting out of cells into ECF with resultant dehydration and shrinkage of cells -Thirst, lethargy, agitation, seizures, and coma - dehydration of brain cells --> Impaired LOC (inc pressure in the brain --> dec LOC) - Symptoms of fluid volume deficit - intense thirst, agitation, decreased alertness --> postural hypotension, weakness, decreased skin turgor caused by decreased sodium excretion (Corticosteroids, Cushing's syndrome, Kidney disease, hyperaldosteronism, excessive oral sodium, decreased water intake, or increased water loss)

Osmotic Pressure

- amount of pressure required to stop osmotic flow of water- the force that draws the solvent (solution) from a less concetraed solute thorugh a slectively permeable memrbaen into a more concetrated solute - Determined by concentration of solutes in a solution - high osmotic pressure = higher the concentration of solutes - or colloidal osmotic pressure = osmotic pressure caused by plasma colloids in solution -major contributor is protein - plasma has substantial amounts of protein, and interstitial space has v little - plasma proteins attract more water pulling fluid from the tissue space into vascular space

Shifts of Interstitial Fluid --> Plasma

- an increase in the plasma oncotic pressure draws fluid into the plasma from the interstitial space - happens with adminstertration of colloids, dextran, mannitol, or hypertonic solutions, administration of colloids, dextran, mannitol - wearing elastic compression gradient stockings decreases peripheral edema= therapeutic application of this effect - can also increase tissue hydrostatic pressure to shift fluid into plasma

Isotonic Solutions

- approximately the same concentration (osmolality) as ECF, thereby remaining within the ECF space - administered to expand ECF volume - will dilute hemoglobin/hematocrit - no effect on cellular dynamics - 0.9% Normal Saline (NS) - Lactated Ringer's (LR) - D5W (will be isotonic in the bag, changes in the body) - watch CHF and CKD patients for overload

Hypophosphatemia Causes

- artificial nutrition to malnourished patients - alcohol withdrawal - DKA - hyperventilation - insulin release - absorption problems - diuretic use

Calcium: Hypocalcemia

- calcium < 8.9 mg/dL (normal value: 8.6-10.2) - role in blood coagulation and transmission of nerve impulses, regulates muscle contraction and relaxation, major component of bones and teeth

Calcium: Hypercalcemia

- calcium > 10.1 mg/dL (normal value: 8.6-10.2) - two major causes of hypercalcemia are cancer and hyperparathyroidism

Know relationship with calcium and phosphate?

- calcium increases, phosphorus decreases - inverse relationship

Sensible Loss

- can be measured - Kidneys: urine - Intestinal tract: feces - Surgical drains

Potassium: Hypokalemia

- chief regulator of cellular enzyme activity and water content - K+ less than 3.5 mEq/L (normal value 3.5-5.0)

Lab Studies to Assess for Imbalances

- complete blood count (CBC) - serum electrolytes, blood urea nitrogen, and creatinine levels - urine pH and specific gravity - arterial blood gases

Primary Organs of Homeostasis

- kidneys - the cardiovascular system - lungs - adrenal glands - pituitary glands - thyroid gland - nervous system - parathyroid glands - GI tract

Sensible Persipration

- like excessive sweating caused by high environmental temperatures may lead to large loss of water and electrolytes

Prolonged Nasogastric Suction-->

- lose sodium, potassium, hydrogen chloride ions --> deficient both sodium and potassium, fluid volume deficit and metabolic alkalosis caused by loss of hydrochloric acid

Magnesium: Hypomagnesmia

- magnesium < 1.2 mEq/L (normal value 1.2-2.3 mEq/L) - aids metabolism of carbs and proteins, activates intracellular enzyme systems, plays a role in neuromuscular function, and acts on CV system as a vasodilator

Magnesium: Hypermagnesmia

- magnesium > 2.5 mEq/L (normal value: 1.2-2.3 mEq/L) - usually occurs with renal failure when kidneys are unable to excrete Mg2+ or from excessive PO intake (ex Milk of Magnesia, antacids, and laxatives containing Mg2+)

Expected Outcomes

- maintain approximate fluid intake and output balance (2,500 mL intake and output over 3 days) - maintain urine specific gravity within normal range (1,010-1,025) - practice self-care behaviors to promote balance

Chloride: Hypochloremia

- major component of interstitial and lymphatic fluid, gastric and pancreatic juices, sweat, bile, and salive - acts with Na to maintain osmotic pressure and regulates acid-base balance - almost all chloride in diet comes from salt - hypochloremia is < 96 mEq/L (normal value: 97-107)

Hyperkalemia Causes

- massive tissue damage causing ICF to enter ECF - kidney failure - excessive dietary intake of K+ (salt substitutes) - potassium-sparing diuretic use - GI bleeding - overdose - burns

Hypomagnesmia Symptoms

- muscle weakness - tremors - tetany - seizures - heart block - MS change - increased DTRs - respiratory paralysis

Hypercalcemia Symptoms

- nausea and vomiting - constipation - bone pain - excessive urination - thirst - confusion - lethargy - slurred speech - in severe cases cardiac arrest may result

Hypermagnesmia Symptoms

- nausea/vomiting - weakness - flushing - lethargy - loss of DTRs - respiratory depression - coma - cardiac arrest

Hypocalcemia Symptoms

- numbness and tingling of fingers, mouth, or feet - tetany - muscle cramps - seizures

Parameters of Assessment

- nursing history and physical assessment - fluid intake and output - daily weights - laboratory studies

Osmolality vs. osmolarity

- osmolality is said to describe fluids inside the body - osmolarity pertains to fluids outside the body Osmolarity- measures the total milliosmoles per liter of solution- concentration of molecules per volume of solution (mOsm/L) (MOLECULES) Osmolality- measures the number of milliosmoles per kg of water, or the concentration of molecules per weight of water (WATER) -Test performed to evaluate concentration of plasma and urine

Risk Factors for Imbalances

- pathophysiology underlying acute and chronic illnesses - abnormal losses of body fluids - burns - trauma - surgery - therapies that disrupt fluid and electrolyte balance - debilitation, poor PO intake

Phosphate: Hypophosphatemia

- phosphate in the body provides energy storage, aids metabolism, regulates hormone and coenzyme activity, has an inverse relationship with calcium - hypophosphatemia is < 2.5 mg/dL (normal value: 2.5-4.5 mg/dL)

Phosphate: Hyperphosphatemia

- phosphate is > 4.5 mg/dL (normal value: 2.5-4.5 mg/dL) - common causes are impaired kidney excretion and hyperparathyroidism - symptoms include tetany, anorexia, nausea, muscle weakness, and tachycardia - treatment: treat underlying causes, monitor intake

Dehydration Causes

- poor intake of fluid - vomiting/diarrhea - high fever without adequate replacement

Causes of Fluid Volume Excess

- renal failure (CKD) - heart failure (CHF) - excessive fluid intake - high corticosteroid levels - high aldosterone levels

Hypochloremia Treatment

- replace GI losses/fluid replacement - correct the cause, ie adjust diuretic treatment

Hypocalcemia Treatment

- replace calcium - educate regarding good dietary sources of calcium - ensure absorption

Hypophosphatemia Treatment

- replace low phos levels before initiating tube feedings - treat underlying causes - monitor intake

Fluid Losses

- sensible loss - insensible loss

Hypochloremia Causes

- severe vomiting and diarrhea - drainage of gastric fluid - diuretics - burns

Sodium: Hyponatremia

- sodium controls and regulates volume of body fluids - Na+ < 135 is hyponatremia (normal value 135-145) - Can be dilutional hyponatremia with excess of body fluid diluting amount of sodium present, CHF, renal failure - Can be euvolemic, ie: SIADH, cerebral salt wasting - Can be hypovolemic as in diuretic therapy, GI losses, fever - can be treated with: replacement therapy, salt tablets - monitor mental status, neurological assessment - treat underlying causes: infection, diuretic therapy - if dehydrated, replace with isotonic fluid therapy - if severe, replace sodium with salt tabs or hypertonic saline, use caution and closely monitor

Hypernatremia Signs and Symptoms

- tachycardia - hypertension - dry mucous membranes - thirst - flushed skin - nausea - increased HCT, BUN, Cl- Severe: - twitching - tremor - hyperreflexia - seizure - coma

Hydrostatic Pressure

- the force of fluid flowing through the blood vessel - it "pushes" fluid out of the vessel

Osmotic Pressure on Red Blood Cells

- the tonicity of a solution affects the cell - hypertonic solutions draw water out of the cell, causing it to shrink - isotonic solutions maintain the cell's volume - hypotonic solutions cause the cell to swell and eventually burst

Dehydration Signs and Symptoms

- thirst - concentrated urine (minimal normal urine output in average adult 0.5 cc/kg/hour, approx. 30 cc/hr) - dry skin - sunken eyeballs - dry tongue - dry conjunctiva, decreased tearing - mental status changes - flat neck veins - hypotension - tachycardia - weak, thready pulse - cool extremities - tachypnea - low grade fever - acute weight loss - elevated H/H, BUN, glucose, and Na > 150 - Urine SpG > 1.030

Functions of Water in the Body

- transporting nutrients to cells and wastes from cells - transporting hormones, enzymes, blood platelets, and red and white blood cells - facilitating cellular metabolism and proper cellular chemical functioning - acting as a solvent for electrolytes and nonelectrolytes - helping maintain normal body temperature - facilitating digestion and promoting elimination - acting as a tissue lubricant

Insensible Loss

- unmeasurable - Skin: perspiration - Respiratory losses

Antidiuretic Hormone (ADH)

- vasopressin - produced by hypothalamus - stored and released by the pituitary gland - increased serum osmolality or decreased blood volume = release of ADH and increase kidneys reabsorption of water - decreased serum osmolality or increased blood volume inhibits release of ADH, water is reabsorbed, urine less concentrated

Hypokalemia Causes

- vomiting - gastric suction - diarrhea - diuretic use - hyperglycemia shifting potassium into the cells and out of ECF - water intoxication

Water Content of the Body

- water accounts for 50-60% of body weight in adults- the more fat in a body, the less total water content- older people have lower body water and men have more body water than women because more muscle mass

Calcium

-4.5-5.6 mg/dL -Ca++ is a ICF and ECF cation -Regulated by the parathyroid glands -Structural support and development of bones and teeth -Converts prothrombin to thrombin -Necessary for blood coagulation, enzyme activation, neuromuscular function, acid-base balance -Reciprocal of phosphorus

VIII. Hypocalcemia Interventions

-Administer calcium orally or IV, never IM (necrosis, burning) -when giving IV calcium, warm solution to body temperature, monitor site for infiltration, give slowly, watch for EKG changes -give medication to increase absorption a. aluminum hydroxide reduces phosphorus levels, thereby increasing calcium levels b. Vitamin D to aid absorption -initiate seizure precautions - Keep 10% calcium gluconate available to treat acute CA deficit - keep environmental stimulation low -move client carefully d/t pathological bone fracture -control pain to prevent hyperventilation-induced respiratory alkalosis

Hypokalemia Causes

-Administration of IV fluids without adequate K+ especially large amounts of D5W -Drugs: Coricosteroids Certain antiobiotics: gentamicin, Adrenergics: albuterol, epinephrine Digoxin -Enemas- multiple enemas

Meds that can cause Hyperkalemia

-Angiotensin (converting enzyme inhibitors) -Antibiotics -Beta adrenergics blockers -Chemo therapeutic agents -Digoxin -Heparin -NSAID -Potassium -Potassium sparing diuretics

Nursing Treatment of Hyperkalemia

-Assess dietary potassium intake -Monitor renal function (Urine output and lab values) -Monitor telemetry -Monitor blood sugar with insulin administration -Administer meds as ordered

Hypermagnesemia

-Causes: renal failure, DKA, or excessive antacid use -Manifestations: hypotension, flushing, V/N, lethargy, dec. DTRs, muscle weakness, EKG changes, respiratory depression -Rx: prevention, calcium gluconate, loop diuretics, NS, LR, hemodialysis

Major Anions

-Chloride (Cl)- --mostly ECF, affects body pH -Bicarbonate (HC03) - --mostly ECF, regulates acid-base balance -Phosphorus (P) - --promotes energy storage -- carbohydrate, protein, and fat metabolism (what we take in to metabolize)

More Nursing Interventions

-Comfort measures -Drinks: Gatorade, Bouillon, Sodas, Popsicles, Jell-O -Monitor response to fluid intake: Improved UO, VS WNL, Improved sensorium, Improved skin/tongue turgor, moist mucous membranes, Lung sounds WNL, Decreased urine SG

Potassium functions

-Contraction and electrical conductivity of cardiac, skeletal and smooth muscle -Promotion of nerve impulse transmission -Maintains fluid balance in cells -Helps with acid-base balance -**Abnormal serum concentrations can have life-threatening consequences! -<2.5 and >6.2 mEq/L is critical!

Treatment of hypokalemia

-DIETARY CHANGES -MEDS: oral meds can be liquid or pill form (potassium chloride, Slow K, K-lyte, IV potassium & supplements) -CONSIDERATIONS: *PO forms irritating to gastric mucosa-dilute liquids in 6-8 oz. of water/juice *IV potassium NEEDS DILUTED-should never be given IV push-can cause cardiac arrest!!

Uses for hypotonic solutions

-DKA after initial NSS and before dextrose infusion -gastric fluid loss from nasogastric suctioning or vomiting -hypertonic dehydration -sodium and chloride depletion -water replacement

Gerontological Considerations

-Decrease percent of body weight of water= increase risk of dehydration -Kidney changes: don't work as well -Loss of SQ tissue -Musculoskeletal changes - Mental status changes -Incontinence

Plasma Expanders: Colloids

-Dextran in NS or D5W -Affects clotting -Remains in circulatory system up to 24hrs -Use: Hypovolemia in early shock, improves microcircilation -Contraindications: Hemorrhage, Thrombocytopenia, Renal Disease, Severe dehydration

Causes of hypernatremia

-Dietary: increase sodium intake, decrease water intake -GI disorders: severe vomiting/diarrhea (gets to the point where all you're excreting is fluid because there's nothing else left) -Renal diseases: not allowing sodium to be excreted, retaining sodium

Management of fluid volume excess

-Diuretics (watch sodium intake) -Fluid restrictions might be appropriate (CHF) -Position changes (elevating legs) -Low sod. diet

Fluid Volume Excess: FVE: hypervolemia

-Due to: fluid overload or diminished homeostatic mechanisms -Risk Factors: HF, renal failure, cirrhosis of liver -Contributing factor: excessive dietary sodium or sodium- containing IV solute -Medical Management: directed at cause, restriction of fluids and sodium, administration of diuretics

Fluid Volume Overload Nursing Interventions

-Ensure patient safety -Restore normal fluid balance -Provide supportive care -Prevent future fluid overload -Drug therapy -Nutrition therapy: Fluid and or sodium restriction -Monitoring

Causes of hyperkalemia

-Excessive intake of potassium supplements, salt substitutes (exchange K for Na retaining K) -Decreased renal function: anuria and oliguria can cause a potassium buildup in the plasma -Severe traumatic injury: damage includes cells and potassium is released -Medications: potassium sparing diuretics, beta blockers, ACE inhibitors

Treatment and Nursing Implications for Hyponatremia

-Fluid lost through perspiration should not be replaced by water alone -Repeated irrigation of tubes generally done with NS not sterile water (can wash out sodium) -Fluid restriction for pt with normal fluid volume or water retention (common) -Isotonic for pt with low sodium and fluid volume deficit (NS or LR have electrolytes)

Treatment of hyperkalemia

-For mild hyperkalemia, restrict potassium intake -MEDS *IV sodium bicarbonate (temporary Tx, changes pH level and encourages potassium to go into cell *Insulin and 10-50% glucose solutions (insulin helps move potassium into cell) *Kayexalate- can be given orally or rectally; binds excess potassium and pt must have BM to excrete potassium (exchanges sodium for potassium and potassium is excreted through stool)

Causes of hypokalemia

-GI: gastric suction, emesis, diarrhea -Dietary changes: alcoholism, malnutrition, anorexia nervosa -Diuretics: Lasix, HCTZ -Steroids: long-term steroids promote potassium excretion and retention of sodium -Low magnesium: can cause kidneys to excrete potassium (need to correct mag. before potassium)

S&S of hypokalemia and hyperkalemia

-HYPOkalemia: muscle weakness, abdominal distention, leg cramps, fatigue, parasthesias, dysrhythmias -HYPERkalemia: skeletal muscle weakness & paralysis, abdominal cramps, oliguria & anuria, cardiac irregularities including cardiac arrest and dysrhythmias (Muscle weakness and dysrhythmias can occur in both)

Management/treatment of hyponatremia and hypernatremia

-HYPOnatremia is aimed toward fluid replacement of 3% NaCl IV carefully monitoring mental status and BP -OR- restricting fluids if from excess fluid volume. -HYPERnatremia: avoid foods high in sodium, review meds to see if any cause retention of sodium (cortisone preps, some laxatives, steroids), encourage fluids

S&S of hyponatremia and hypernatremia

-HYPOnatremia: nausea & vomiting, tachycardia, HYPOtension, muscular weakness, dry skin, headaches, confusion, seizures -HYPERnatremia: nausea & vomiting, tachycardia, possible HTN, restlessness, muscular twitching (nausea & vomiting and tachycardia could occur with both)

Function of sodium and primary regulators

-Helps with acid-base balance, helps to control extracellular fluid volume, retains water -Primary regulators are the kidneys- ADH doesn't allow kidneys to excrete sodium (retains sodium), and aldosterone absorbs/retains sodium and excretes potassium

Fluid and Electrolyte Movement

-Homeostasis -fluids and solutes move constantly within body -through semi-permeable membranes -diffusion (high--> low) -active transport(need ATP-->aerobic metabolism) -osmosis (mov't of fluid) -through capillaries -capillary filtration -reabsorption (in kidneys) mov't of fluid thru capillaries -fluid through the cap. walls depends on hydrostatic pressure (exerted on walls of blood vessels) and osmotic pressure (exerted by protein in plasma)

Hyperkalemia serum values and hypokalemia serum values

-Hyperkalemia: serum potassium of greater than 5.3 mEq/L; critical values occur at levels around 7.0 mEq/L -Hypokalemia: serum pot. less than 3.5 mEq/L; critical values occur at levels below 2.5 mEq/L

FVE: Nursing Management

-I&O and daily weights; assess lung sounds, edema, etc -monitor responses to medications - diuretics -promote adherence to fluid restrictions, pt. teaching related to Na and fluid restriction -monitor, avoid sources of excessive Na including meds -Semi-fowlers position for orthopnea ("position of comfort") -skin care, positioning/turning

Intracellular fluid vs. extracellular fluid

-INTRACELLULAR: 2/3 of total body fluid; Contains solutes, substances that dissolve in fluid such as oxygen, electrolytes, and glucose -EXTRACELLULAR: 1/3 of total body fluid; ECF has two compartments-intravascular fluid, or plasma, (within the vascular system) and interstitial fluid (surrounds the cells)

Compartments within the ECF (extracellular fluid)

-INTRAVASCULAR fluid, or plasma, is fluid within the vascular system (about 75% of ECF) -INTERSTITIAL fluid surrounds the cells -The other compartments of ECF are the lymph and TRANSCELLULAR fluids -Ex of transcellular fluids: CSF, peritoneal (intra abdominal), pleural (lungs), and synovial fluids (joints)

FVD or fluid volume deficit

-Isotonic fluid loss, hypovolemia-decrease in fluid -Regulatory mechanism: third mechanism stimulated; ADH and aldosterone are released prompting sodium and water retention by the kidneys -Infants & elderly are most at risk -Third spacing

Examples of hypotonic and hypertonic solutions

-Isotonic solutions would be NS 0.9% and D5W -Hypotonic solutions would be any NS less than 0.9% or any Dextrose less than 5% -Hypertonic solutions would be any NS greater than 0.9% or any Dextrose greater than 5%

Causes of hyponatremia

-Loss of sodium or increase in water -Can be lost through vomiting, diarrhea, sweating, use of diuretics -Decrease of sodium will shift water into cells causing swelling of the cells (confusion, hypotension, edema, muscle cramps & weakness) *If serum sodium is reduced, vascular status is more hypotonic, shifting water into cell making it swell.

Intake: Things to Remember

-Measue intake from water pitcher at end of shift, then refill -Ice chips: recorded at 1/2 their volume -Record ice cream, sherbet, custard and jello as intake

Hypocalcemia

-Medical Management -IV calcium gloconate; diet -calcium 1000 mg-1500 mg daily -vit. d 400-600 IU daily (enhances Ca absorption) -Nursing Assessment and Management -severe hypocalemia is life threatening-seizure precautions -weight bearing exercises to dec. bone calcium loss -pt. teaching related to diet and medications -nursing care related to IV calcium administration

Hypokalemia Treatment

-Medical Management -K+ replacement; inc. dietary K+ -IV for severe deficit -Nursing Management -assessment (severe hypokalemia-life threatening), monitory EKG; arterial blood gases, dietary potassium. IV potassium administration -pt would have cardiac monitor and NO IV push

Hyperkalemia Treatment

-Medical Management -monitor ECG, cation exchange resin, IV sodium bicarb, IV calcium gluconate, regular insulin, and hypertonic dextrose IV and beta 2 agonists; limit dietary K+, dialysis may be necessary

Metabolic Alkalosis: Treatment

-Medical Management: -correct underlying disorder -supply chloride to allow excretion of excess bicarbonate -restore fluid volume with sodium chloride solutions -Nursing management: -assess electrolyte imbalances -pt. educucation

Hypernatremia Management

-Medical management -gradual lowering -hypotonic electrolyte solution D5W (take out of vascular and bring to cell) -Nursing management -assessment and prevention -OTC sources of sodium -offer and encourage fluids to meet patient needs -provide sufficient water with tube feedings

Hypercalcemia treatment

-Medical management -treat underlying cause, administer fluids, furosemide, phosphates, calcitonin, and biphosphates -Nursing management -assessment-hypercalcemic crisis has high mortality, encourages ambulation, fluids of 3-4L/day provide fluids containing Na+ unless contradicted; fiber for constipation and ensure safety

Hyponatremia management

-Medical management: -water restriction -sodium replacement -nursing management: -assessment and prevention -monitor fluid intake and dietary sodium -identify, monitor of at-risk pt. -effects of meds (diuretics, lithium)

Metabolic Acidosis: Treatment

-Medican Management -correct any imbalance -administer bicarbonate -treat hyper/hypo kalemia -Nursing Management -assess electrolyte imbalances -patient education

Nursing Interventions

-Monitor neuro status -Strict I&O's -Daily Weight -Assess skin turgor -Monitor VS -Monitor labs: Na+, Cl-, Urine SG

Sodium 136-145 mEq/L

-Na+ is the principle cation of ECF -Is dilutional, must be interpreted in light of patient's hydration -Where sodium goes, water follows -Regulates balanced acid-base pH by combining with bicarbonate(NaHCO3) -Promotes neuromuscular response -Na+ retention or loss regulated by aldosterone from the adrenal cortex

More Assessments for Hyponatremia

-Neurological sx (water intoxication) and seizures with severe Na <120 -Neuro-muscular irritability: muscle weakness, abdominal cramps, nausea -Misc.: postural hypotension, anorexia, exhaustion, weight loss, N/V

Potassium

-Normal range: 3.5-5.0 mEq/liter (adult) -Is the main intracellular ion -Body cannot hold K+ for when it needs it

Assessment for Hyponatremia

-Old and sick -Fld. overload -Diuretics -N/G tube -Severe diarrhea, vomiting -Decreased intake of Na -Pt with HF, Cancer, or GI disorders

Methods of Hydration

-Oral fluids-preferred route -Ice Chips- record 1/2 the initial volume -Foods that liquefy @ room temp -Tube Feedings -Parenteral fluids -IV meds -Irrigants- must be measured if not immediately withdrawn or returned

FVD therapies

-Oral rehydration (about 30 mL/kg ideal body weight is required for maintenance)- gradual replacement -IV fluids: isotonic solutions-NS, Lactated Ringers; want to replace electrolytes and fluids in same proportion

Fluid Replacement

-Parenteral -Intravenous Crystalloids

Removal of Potassium

-Polystyrene sulfonate: binds to K in exchange for Na, K is excreted in the stool -Glucose with insulin: patient is NPO, K moved from serum to ICF -Dialysis

Major Cations+

-Potassium (K+) --mainly in ICF, regulates cell excitably, affects cell electrical status -Sodium (Na+) --mainly ECF, activates nerve and muscle cells --mainly in teeth and bones, cell membranes --most important to keep fluid balance -Calcium(Ca+) --fairly equal ICF and ECF --mainly in teeth and bones, cell membrane --needed by muscles to contract, aids in clothing; calcium cascade -Magnesium (Mg+) --mostly ICF, protein synthesis --nerve impulse transmission, skeletal muscle response

Functions of Electrolytes

-Promote neuromuscular irritability -Maintain body fluid volume and osmolality -Distribute body water among fluid compartments -Regulate acid-base balance

Fluid Volume Excess Causative Factors

-Renal failure - Heart failure -Cirrhosis of liver -Cushings syndrome -NS given IV -Excessive ingestion of NaCl -Corticosteroid therapy -Use of Plasma Proteins (Albumin)

Treatment- Nursing Interventions

-Replacement therapy must begin promptly -Oral: safest route -Dilute with 4oz juice -Tablets with a meal or just after a meal, or snack -IV: KCL MUST BE DILUTED-NEVER GIVE IV PUSH -Est. IV access in large vein, avoid hand -A controlled infusion device should be used

Treatment and Nursing Interventions

-Restrict Na in diet: 1gm. 2gm, 3gm -Infuse an isotonic (0.9% NaCl) or hypotonic solution (.45% NaCl or 5% dextrose in water) -Offer fluids regularly to pt. unable perceive or respond to thirst -Possibly diuretics: Produce excretion of water and sodium -Nursing interventions...

Hypervolemia Nursing Assessment

-Same as CHF (Coronary Heart Failure) - cough, dyspnea, crackles, tachypnea - Increased BP, pulse - Low HCT (hemodilutino) - h/a - Wt gain (1Liter = 1 kg) - Increased CVP- central venous pressure - Flushed skin - LATE SIGNS: neck vein distention, tachycardia, pitting edema

Commonly Measured Serum Electrolytes Venous Blood

-Serum Sodium: 136-145 mEq/L -Serum Potassium: 3.5-5.0 mEq/L -Serum Chloride: 98-106 mmol/L -Serum Magnesium: 1.3-2.1 mEq/L

Hypocalcemia

-Serum level <8.6 -Causes: hypoparathyriodism, malabsorption, pacreatitis, alkalosis, massive transfusion of citrated blood, renal failure, hyperphosphatemia, low vit. D, low serum albumin, prolonged laxative use -Manifestations: seizures, circumoral numbness, parathesias, hyperactive DTRs, tetanym Trousseau's sign(palmar flexion), Chovstek's sign (twitch of facial nerve), respiratory symptoms-dyspnea, and laryngospasm, abnormal clotting, osteoporosis, EKG changes

Patient Teaching- Hypokalemia

-Signs and symptoms of hypokalemia -Potassium losing diuretics: furosemide, hydrochlorothiazide -Potassium sparing diuretics: Spironolactone, Triametrene -Teach patient on diuretics need to increase dietary source of K+

Nursing Interventions

-Strict I&O's -Daily Weight -Monitor for orthostatic hypotension -Collaborate with MD: IV fluids and tube feedings -Monitor labs: BUN/Cr ratio, Urine spec. gravity -Eats foods high in Na, protein and K+ if permitted by PMD -Replace fluids as prescribed: IV fluids, Increase oral intake

S&S of FVD or fluid volume deficit

-Thirst, hypotension, tachycardia, tachypnea, lethargy, dry mucous membranes * REMEMBER: Loss of 1 kg body weight = 1 liter of fluid

ECG Effects of Hyperkalemeia

-Wide, flat P wave - Prolonged PR interval - Decreased R wave amplitude - Widened QRS - Depressed ST segment - Tall, peaked T wave

Major Compartments

-active chemicals; carry electrical charges -cations are +; anions - -charge helps cells to function -electrolyte concetrations differ in fluid compartments (vary based on where it is in the pt.)

Fluid Compartments

-approx. 60% of typical adult person is fluid -varies with age, body, size, gender -Intracellular fluid (ICF) -Extracellular fluid (ECF) --intravascular (plasma) --interstitial (tissue space) --transcellular --*this is how fluid moves back and forth -third spacing: fluid trapped "lost" in interstitial spaces; nonfunctional; ascites. burns-space that does not help equilibrium

Nursing Management

-assess and monitor symptoms --I&O, VS, daily weight -skin turgor, tongue, and mucosa, UO, mental status -measures to minimize fluid loss -administration of oral fluids -administration of parenteral fluids -oral care

Homeostatic Mechanism

-body mechanisms maintain composition and fluid volume within normal limits (WNL) --kidneys --lungs --adrenal glands (Aldosterone) --parathyroid gland --pituitary gland

Compensation

-body tries to restore normal pH by altering --buffer system component not involved in imbalance -fully compensated will provide PH, WLN, but with an abnormal PaCO@/HCO3 -if pH within normal/limits/abnormal PaCO2 --use 7.40 as pH indicator

Arterial Blood Gases: ABGs

-determines acid-base balance -determines arterial oxygenation -componenets of arterial blood -pH: 7.35-7.45 -PaCO2: 35-45 -HCO3: 22-26 -PaO2: 80-100

Dehydration: Risk Factors

-diabetes insipidus, adrenal insufficiency, osmotic diurresis, hemorrhage, coma, third space shifts

FVE: Manifestations

-edema, JVD, abnormal lung sounds, tachycardia, inc. blood pressure and CVP, inc. weight, inc. UO, SOB, wheezing

Dehydration: Lab Data

-elevated BUN in relation to serum creatinine, inc. hemocrit -serum electrolyte changes occur

Lungs Role

-exhalation --remove H2O daily (300 mL) -maintain acid-base balance -abnormal respirations inc. the loss and dec. the loss

Kidney's Role

-filter plasma (180 L) -excrete urine (1000-2000 ml/day) -spontaneously or in response to aldosterone & ADH -regulate ECF volume and osmolality -regulate electrolyte levels (retain/excrete) -regulate pH by retaining hydrogen ions -excrete metabolic wastes/toxins -dialysis: kidney outside of body (BUN, creatinine)

Dehydration: Causes

-fluid loss from vomiting, diarrhea, GI suctioning, sweating, dec. intake, inability to gain access to fluid

Complications of IV Therapy

-fluid overload -air embolism -septicemia & other infarctions -infiltration and extravasation -phlebitis and thrombophlebitis -hematoma -clotting and obstruction

Medical Management

-fluid replacement --PO route if not severely dehydrated --IV route if severely hydrated -isotonic solutions for hypotensive state (fluids with some osmolality as cell-expand plasma volume -hypotonic solution for normotensive state --solutes less concentrated --provide electrolytes and H2O --may need fluid challenges (verify kidney problems) --caution with inc. intracranial pressure (ICP) --draws H2O from ECF into cells (cells swell)

Fluid Volume Imbalance

-fluid volume deficit --hypovolemia -fluid volume excess --hypervolemia

Routes of Fluid Gains and Loses

-gain --dietary intake of fluid and food or enteral feeding --parenteral (IV) fluids -loss --kidney: urine output ~1500cc --skin loss: sensible and insensible ~300-400cc --lungs: expiration ~300-400 --GI tract: reabsorbed for GI tract to ECF

Metabolic Acidosis: Manifestations

-headache, confusion & drowsiness, resp. rate and depth, BP, CO, dysrhythmia, shock -if slow dec., pt. may be asymptomatic until bicarbonate is <- 15 -correct underlying problem, correct balance -bicarbonate may be administered

Hypernatremia

-high Na+ -serum sodium: >145 -Causes: excess water loss, dehydration, diarrhea, diabetes insipidus, heat stroke, excess sodium administration, hypertonic solutions -Manifestations: thirst, elevated temp, dry tongue, sticky mucosa, neuro symptoms, restlessness, oliguria, muscle weakness

Respiratory Alkalosis

-high pH>7.45 -PaCO2<35 -always due to hyperventilation -anxiety -high altitude -pregnancy -fever -PE Manifestations: lightheadedness, inability to concentrate, numbness and tingling, sometimes LOC -correct cause of hyperventilation

Hypertonic solution facts

-higher osmolality than plasma (usually > 295 mOsm/kg) Infusion can significantly raised plasma osmolality can cause vascular volume expansion and ICF deficit Cell shrinks

Acid-Base Balance

-homeostasis requires balance -normal plasma pH 7.35 to 7.45: hydrogen ion concentration -major extracellular fluid buffer system; bicarbonate--carbonic acid buffer system -acids (H++ hydrogen ions) -bases or alkaline substances (bicarbonate) -metabolic and respiratory processes work together to keep H+ levels normal and stable -physiologic buffers -pulmonary system: lungs-control carbonic acid levels -renal system: kidneys- controls bicarbonate levels

Thirst Mechanism

-hypothalamus -later compensatory mechanism --ingested fluid absorbed from intestine into blood stream -fluid must move between compartments to balance levels

Fluid Volume Deficit

-hypovolemia --electrolytes lost in same proportion of volume --blood loss -dehydration --loss of water; inc. serum sodium level --may occur in combination with others imbalances (refer to specific electrolyte imbalances) -FVD occurs when loss of ECF exceeds in the intake of fluid

Atrial Natriuretic Peptide: ANP in Maintenance of Fluid Balance

-inc. ANP dec. BP & blood volume -opposite action of RAA system -ANP: in response to inc. atrial pressure -the action of ANP is the direct opposite of the RAA system -inc. ANP dec. blood pressure and volume

FVE

-isotonic expansion of ECF -caused by abnormal Na and H2O retention -simple fluid overload -diminished function of homeostatic mechanisms

Fluid and Electrolyte Balance

-life sustaining -homeostasis (maintaining balance): maintaining equilibrium -nursing role -prevent and manage imbalances -treat fluid, electrolyte disturbances -ex: output+ -->concern K+ imbalance; low K+=cardiac issues -fluids help maintain body temp., cell shape, and transport nutrients, gasses and wastes

Hypokalemia

-low K+ -concerned with heart -serum K+: <3.5 -Causes: GI loses, medications, acid-base balance alterations, hyperaldosteronism, poor dietary intake -Manifestations: Dysrhythmias, cramps, paraesthesias, fatigue, anorexia, N/v, gluc. intolerance, dec. muscle strength and DTRs, EKG changes

Hyponatremia

-low Na+; serum <135 -Causes: water intoxication, SIDADH, adrenal insufficiency, sweating, vomiting, diarrhea, diuretics, certain meds, too many diuretics -Manifestations: postural BP, tachycardia, dry mucosa, oliguria, headahce, poor skin turgor, confusion, edema, nausea, abdominal cramping, seizures, and wt. gain -acute hyponatremia in less than 48H may be ass. with brain herniation

hypertonic

5% dextrose in Lactated Ringer solution 5% dextrose in 0.45% saline 5% dextrose in 0.9% saline 10% dextrose in water

Isotonic solutions

5% dextrose in water 5% dextrose in 0.225% saline Lactated Ringers Solution 0.9% saline

pH

7.35-7.45

Normal Values: BUN

8-20

Ca

8.5-10.5 mg/dL

Calcium (Ca)

8.5-10.5 mg/dL ---------------------------------------------------------------------------------------------------------- small amounts found in ECF ---------------------------------------------------------------------------------------------------------- vital for regulating muscle contraction and relaxation, neuromuscular function, and cardiac function

Calcium levels

8.6- 10 mg/dl

Normal Values: Ca

8.6-10.2

Calcium

9-11 mg/dl

Normal Values: Cl

97-107

BUN is high but creatine is ok

= uremia but it is ok - uremia indicates BUN level not the creatinine

What causes diabetes insipidus?

A reduction in the release of ADH

Hypernatremia

A serum sodium level above 145 mEq/L is termed hypernatremia May occur as a result of fluid deficit or sodium excess Frequently occurs with fluid imbalance Develops when an excess of sodium occurs without a proportional increase in body fluid or when water loss occurs without proportional loss of sodium Risk Factors: excess dietary or parenteral sodium intake, watery diarrhea, diabetes insipidus, damage to thirst center, those with physical or mental status compromise, and people with hypothalamic dysfunction

Define Isotonic Solution:

A solution with the same osmolality as serum and other body fluids. Osmolality falls within the normal range for serum (280-300 mOsm/kg)

Which one of the following elecrolyte imbalances occurs due to a sodium deficit in ECF caused by a loss of sodium or gain of water? A. Hyponatremia B. Hypernatremia C. Hypokalemia D. Hyperkalemia

A. Hyponatremia Rationale: Hyponatremia refers to a sodium deficit in ECF caused by a loss of sodium or gain of water. Hypernatremia refers to a surplus of sodium in ECF. Hypokalemia refers to a potassium deficit in ECF. Hyperkalemia refers to an excess of potassium in ECF.

Hypercalcemia symptoms

CV changes: mild:increased heart rate and B/P severe: slowing heart rate; blood clot formation Neuromuscular changes: weakness, decreased reflexes, altered LOC GI changes:decreased peristalsis--constipation, nausea LOC changes(decreased memory, confusion, personality changes, psychosis, stupor, coma ECG changes

Hyperkalemia symptoms

CV:bradycardia, hypotension,ECG changes( tall, peaked T waves; St depression, flattened P waves, leading death if untreated) Neuro: skeletal muscles twitch, tingling and burining sensation followed by numbness in hands and feet(paresthesia) GI:increased motility(hyperactive bowel sounds), diarrhea

what is the range for hypercalcemia?

Ca++ > 10.5 mg/dl

Teaching patients about Edema: FVE:

Common manifestation of FVE edema can occur from increased capillary fluid pressure, decreased capillary oncotic pressure, or increased interstitial oncotic pressure, thus expanding the interstitial fluid compartment. Edema can be localized in (ankle, as in rheumatoid arthritis) or generalized ( cardiac and renal failure)

Hyponatremia

Common with thiazide diuretic use, but may also be seen with loop and potassium-sparing diuretics as well Occurs with marked sodium restriction, vomiting and diarrhea, SIADH, etc. The etiology may be mulfactorial May also occur postop due to temporary alteration in hypothalamic function, loss of GI fluids by vomiting or suction, or hydration with nonelectrolyte solutions Postoperative hyponatremia is a more serious complication in premenopausal women. The reasons behind this is unknown

Physical Assessment

Compare I&O''s- look for big differences in input and output 1ml= 1cc 1oz. = 30 ml 1 qt. = 1000ml = 1L 1 gm= 1 cc 1 tsp = 5 ml 1 cup = 8 oz. = 240 ml

hypernatremia s/s (COMES LFFTD)

Confusion Oliguria Muscles twitching Elevated temperature Seizures Loss of skin turgor Flushed skin Fatigue Thirst Dry mucous membranes

Behavior fluid loss

Confusion, Apathy

Insensible Loss

Continuous loss occurring through skin and lungs.

Sodium

Controls and regulates volume of body fluids Its concentration is the major determinant of ECF volume Is the chief electrolyte of ECF Influence ICF Volume Participates in the generation and transmission of nerve impulses Is an essential electrolyte in the sodium-potassium pump RDA: not known precisely. 500 mg Eliminated primarily by the kidneys, smaller in feces and perspiration Salt intake affects sodium concentrations Sodium is conserved through reabsorption in the kidneys, a process stimulated by aldosterone Normal value: 135-145 mEq/L

Regulation of Water Balance- ADH

Anti Diuretic Hormone

Dehydration:Collaborative care

Assessment -exact intake and output volumes -serial daily weights History -kideney disease -diuretics Physical assessment/clinical manifestations: -cardiovascular changes, increased heart rate, orthostatic blood pressure -respiratory changes, increases rate -skin changes, dry mucous membranes, poor turgor -neurologic changes- in mental status -renal changes-document color and amount of urine

Fluid Overload: Collaborative care

Assessment -pitting edema Patient safety -monitor increased neck vein distention, crackles pulmonary edema drug therapy -diuretics nutrition therapy -fluid restrictions monitorying of I&O

Assessment and Diagnostic findings of FVE:

BUN and Hematocrit levels are decreased because of PLASMA DILUTION other causes for low values are because of: low protein intake anemia In chronic renal failure, serum osmolality and the sodium levels are decreased due to excessive retention of water. Urine sodium level is increased if the kidneys are attempting to excrete excess volume. Chest x-rays may reveal pulmonary congestion. Hypervolemia occurs when ALDOSTERONE is CHRONICALLY STIMULATED ( cirrhosis, heart failure, nephrotic syndrome) Urine sodium levels, therefore, will not rise in these conditions.

Assessment and Diagnostic Findings of FVD

BUN levels can be elevated due to DEHYDRATION or DECREASED RENAL PERFUSION AND FUNCTION. ALSO HEMATOCRIT LEVEL IS GREATER THAN NORMAL BECAUSE RBC'S BECOME SUSPENDED IN A DECREASED PLASMA VOLUME SERUM ELECTROLYTE CHANGES MAY ALSO EXIST. POTASSIUM AND SODIUM LEVELS CAN BE REDUCED (HYPOKALEMIA, HYPONATREMIA) OR ELEVATED (HYPERKALEMIA , HYPERNATREMIA)

Hypercalcemia

calcium >10.5 mg/dL ---------------------------------------------------------------------------------------------------------- most often occurs when calcium is mobilized from the bony skeleton, due to malignancy or prolonged immobilizatoin

Fluid and electrolyte imbalance

can result from excessive losses with severe vomiting, severe diarrhea, when gastric suction removes gastric secretions

manifestations of hyperkalemia

cardiac changes and dysrhythmias, muscle weakness with potential respiratory impairment, paresthesias, anxiety, and GI manifestations

Sodium Replacement for hyponatremia:

careful administration of sodium by mouth, NG, or parenteral route. Patients who can eat and drink sodium is replaced in a normal diet. For those who cannot eat, lactated ringers (0.9% sodium chloride may be prescribed.) Serum sodium must not be increased by greater than 12 mEq/L in 24 hours to avoid neurological damage.

Lasix (diuretic)

causes loss of potassium. (hypokalemia)

Fluid Spacing

Describes the distribution of body water - First spacing: normal distribution - Second spacing: abnormal accumulation of interstitial fluid- edema: fluid moves interstitial - Third spacing: fluid accumulation in part of body where it is not easily exchanged with ECF= fluid accumulates in portion from which it is not easily exchanged with rest of ECF- trapped and unavailable for functional use- ascites, edema associated with burns, trauma or sepsis - Third spacing: accumulation and trapped extracellular fluid in actual or potential body space as a result of disease or injury- represents a volume loss can't use it

Detecting and Controlling FVE:

Detecting FVE is of primary importance before it becomes critical. Interventions include: promoting rest restricting sodium intake monitoring parenteral fluid therapy administering appropriate meds. Some patients benefit from regular rest periods, as bed rest favors diuresis of edema fluid. Mechanism is related to diminished venous pooling and the subsequent increase of ineffective circulating blood volume and renal perfusion. ***If dyspnea or orthopnea is present place patient in semi-folwers position to promote lung expansion. Patient is turned and positioned at regular intervals because edematous tissue is more prone to skin breakdown than normal tissue.***

The function of Baroreceptors:

Detects changes in pressure within blood vessels and transmit info to CNS. Responsible for monitoring the circulating volume, and they regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Low pressure barorceptors: Cardiac atria/ Left atria High Pressure barorceptors: nerve endings in the aortic arch and in the cardiac sinus also in afferent arteriole of juxtaglomerular apparatus of the nephron. Arterial pressure decrease=baroreceptors transmit fewer impulses from the carotid sinuses and the aortic arch to the vasomotor center. A decrease in impulses stimulate the sympathetic nervous system and inhibits the parasympathetic nervous system. Outcome= increase in cardiac rate, conduction, and contraction in circulating blood volume. Sympathetic stimulation constricts renal arterioles; this INCREASES release of Aldosterone, decreases glomerular filtration, and increases sodium and water reabsorption. *****" THE 5 C'S******!!!! **SYMPATHETIC VS PARASYMPATHETIC***** 1- CONTRACTION 2- CONDUCTION 3-CIRCULATION 4- CARDIAC RATE 5- CONSTRICTION

Hypocalcemia treatment

Drug therapy -Calcium replacement -Enhance absorption of calcium with vit D Nutrition therapy -high calcium diet Environmental management -keep room quiet, limit visitors, seizure precautions Injury prevention -fall precautions Observe post op neck surgery patients for hypocalcemia

Electrolytes

Electrolytes are substances that, when in solution, separate into electrically charged particles called ions

Sodium-Potassium pump

Emesis Tubes in the GI tract or other body cavities Hemorrhage Pumps 3 Na+ OUT of cell 2 K+ IN to cell

S&S of Hypernatremia

Extreme thirst, sticky tongue and mucous membranes, postural hypotension.

Signs and Symptoms Hypernatremia

FRIED: Fever Restlessness Increased fluid retention increased B/P Edema Decreased urinary output, dry mouth and increased thirst Twitching Dyspnea Pulmonary edema, seizures, coma

Regulation of Water Balance- The Heart

High volume of water sensed w/ stretch receptors and right atrium Make heart bigger to pump more, works harder to push out Ex: CHF does not push everything out like it is supposed to

Clinical Manifestations of FVD:

Important Characteristics include: Weight loss decreased skin turgor oliguria (small amounts of urine) concentrated urine postural hypotension weak,rapid heart rate FLATTENED NECK VEINS increased temperature decreased central venous pressure cool, clammy skin r/t peripheral vasoconstriction Thirst Anoxeria nausea lassitude(lack of energy) muscle weakness cramps

V. HYPERNATREMIA (NCLEX) C. Assessment a. cardio b. respiratory c. neuromuscular d. CNS e. GI f. Renal g. integumentary h. Lab

a. HR and BP respond to fluid status b. pulmonary edema if hypervolemia is present c. Early: muscle twitches, irregular muscle contractions. Late: muscle weakness, deep tendon reflexes weak or absent. d. Altered cerebral function is most common manifestation of hypernatremia. normo-hypovolemia- agitation, confusion, seizures. Hypervolemia- lethargy, stupor, coma e. extreme thirst f. decreased urine output g. dry flushed skin, dry mucous membranes, edema depending on fluid volume h. Serum sodium level greater than 145

________ helps move potassium into cells and ________ helps excrete potassium.

Insulin; aldosterone

ECF Compartments

Interstitial- Fluid surrounding the cell Intravascular- in the blood (plasma) Transcellular- secreted by epithelial cells: CSF, synovial, pericardial, intraocular, pleural fluids Compartments are separated by cell membranes

II. Fluid Volume Deficit B. Types if Fluid Volume Deficits 3. Hypotonic dehydration a. description b. what happens c. what causes clinical problems

a. electrolyte loss exceeds water loss b. Fluid moves from ECF into cells, casing them to swell c. Clinical problems result form shift of fluid, decrease in plasma volume

Potassium is responsible for:

Maintaining the heartbeat

Purpose of IVF Administration

Maintenance of fluid and electrolyte balance Fluid and electrolyte replacement Management of concurrent fluid and electrolyte losses Nutritional supplementation Administration of meds Administration of blood products

Postassium (K)

Major cation in the intracellular fluid.

III. Fluid Volume Excess (NCLEX) C. Causes 2. Hypertonic overhydration

a. excessive sodium ingestion b. rapid infusion of hypertonic saline c. excessive sodium bicarbonate therapy

Signs and and Symptoms of Hypocalcemia:

Numbness, tingling of fingers, toes, and circumoral region; positive Trousseau's sign and Chvostek's sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irri- tability, bronchospasm, anxiety, impaired clotting time, ↓ prothrombin, ECG: prolonged QT interval and lengthened ST.

Parathyoid Functions composition and balance of body fluid:

Parathyroid embedded in the thyroid gland, regulate calcium and phosphate balance by means of parathyroid hormone (PTH). PTH influences bone resorption, calcium absorption from intestines, and calcium reabsorption from the renal tubules. ***PHOSPHOROUS AND CALCIUM ARE INVERSELY RELATED TO EACHOTHER, WHEN GOES UP, THE OTHER GOES DOWN!!!******

Signs and Symptoms of Phosphorous Deficit:

Paresthesias, muscle weakness, bone pain and tenderness, chest pain, confusion, cardiomyopathy, respiratory fail- ure, seizures, tissue hypoxia, and increased susceptibility to infection

Hypocalcemia

Possible Causes -Inadequate oral intake calcium -Lactose intolerance -Inadequate intake Vitamin D -End stage renal disease -Conditions affecting parathyroid function -Surgical removal of part of all of the parathyroid gland during neck surgery -Increased serum phosphorus causes decreased serum calcium -Pancreatic cells retain calcium. Pancreatitis causes the pancreas to lose calcium -Immbolity

Hypokalemia

Possible Causes: -GI losses: diarrhea, vomiting, fistula, GI suction -Renal losses: hypoaldosteronism, diuretics -Magnesium depletion, diaphoresis, dialysis -shift into cells: increased insulin, alkalosis, increased epinephrine(stress) -Poor intake: starvation, decreased potassium diet, NPO status without IV replacement

hyperphosphatemia

Possible Causes: -renal failure -chemo -phosphorus enemas (fleet) -excessive intake -excessive intake of vitamin D -hypoparathyroidism

Hyponatremia

Possible Causes: Sodium Loss -Diarrhea, vomiting, NPO, NG suction -Diurectics, renal or adrenal dysfunction -Burns, wound drainage Sodium Dilution(water gain) -SiADH, HF, hyperglycemia, excessive water intake

Hypernatremia

Possible Causes: Water Loss -Increased insensible water loss, diabetes insipidus, osmotic diuresis, altered thirst mechanism Sodium Gain -IV hypertonic NaCl or sodium bicarb -Excessive Isotonic IVF -Hyperaldosterone, saltwater near drowning

Hypermagnesemia

Possible cause -renal failure -excessive magnesium administration(i.e eclampsia) -Adrenal insufficiency

Hyperkalemia

Possible causes -Renal failure -Massive cell destruction(severe burn & crush injuries, tumor lysis) -rapid transfusion of aged blood -hemolysis -metabolic acidosis -adrenal deficiencies -drugs(potassium sparring diuretic retention, ACE inhibitors) -uncontrolled diabetes mellitus -salt substitutes -tissue damage -Potassium chloride

Hypercalcemia

Possible causes -hyperparthyroidism -malignancies -vitamin D overdose -prolonged immobilization

Hypophosphatemia

Possible causes: -Malnourishment -malabsorption syndromes -alcohol withdrawal -alcohol withdrawal -excessive use of phosphate binding antacids -parenteral nurition without phosphorous replacement -respiratory alkalosis -glucose administration

Hypomagnesemia

Possible causes: -prolonged fasting or starvation -chronic alcoholiism -gastrointestinal fluid loss -prolonged parenteral nutrition without mag -diuretics -osmotic diuresis -polyuria

Clinical dehydration clinical manifestation

Postural blood pressure decrease with concurrent increased heart rate Lightheadedness, dizziness, or syncope on standing Flat neck veins when supine or neck veins that collapse during inspiration (older children and adults) Sunken fontanel (infants) Rapid, thready pulse Sudden weight loss Decreased skin turgor Dryness of oral mucous membranes Hard stools Soft, sunken eyeballs Longitudinal furrows in the tongue Thirst Increased serum sodium concentration Confusion, lethargy Coma Hypovolemic shock Oliguria

Hypokalemia treatment

Potassium chloride supplements increase of potassium dietary intake IV replacement prevention

Primary contributors to osmolality of ICF

Potassium, glucose, urea

hypercalcemia interventions (PAIR M^7S

Prepare calcitonin(Calcimar)increase calcium in the bones, and phosphate (AP) Avoid large doses of Vit. D supplements, avoid thiazide diuretic Increase mobility Restrict calcium intake Monitor VS Monitor for dysrhythmias Move clients safely, assist in ROM when ambulation isnt possible Monitor for dev. of pathological fractures Monitor for severe flank & abd. pain Monitor LOC Monitor for confusion and neurological changes Strain urine watch for urinary stones

Foods High in Sodium

Processed foods, soups, meat, hot dogs, McDonalds, baking powder and baking soda, ketchup Meds, OTC cough meds, steroids, alkaseltzer 6-15 grams of salt Sodium restricted- 250mg Mild restriction- don't add any salt

Natriuretic Peptides

Promote fluid excretion in the urine by causing natriuresis (sodium excretion in the urine) NPs oppose the action of aldosterone, but not as strong as ADH A-type natriuretic peptide (ANP) Normally secreted from cells in the heart when the atria are stretched B-type natriuretic peptide (BNP) Released from ventricular cells when ventricular diastolic pressure increases abnormally, as in heart failure When vascular volume increases: NP cause kidneys to excrete excess fluid When vascular volume is decreased: NP cause kidneys to excrete less fluid

WHAT DO ELECTROLYTES DO?

Promote neuromuscular irritability Maintain body fluid volume and osmolarity Distribute body water between fluid compartments Regulate acid-base balance

Hypernatremia

Serum Na >145 mEq/L Causes: 1. More water than sodium is lost from the body- ratio of Na & H2O is increased 2. Increased intake oral or IV 3. Pulmonary Infections 4. Vomiting 5. Severe diarrhea

Importance of serum sodium levels

Serum Na++ levels are vital for skeletal muscle contraction, cardiac contraction, nerve impulse transmission & normal osmolarity & volume of the ECF Serum sodium concentration reflects osmolality of blood Sodium controls the osmolality of the ECF

Diagnostic tests

Serum electrolytes, CBC, Urine and serum osmolarity, Urine specific gravity (1.005-1.030)

Hypernatremia

Serum sodium concentration above upper limit of normal (135 to 145 mEq/L) >145 mEq/L Extracellular fluid contains relatively too little water for the amount of sodium ions present; it is too concentrated Cells shrivel Etiology Gain of more salt than water Loss of more water than salt Also called Water deficit Hypertonic syndrome Hyperosmolality Pituitary releases ADH Kidney excretes less urine

More Nursing Interventions

Severe hyponatremia: -IV solution hypertonic, 3% NS needs to be closely monitored in ICU -Assessments: Neuro, lungs, how much processed food they take in Patient teaching -Diet -I&O -Weight -Fluid restriction if applicable

hypokalemia s/s (SHALL PC)

Shallow respirations & thready pulse Hypoactive bowel sounds Absent or decreased reflexes Leg and abdominal cramps Lethargy and weakness Postural hypotension Confusion

Fluid loss through abnormal routes

Significant factor in altering fluid status Tubes in the GI tract or other body cavities Hemorrhage Emesis Drainage from fistulas, wounds or open skin Paracentesis

I. Concepts of Fluid and Electrolyte Balance (NCLEX) H. Body fluid Intake and Output 2. Body fluid output - ways fluids exit body

a. insensible loss- water lost through skin, person is unaware of loss (insensible) b. perspiration loss varies, but average around 100 mL/day c. water lost through lungs varies- insensible loss also. d. kidneys excrete the most fluids. SO- fluid lost insensibly (skin, lungs) and through kidneys (most) and GI tract !! large amounts of fluid go into GI but almost all is reabsorbed. So client with diarrhea at high risk for fluid/electrolyte imbalances !!

III. Fluid Volume Excess B. Types 2. Hypertonic overhydration

a. occurrence is rare, caused by excessive sodium intake b. fluid is drawn from ICF into ECF

III. Fluid Volume Excess (NCLEX) C. Causes 1. Isotonic overhydration

a. poorly controlled IV therapy b. Kidney disease c. long-term corticosteroid therapy

What happens to older adults' kidney functions?

Structural changes to the kidney and a decrease in the renal blood flow lead to a decrease in the glomerular filtration rate, decreased creatinine clearance, the loss of the ability to concentrate urine and conserve water, and narrowed limits for the excretion of water, sodium, potassium, and hydrogen ions.

Aldosterone

Synthesized and secreted by cells in the adrenal cortex Major stimulus for its release 1. Decreased circulating blood volume 2. renin-angiotensin system > Angiotensin II 3. Increased concentration of potassium ions in the plasma 4. Renal tubules to reabsorb sodium & water 5. Decreases fluid excretion, although by a different mechanism than ADH When more aldosterone is secreted, urine volume is smaller Decreased secretion of aldosterone causes a larger urine volume

ADH

Synthesized in the hypothalamus Released from the posterior pituitary gland Factors that increase release of ADH - Increased osmolality (concentration) of the extracellular fluid - Decreased circulating fluid volume - Pain - Nausea - Physiologic and psychological stressors Causes reabsorption of water, which: - Decreases urine volume and fluid excretion - Concentrates the urine If ADH release is decreased > large volume of dilute urine - Decreased osmolality of extracellular fluid - Ethanol intake

Define Diffusion:

The process by which SOLUTES move from an area of HIGHER CONCENTRATION TO ONE OF LOWER CONCENTRATIONS; does NOT require expenditure of energy.

Behavior fluid excess

Tires easily, change in behavior

What are the goals of treatment in fluid imbalances ?

To correct the UNDERLYING CAUSE and to restore fluid and electrolyte balance.

What is a major risk Hyponatremia/Hypernatremia causes in the older adult?

altered level of consciousness

Define Alkalosis:

an acid-base imbalance characterized by a reduction of H+ concentration (increased blood pH). A high arterial pH with INCREASED BICARBONATE CONCENTRATION

Define Acidosis:

an acid-base imbalance characterized by an increase in H+ concentration (decreased blood pH). A low arterial pH due to REDUCED BICARBONATE concentration is called METABOLIC ACIDOSIS; a low arterial pH due to INCREASED PCO2 is respiratory acidosis.

what can K-sparing diuretics cause

an elevation of K and should not be used in patients with renal dysfunction

hypovolemic shock

an emergency condition in which severe blood and fluid loss makes the heart unable to pump enough blood to the body. This type of shock can cause many organs to stop working. The body tries to adapt by increasing the HR and peripheral vasoconstriction to increase the volume of blood returned to the heart and increase cardiac output

What is hyperkalemia?

an increase in potassium

Urine Specific Gravity

an indicator of urine concentration ---------------------------------------------------------------------------------------------------------- normal ranges 1.005-1.030 (usually 1.010-1.025) ---------------------------------------------------------------------------------------------------------- When urine is concentrated, specific gravity is high ---------------------------------------------------------------------------------------------------------- In dilute, urine, specific gravity is low

Signs and Symptoms of Sodium deficit:

anorexia, nausea and vomiting, headache, lethargy, confusion, muscle cramps and weakness, muscular twitching, seizures, papilledema, dry skin, increased pulse, decreased BP, Labs: decreased serum and urine sodium, decreased urine specific gravity and osmolality

Electrolytes

any substance that dissociates into ions when dissolved in water and is capable of conducting electricity

Give clinical manifestations of hyponatremia because of water gain....

apathy, weakness, confusion, nausea, vomiting, weight gain, increase BP, muscle spasms, seizures, coma, headaches

List ways a nurse can care for the patient with hypocalcemia...

assess Ca++ level, pain, anxiety, recent thyroid/neck surgery, treatment geared at the cause, oral/IV supplements, vitamin D supp., diet high in Ca++ rich foods.

List nursing care for the patient with hypercalemia....

assess Ca++ levels, I&O, promote urine ouput, administer loop diuretic, isotnic IVF, diet low in Ca++, calcitonin, mobilization.

List nursing care for patients with hyperkalemia...

assess K+ level, EKG, I&O, eliminate oral/IV K+, increase the elimination of K+, force K+ from ECF-ICF, reverse the membrane effects of the increase ECF K+

What is nursing care for the patient with hypokalemia?

assess K+ level, diuretics, provide K+ supplements either IV or PO, Never Give K+ IVP, educate patients who are at risk for K+ depletion (digoxin, diuretics)

nursing management for hypernatremia

assess over the counter sources of sodium, offer and encourage fluid to meet patient needs, provide sufficient water with tube feeding; sodium restricted diet

hyperkalemia nursing management

assess serum K levels, mix well IVs containing K, monitor meds effects, initiate dietary K restriction and dietary teaching for patients at risk

Sources of potassium - vegetables

avocado, raw carrot, baked potato, raw tomato, spinach

hypokalemia

below normal serum potassium (<3.5 mEq/L) may occur with normal potassium levels in alkalosis due to shift in serum potassium into cells

Interstitial

between cells and outside vessels(contain lymph)

Name a few of the fluids in the body required for homeostasis

blood, serum, albumin, urine, bile, hormones, or cerebrospinal fluid (CSF) - within each of these fluids are electrolytes

What are causes of hypernatremia?

Water loss: increase water loss or perspiration, high fevers, heatstroke, diabetes insipidous. Sodium Gain: IV hypertonic NS, IV sodium bicarb, IV excessive isotonic NS

List clinical manifestations of hypernatremia...

Water loss: intense thirst, dry swollen tongue, restlessness, agitation, twitching, seizures, coma, weakness, postural hypotension, weight loss. Sodium gain: intense thirst, restlessness, agitation, twitching, seizures, coma, flushed skin, weight gain, pheriperal & pulmonary edema, increase BP.

Dehydration

Water lost from body - no loss of electrolytes.

What is third spacing?

When fluid accumulates in a portion of the body from which it is not easily exchanged with the rest of the ECF (e.g., burns, blisters).

Returning Sodium level to normal:

When the primary problem is water retention, its safer to restrict fluid intake, than to administer sodium. Aim of therapy is to elevate the serum sodium level only high enough to alleviate neurological signs and symptoms.

Third spacing

Where fluid goes into transcellular compartments (abdomen); it hasn't left the body but it cannot be used; it's not available because it's in other spaces in the body

Hypernatremia definition

a high concentration of sodium in the BLOOD

Define Hypertonic Solution:

a solution with an osmolality higher than that of SERUM

Define Hypotonic Solution:

a solution with an osmolality lower than that of SERUM

I. Concepts of Fluid and Electrolyte Balance G. Movement of Body Fluid 5. Active transport a. description b. examples

a. A solute moving against a concentration gradient, from low to high, requires active transport b. metabolic processes within the cell supply the energy for active transport c. Sodium, potassium, calcium, iron, some sugars, amino acids

I. Concepts of Fluid and Electrolyte Balance A. Electrolytes 1. Description

a. A substance that, when dissolved in solution, ionizes, or splits up into electrically charged cations or anions.

III. Fluid Volume Excess B. Types 1. Isotonic overhydration a. AKA b. fluid shift c. clinical result and rick

a. AKA hypervolemia, results from excessive fluid in ECF b. Only ECF is expanded, fluid does not shift between ICF c. (NCLEX) results in circulatory overload, in pt. with poor cardiac fx, HF or pulmonary edema can occur

II. Fluid Volume Deficit B. Types if Fluid Volume Deficits 1. Isotonic Dehydration a. AKA b. description c. physio result

a. AKA hypovolemia, most common type of dehydration b. water wand solutes are equally deficient c. Results in decreased circulating blood volume and decreased tissue perfusion.

III. Fluid Volume Excess B. Types 3. Hypotonic overhydration

a. AKA water intoxication b. excess fluid moves into ICF, all compartments expand c. (NCLEX) Electrolyte imbalances occur from dilution

I. Concepts of Fluid and Electrolyte Balance E. Body Fluid 1. Description, % of body weights, clinical risks

a. Body fluid transport nutrients to the cells and carry waste products from the cells. b. Total body fluid (intracellular and extracellular) amounts to 60% of body weight in adult, 55% in older adult, and 80% in infant. c. Thus, infants and older adults are at greater risk for fluid-related problems. !! Infants and older adults need to be closely monitored for fluid balance problems !!

I. Concepts of Fluid and Electrolyte Balance E. Body fluid 2. Constituents of body fluids a. body fluid components b. largest constituent c. substance characteristics in solution

a. Body fluids consist of water and dissolved substances b. The largest single constituent of the body is water. c. Some substances do not dissociate in solution (glucose, urea, creatinine) d. Some substances do dissociate in solution (sodium chloride)

I. Concepts of Fluid and Electrolyte Balance G. Movement of Body Fluid 1. Description a. barriers between compartments b. barriers characteristics c. forces affecting fluid/ solute movement

a. Cell membranes separate the interstitial fluid from intravascular fluid. b. These membranes are selectively or semipermeable, allowing water and some solutes to pass freely. c. Several forces affect the movement of fluids and solutes, like osmotic pressure, hydrostatic pressure, diffusion..

II. Fluid Volume Deficit C. Causes of Fluid Volume Deficit 3. Hypotonic dehydration

a. Chronic illness b. Excessive fluid replacement (hypotonic) c. Kidney disease d. Chronic malnutrition

I. Concepts of Fluid and Electrolyte Balance G. Movement of Body Fluid 3. Hypotonic Solutions a. explanation, definition b. examples

a. Contains less solutes/ are less concentrated than body fluid. Dilutes the ECF, causing osmosis to draw water into cells expanding ICF. b. 0.45% sodium chloride (1/2NS) 0.33% NaCl (1/3NS) 0.225% sodium chloride (1/4 NS) 5% dextrose in water (D5W) physiologically hypotonic, dextrose metabolizes fast leaving free water) !! Free water, or very hypotonic solutions lyse RBCs !!

I. Concepts of Fluid and Electrolyte Balance G. Movement of Body Fluid 4. Hypertonic solutions a. description b. examples

a. Contains more solutes/ is more concentrated than body fluids. b. 3% NaCl (3%NS) 5% Normal saline (5%NS) 10% dextrose in water (D10W)

I. Concepts of Fluid and Electrolyte Balance F. Body Fluid Transport 1. Diffusion a. definition b. action c. permeable membrane d. permeable membrane e. what membrane allows diffusion

a. Diffusion is the process whereby a solute spreads through a solvent. b. Diffusion spreads the molecules of a solute from high concentration to low concentration. c. A permeable membrane allows substances to pass through without restriction d. A selectively or semipermeable membrane allows some solutes to pass but not others. e. Diffusion only occurs if the barrier between compartments is permeable to the diffusing substance.

I. Concepts of Fluid and Electrolyte Balance F. Body Fluid Transport 3. Filtration a. filtration def. b. filtration action

a. Filtration is the movement of solutes and solvents by hydrostatic pressure. b. The movement is from an area of high pressure to an area of low pressure.

I. Concepts of Fluid and Electrolyte Balance B. Body fluid compartments 1. Description

a. Fluid in each body compartment contains electrolytes b. Each compartment has a particular composition of electrolytes c. Normal function requires electrolytes in the right compartment and concentration d. Whenever an electrolyte moves out of a cell, another moves in to replace it e. Cations and anions must be equal for homeostasis f. Compartments are separated by semipermeable membranes

What is Hypocalcemia?

decrease in calcium

What is hypokalemia?

decrease in potassium

Interstitial fluid to plasma results in

decreased edema

Signs of and changes with FVD

decreased pulse volume ---------------------------------------------------------------------------------------------------------- tachycardia ---------------------------------------------------------------------------------------------------------- elevated temperature ---------------------------------------------------------------------------------------------------------- BP may fall significantly

Dehydration

decreased volume of water and electrolyte change

Hypovolemia

deficiency in amount of water and electrolytes in ECF with near-normal water/electrolyte proportions

What are nursing diagnosis for sodium & volume imbalances deficit?

deficient fluid volume, decreased cardiac output

Causes of fluid and electrolyte imbalance

dehydration, renal failure, and almost every illness has the potential to threaten this balance; as well as excessive temperatures or vigorous activity if adequate intake of water and electrolytes is not maintained

What do isotonic solutions help with?

dehydration, vomiting, infection

risk factors for fluid volume deficit

diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage, coma, and third space shifts

Potassium Deficit (hypokalemia) < 3.5 mEq/L serum potassium Contributing factors

diarrhea, vomiting, gastric suction, corticosteroid administration, hyperaldosteronism, carbenicillin, amphotericin B, bulimia, osmotic diuresis, alkalosis, starvation, diuretics, and DIGOXIN TOXICITY!!!

Gains

dietary intake of fluid and food or enteral feeding; parenteral fluids

Solute

dissolved substance in a solution cells, cellular debris, salts, nutrients, wastes

Third-Space Fluid Shift

distributional shift of body fluids into potential body spaces, ie edema, ascites

What are the causes of hypokalemia?

diuresis, vomiting, diarrhea, laxative abuse

Sources of potassium - fruits

dried fruits (raisins, dates), banana, apricot, cantaloupe, orange

Fluid volume excess definition

due to overload or diminished homeostatic mechanisms

Clinical manifestations of FVE:

edema distended neck veins ***CRACKLES***** ( soft-high pitched discontinuous popping sounds) tachycardia increased BP increased pulse pressure increased central venous pressure increased weight increased urine output and shortness of breath/wheezing

FVE symptoms

edema, distended neck veins, abnormal lungs sounds (crackles), tachycardia, increased BP, pulse pressure, and CVP, increased weight, increased UO, shortness of breath, wheezing

symptoms of hypervolemia

edema, distended neck veins, crackles/rales in lower back

S&S of fluid volume excess

edema, pitting edema, weight gain

Ions

electrically charged particles

Potassium (K)

electrolyte imbalance in which cardiovascular is always a concern.

substances capable of breaking into ions (charged particles)

electrolytes

Lab results of FVD

elevated BUN in relation to serum creatinine, increased hematocrit, and possible serum electrolyte changes

Dehydration:lab assessment

elevated hemoglobin elevated hematocrit elevated serum osmolarity elevated glucose elevated protein elevated BUN elevated electrolytes Hemoconcentration

Fluid overload

excess of body fluid Most problems caused by Overhydration r related to fluid volume excess in the vascular space or to dilution of specific electrolytes and blood components.

Volume Overload

excess of fluid in either the intravascular or extra-vascular space

causes of hypernatremia

excess water loss, excess sodium administration, diabetes insipidus, heat stroke, hyperstonic IV solution

Edema

excessive ECF accumulates in tissue spaces

How can water be gained ABNORMALLY?

excessive parenteral administration of dextose and water solutions, particulary during periods of stress , ALSO may be gained by compulsive water drinking (psychogenic polydipsia)

Hypervolemia

excessive retention of water and sodium in ECF, may have jugular venous distention (JVD)

what can drawing blood above IV site result in

false lab result

Signs and Symptoms of Hypokalemia

fatigue, anorexia, nausea and vomiting, muscle weakness, polyuria, DECREASED BOWEL MOTILITY, ventricular asystole or fibrillation, paresthesias, leg cramps, decreased BP, ileus, abdominal distention, hypoactive reflexes, ECG: flattened t waves, prominent u waves, ST depression, prolonged PR interval

hypokalemia manifestations

fatigue, anorexia, nausea, vomiting, dysrhythmias, muscle weakness, cramps, paresthesias, glucose, intolerance, decreased muscle strength, deep tendon reflexes (DTRs), decreased cardiac output

Give clinical manifestations of hypocalcemia...

fatigue, depression, anxiety, confusion, numbess, tingling in extremities & around mouth, muscle cramps, chvostek's, trousseau's,laryngeal spasm, seizures

List clinical manifestations of hypokalemia...

fatigue, muscle weakness, leg cramps, nausea, vomiting, paresthesia w/ decrease reflexes, weak irregular pulse, polyuria, hyperglycemia

What is pulmonary edema and what are some manifestations:

fluid in the pulmonary interstitium and alveoli increases. Manifestatons include shortness of breath, increased respiratory rate, diaphoresis, and **crackles and wheezing** on auscultation of the lungs. Decreased hematocrit resulting from hemodilution, arterial blood gas results indicative of RESPIRATORY ALKALOSIS and HYPOXEMIA, and DECREASED SERUM SODIUM AND OSMOLALITY FROM RETENTION OF FLUID may occur with edema. BUN AND CREATININE LEVELS INCREASE, URINE SPECIFIC GRAVITY DECREASES, AS THE KIDNEYS ATTEMPT TO EXCRETE EXCESS WATER, AND THE URINE SODIUM LEVEL DROPS DUE TO INCREASED ALDOSTERONE PRODUCTION.

Dehydration occurs when

fluid intake is less than is needed to meet the body's fluid needs resulting in a fluid volume deficit.

Extracellular fluid (ECF)

fluid outside cells includes intravascular and interstitial fluids

Explain Fluid Volume Deficit: Hypovolemia:

fluid volume deficit occurs when loss of ECF volume exceeds the intake of fluid. Occurs when water and electrolytes are lost in the same proportion as they exist in normal body fluids, so that the ratio of serum electrolytes to water remains the same. SHOULD NOT BE CONFUSED WITH THE TERM DEHYDRATION, WHICH REFERS TO THE LOSS OF WATER ALONE WITH INCREASED SERUM SODIUM LEVELS!!!

What are nursing diagnosis for sodium & volume imbalances excess?

fluid volume excess, ineffective airway clearance, risk for impaired skin integrity, disturbed body image

Intracellular fluid (ICF)

fluid within cells

loop diuretics

for edema, causes loss of water and sodium at the same time

Detecting and controlling hyponatremia:

for patients who can consume general diet: broth with beef cubes, 8oz of tomato juice. For patients taking lithium, the nurse observes for lithium toxicity when sodium is lost by abnormal route.

What is ascites?

form of edema where fluid accumulates in the peritoneal cavity, results from cirrhosis. Patients commonly report shortness of breath and a sense of pressure on the diaphragm.

Extracellular fluid (ECF)

found outside the cells and accounts for 1/3 of body fluid ---------------------------------------------------------------------------------------------------------- the transport system that carries nutrients to and waste products from the cells

Intracellular fluid (ICF)

found within the cells of the body and accounts for about 2/3 of total body fluids ---------------------------------------------------------------------------------------------------------- provides a medium in which metabolic processes of the cell take place

What are replacements for fluid and electrolytes?

gatorade, pedialyte, IV's-hypertonic, hypotonic, Isotonic

Hypertonic

greater concentration of particles than plasma

hypernatremia serum sodium

greater than 145 mEq/L

Alkasetlzer

has a lot of sodium

When does Hyponatremia and Hypernatremia happen in regards to FVD:

hyponatremia--> occurs with increased thirst and ADH release Hypernatremia--> increased insensible WATER losses and diabetes insipidus--> (vasopressin deficiency) vasopress is a hormone that causes water retention

In what IV solution does water move from a vein into a cell?

hypotonic

hypernatremia intervention

hypotonic electrolyte solution or D5W

What happens to cells in hypertonic vs hypotonic solution?

hypotonic- cells burst hypertonic - cells shrink

fluid volume deficit (FVD)

hypovolemia

IV fluids putting water in

in ECF ALWAYS?

Water restriction with hyponatremia:

in a patient with normal or excess fluid volume, hyponatremia is treated by restricting fluid to a total of 800 mL in 24 hours. When neurologic symptoms are present, may be necessary to administer hypertonic sodium solutions such as 3-5% NaCl solution. If hyponatremia and edema occur together, both sodium and water is restricted.

hypokalemia medical management

increase dietary potassium, K replacement, and IV for severe deficit

What is hypercalcemia?

increase in calcium

acidosis

increased hydrogen ions, occurs when arterial pH falls below 7.35

Thyroid Gland

increases the blood flow in the body and increases renal circulation

Nervous System

inhibits and stimulates mechanisms influencing fluid balance

intracellular

inside cells

intervascular

inside vessels(blood plasma)

Which fluid compartment has the most fluid?

intracellular fluid; ICF constitutes about two-thirds of the total body fluid in adults

Hypomagnesmia Treatment

involves PO or IV replacement, increased dietary intake

Nutritional Therapy of FVE:

involves dietary restriction of sodium. SODIUM SALT, AND SODIUM CHLORIDE CONTRIBUTE TO EDEMA RATHER THAN SODIUM ITSELF!

What are clinical manifestations of hyperkalemia?

irritability, anxiety, abdominal cramping, diarrhea, weakness of lower extremities, paresthesia, irregular pulse, EKG changes, cardiac arrest.

Give clinical manifestations of hyponatremia because of sodium loss...

irritability, apprehension, confusion, postural hypotension, tachycardia w/ rapid, thready pulse, nausea, vomiting, dry mucous membranes, wgt. loss, tremors, seizures, coma

pH < 6.9 or > 7.8

is usually fatal.

NS or 0.9% NaCl (308 mOs/liter) is what kind of IV solution?

isotonic

Some body organs that aid in maintenance of homeostasis

kidneys, heart and BVs, lungs, GI tract (digestion & elimination), brain (pituitary gland & hypothalamus), organs in endocrine system (adrenal & thyroid glands)

What are causes of hyperkalemia?

large quantity of K+intake, impaired renal excretion, shift of K+ from ICF-ECF, burns, rapid transfusion of aged blood, severe infections, medications(ace inhibitors)

Magnesium sources

legumes green, leafy vegetables nuts, peanut butter whole grains bananas, avocados, oranges chocolate milk

hyponatremia serum sodium

less than 135 mEq/L

hypocalcemia serum

less than 8.5 mg/dL and must be considered in conjunction with serum albumin level

Hypotonic

lesser concentration of particles than plasma

Hypermagnesemia symptoms

lethargy drowsiness nausea & vomiting absence of deep tendon reflexes somnolence resp arrest cardiac arrest

What are the clinical manifestations of hypercalcemia ?

lethargy weakness, decrease reflexes, decrease memory, confusion, personality changes, anorexia, nausea, vomiting, bone pain, polyuria, dehydration, nephrolithiasis, coma

S&S of Hyperkalemia

life threatening dysrhythmias

Solvents

liquids that hold a substance in solution

Osmoreceptors

located on surface of hypothalamus. Sense changes in sodium concentration As pressure increases, the neurons become dehydrated, and quickly release impulses to the posterior pituitary which increases the release of ADH. ADH travels in the blood to the kidneys, where it alters permeability to water, causing increased reabsorption of water and decreased urine output. The retained water dilutes ECF and returns its concentration to normal. Restoration of normal osmotic pressure provides feedback to the osmoreceptors to INHIBIT FURTHER ADH RELEASE. *** ^ OSMOTIC PRESSURE= ^ ADH RELEASE** DIRECTLY PROPORTIONAL

hypercalcemia treatment

loop diuretics isotonic saline oral intake of 3-4 liter of fluid per day synthetic calcitonin reduce dietary calcium mobilization & weight bearing activity Calcium chelators or calcium binders

Third Spacing

loss of ECF into a space that does not contribute to equilibrium, is the physiological concept that body fluids may collect in a "third" body compartment that isn't normally perfused with fluids. For example, with severe burns, fluids may pool in the burn site and cause depletion of the fluids in the first and second compartments. With pancreatitis, fluids may "leak out" into the peritoneal cavity, also causing depletion of the first and second compartments. Patients who undergo long, difficult operations in large surgical fields collect third-space fluids and become intravascularly depleted despite large volumes of intravenous fluid and blood replacement. (http://en.wikipedia.org/wiki/Third_spacing_of_fluids)

fluid volume deficit definition

loss of extracellular fluid exceeds intake ratio of water, and electrolytes are lost in the same proportion as they exist in normal body fluids

isotonic dehydration

loss of sodium and water from the body, decreased in the volume of extracellular fluid; diarrhea and vomiting

Sodium deficit (hyponatremia) contributing factors: <135 mEq/L

loss of sodium in use of diuretics, loss of GI fluids, renal disease, adrenal insufficiency, gain of water, excessive administration of D5W and water supplements receiving hypotonic tube feedings, hyperglycemia and heart failure cause a loss of sodium

hypotonic

loss of sodium, fluid goes into cells, inadequate aldosterone secretion

Sensible Loss

loss that is perceived or is measurable. (wound drainage, GI tract, urine)

Metabolic Alkalosis

low potassium -high pH >7.45 -high bicarbonate >26 -Causes: most commonly due to vomiting or gastric pain; may also be due to meds, esp. long term diuretic use, hypokalemia, or diarrhea-laxative abuse -hypokalemia will produce alkalosis -manifestations: symptoms related to dec. calcium, resp. depression, tachycardia, symptoms of hypokalemia

Facts on hypotonic solutions

lower osmolality than plasma (usually less than 275 mOsm/kg) -hypo-osmolality possible with infusion because solutions have a lower concentration of electrolytes than plasma does -transcend all membranes from vascular space to tissue to cell -cell swells

Sodium-Potassium (Na-K) pump

maintains the higher concentration of extracellular sodium and intracellular potassium

Sodium (Na)

major electrolyte found in extracellular fluid

causes of hypercalcemia

malignancy and hyperparathyroidism,bone loss related to immobility

pH

measures hydrogen ion concentration in the body fluids.

Sources of calcium

milk and milk products, canned salmon

Sources of potassium - beverages

milk, apricot nectar

hyperkalemia medical management

monitor ECG, cation exchange resin (Kayexalate), IV sodium bicarbonate, IV calcium gluconate, regular insulin and hypertonic dextrose IV, and B-2 agonists: limit dietary K and perform dialysis

Nursing care for FVD

monitor I/O and volumetric solution, monitor skin and tongue turgor, mucosa, MENTAL STATUS, provide oral care, admin fluids and parenteral fluids

hypokalemia nursing management

monitoring of ECG, AGBs, dietary K, and providing care related to IV admin KCL

osmosis

movement of fluid from an area of lower solute concentration to an area of higher solute concentration

Interstitial-to-Plasma shift

movement of fluid from space surrounding cells to blood

diffusion

movement of molecules and ions from an area of higher concentration to an area of lower concentration

filtration

movement of water and solutes from an area of higher hydrostatic pressure to an area of lower hydrostatic pressure

what are causes of hypercalcemia?

multiple myeloma, malignancy, prolonged immobilization, hyperparathyroidism, vitamin D overdose, thiazide diuretics

S&S of Hypokalemia

muscle weakness & cramps, irregular pulse

manifestations of hypercalcemia

muscle weakness, incoordination, anorexia, constipation, nausea and vomiting, abdominal and bone pain, polyuria, thirst, ECG changes, and dysrhythmias

anions

negative electrical charge

Anions

negatively charged ions

Kidneys

normally filter 170 L of plasma and excrete 15 L of urine

Bicarbonate

norms: 22-26 mEq/L HCO3= 1 molecule of hydrogen +1 molecule of carbon + three molecules of oxygen Functions: -Major renal component of the acid base balance -serves as a buffer in body's ECF Excess: Alkalosis Deficiency: Acidosis

Preventing FVD:

nurse identifies patient at risk and takes measures to minimize fluid losses. For example, if patient has diarrhea, diarrhea control measures should be implemented and replacement fluids administered. may include; anti-diarrheal meds and small volumes of oral fluids at frequent intervals.

Nursing management of FVE:

nurse measures I&O patients weight assess breath sounds monitor the degree of edema Extent of peripheral edema is monitored by measuring the circumference of the extremity with a tape marked in millimeters.

extracellular fluid

outside of cell

If patient's urine is diluted, what would their hydration status be?

overhydrated; urine is dilute when overhydrated, and specific gravity would be more on the low end towards 1.005 Vice versa: urine is more concentrated when dehydrated specific gravity would be more on the high end towards 1.030

Metabolic Acidosis

pH < 7.35 , PaCO3 normal or < 35, HCO3 < 22

Respiratory Acidosis

pH < 7.35, PaCO2 > 45, HCO3 >26

Respiratory Alkalosis

pH > 7.45, PaCO2 < 35, HCO3 < 22

Metabolic Alkalosis

pH > 7.45, PaCO2 normal or > 45, HCO3 > 26

Filtration

passage of fluid through a permeable membrane from the area of higher to lower pressure

S&S of Hypocalcemia

pathological fractures, Trousseau's sign, Chvostek's sign

S&S of Hyponatremia

personality change, postural hypotension

Major anions in ICF

phosphate, sulfate

Define Active Transport:

physiologic pump that moves fluid from an area of LOWER CONCENTRATION to one of HIGHER CONCENTRATION; requires ATP for energy to go AGAINST concentration gradient.

active transport

physiologic pump that moves fluid from an area of lower concentration to one of higher concentration; movement against the concentration gradient

Primary components of ECF

plasma and interstitial fluid

manafestations of hyponatremia

poor skin turgor, dry mucosa, headache, decreased salivation, decreased BP, nausea, abdominal cramping, and neurologic changes

cations

positive electrical charge

Cations

positively charged ions

reciprocal

potassium has action with sodium.

Other electrolytes in ECF in smaller quantities

potassium, calcium, magnesium

Primary cations in ICF

potassium, magnesium

Foods high in potassium

potatoes, raisins, bananas, spinach, avacados, carrots

Osmotic pressure

pressure exerted by the protein in the plasma

hydrostatic pressure

pressure exerted on the walls of blood vessels

Hypermagnesemia treatment

prevention IV calcium gluconate/calcium chloride Push fluids dialysis for renal patients

Sodium sources

processed foods: cured ham, cold cuts, snack foods, canned vegetables & soups Prepared sauces & seasonings Pork, beef, poultry ,eggs Milk & cheese

Contributing factors of Potassium Excess: (Hyperkalemia) > 5.0 mEq/L

pseudohyperkalemia, oliguric renal failure, use of potassium conserving diuretics in patients with renal insufficiency, metabolic acidosis, addison's disease, crash injury burns, stored bank blood transfusions, and rapid IV admins. of potassium

Cardiovascular System

pumps and carries nutrients

What are symptoms of hyPOnatremia?

rapid pulse, shallow breathing, confusion, headache, seizures, increased urine output, hyperactive bowel.

manifestations of FVD

rapid weight loss, decreased skin turgor, oliguria, concentrated urine, postural hypotension, rapid and weak pulse, increased temp, cool and clammy skin due to vasoconstriction, lassitude, thirst, nausea, muscle weakness, cramps

gerontologic considerations

reduced homeostatic mechanisms: cardiac, renal, and respiratory function; decreased body fluid %; medication use; presence of concomitant conditions; (more of a fragile fluid balance)

Gerontologic Considerations physiological changes for FVD:

reduction in total body water (associated w/ increased body fat content, and decreased muscle mass); reduction in renal functions; resulting in decreased ability to concentrate the urine. Decreased cardiovascular and respiratory functions; and disturbances in hormonal regulatory functions. PHYSIOLOGIC CHANGES MUST BE ADDRESSED DURING ASSESSMENT.

Define fluid volume excess: FVE

refers to an isotonic expansion of the ECF caused by abnormal retention of water and sodium in approximately the same proportion in which they normally exist in the ECF. It is always secondary to an increase in the total body sodium content, which, in turn, leads to an increase in total body water. Because there is an isotonic retention of body substances, the serum sodium concentration remains ESSENTIALLY NORMAL.

dehydration

refers to loss of water alone, with increased serum sodium level

Lungs

regulate oxygen and carbon dioxide levels of the blood

Parathyroid Glands

regulate the level of calcium in ECF

potassium

regulates contraction and nerve impulses, regulates hr and acid-base fluid balance, regulates fluid ion balance, 95% in intracellular fluid, levels 3.5-5 mEq/L, irritating to the veins

Antidiuretic hormone (ADH)

regulates water excretion from the kidneys

RELEASE OF ATRIAL NATRIURETIC PEPTIDE (ANP)

released by cardiac cells in the atria of the heart in response to increased atrial pressure. Any disorder that results in volume expansion or increased cardiac filling pressures (high sodium intake, heart failure, chronic renal failures, atrial tachycardia, vasoconstrictor agents) will increase release of ANP. normally 20-77pg/mL BASICALLY DECREASES BLOOD PRESSURE

cause of decreased excretion

renal disease,cancer

Active Transport

requires energy for movement of substances through the cell membrane from the lesser solute concentration to the higher solute concentration

Nursing care for FVE

restriction of fluids and sodium and administration of diuretics, use semi-fowler's position for orthopnea, provide skin care and position/turning, promote rest

Hypotonic solution

reverses dehydration.

Isotonic

same concentration of particles as plasma

Facts on isotonic solutions

same osmolality as plasma (app. 275 to 295 mOsm/kg) -vascular space osmolality not altered by infusion -expand intracellular and extracellular space equally; degree of expansion correlates with amount of fluid infused -no solution-related shifting between ICF and ECF spaces -cells neither shrink nor swell with fluid movement

Weigh patient how?

same time, same scale, same clothes, after voiding.

Hyponatremia

serum Sodium level less than 135 mEq/L

hypercalcemia serum

serum level above 10.5 mg/dL

Hypernatremia value

serum sodium greater than 145 mEq/L

hypocalcemia nursing management

serverarity can be life-threatening, weight-bearing exercises to decrease bone calcium loss, patient teaching related to diet and medications, and nursing care related to IV calcium administration

Define Anasarca:

severe generalized edema.

Most abundant electrolyte in ECF

sodium

Example of cations

sodium (Na+), potassium (K+), calcium (Ca++), magnesium (Mg++)

Preventing FVE:

sodium restricted diets adherence to diets avoid OTC meds hidden sources of sodium ( water supply/ water softeners should be considered) Should use DISTILLED water.

Principle electrolytes in ECF

sodium, chloride, bicarbonate

major cations

sodium, potassium, calcium, magnesium, hydrogen ions

Hypertonic solution

solution with greater concentration than plasma.

tetany

spasms of hands and feet; excitability of body

Balance =

stable concentration of hydrogen ions in body fluids

Pituitary Gland

stores and releases ADH

Solutes

substances dissolved in a solution (electrolytes and nonelectrolytes)

Solute

substances that dissolve in a liquid

S&S of getting more isotonic fluid than the body needs, or "fluid overload"

swelling, crackles in the lungs, dyspnea

Preventing Hypokalemia

teach signs & symptoms of hypokalemia teach importance of increased potassium in diet for those on loop diuretics. Teach foods high in potassium. Explain content of salt substitutes. teach to take meds with water. explain importance of follow up for monitoring.

Diffusion

tendency of solutes to move freely throughout a solvent (downhill)

manifestations of hypocalcemia

tetany, circumoral numbness, parethesias, hyperactive DTRs, Trousseau's sign, Chvotek's sign, seizures, respiratory symptoms of dyspnea and laryngospasm, abnormal clotting, anxiety

Solvent

the component of a solution that can dissolve a solute

determines the fluid direction

the differences of hydrostatic and osmotic pressure

GOAL OF TREATMENT FOR FVE

the goal is to preserve or restore the circulating intravascular fluid volume. In addition to treating cause, other treatments include diuretic therapy, restriction of fluids and sodium, elevation of extremities, application of elastic stockings, paracentesis [fluids removed from belly], dialysis ( artificial kidneys), continuous arteriovenous hemofiltration in cases of renal failure or life threatening fluid volume or overload.

manafestations of hypernatremia

thirst, elevated temp, dry, swollen tongue, sticky mucosa, neurologic sysmptoms, restlessness, weakness

Signs and symptoms of Sodium Excess:

thirst, elevated temperature, swollen dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, focal or grand mal seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, increased pulse, increased BP Labs: increased serum sodium, decreased urine sodium, increased urine specific gravity.

Explain SIADH

this is excessive ADH activity, with water retention and hyponatremia, and inappropriate urinary EXCRETION of SODIUM in the presence of hyponatremia. <<< THIS IS HOW YOU GET FLUID VOLUME EXCESS BECAUSE ADH CONSERVES THE WATER

Homeostasis

total cations equal to total anions

hypercalcemia medical management

treat underlying cause, administer fluids, furosemide, phosphates, calcitonin, biphosphonates

hyperphosphatemia treatment

treatment of cause dietary restriction calcium supplements phosphate-binding agents (Renagel)

Output includes -

urine, diarrhea, vomitus, gastric suction, all drains/tubes

Correcting FVD:

when possible, oral fluids are administered. type of fluid patient lost is considered and attempts are made to select fluids most likely to replace the lost electrolytes. If patient is reluctant to drink because of oral discomfort, nurse assists with mouth care and provides non irritating fluids. Nausea present, adminster antiemetics may be needed before fluid replacement can be tolerated. If patient cannot eat and drink, nurse may need to administer fluid by another route prescribed to prevent renal damage related to prolonged FVD.

Normal Values: P

2.5-4.5

causes of Hyperkalemia

Fluid Volume Deficit, Renal Failure, Acidosis

Renin

Released in response to decreased blood flow or decreased pressure in nephrons.

What does the measure of osmolality indicate?

The water balance of the body.

Intracellular fluid (ICF)

2/3 body fluid in healthy adults Contains large amounts of K+ Approximately 40% of body weight

Dehydration

Fluid intake/retention does not meet body's fluid needs; results in fluid volume deficit Consideration for older adults

What is the main mechanism for fluid balance?

The thirst mechanism

Sodium (Na)

controls water distribution in maintaing fluid and electrolyte balance, osmotic pressure, participates in acid-based balance

fluid volume excess (FVE)

hypervolemia

Fluid Imbalances

- involve either volume or distribution of water or electrolytes - hypovolemia - dehydration - volume overload - third-space fluid shift

S&S of Hypercalcemia

hypoactive reflexes, cardiac arrest

Hypermagnesmia Treatment

- involves stopping PO or IV replacement - calcium gluconate may be helpful to stabilize cardiac symptoms in severe cases

Hypernatremia Mnemonic

"Fried Salt" Flushed skin and fever Restless, irritable, anxious, confused Increased BP and fluid retention Edemas, peripheral and pitting Decreased urine output and dry mouth Skin flushed Agitation Low-grade fever Thirst

Hyperkalemia Symptoms

- irregular slow heart rate - decreased BP - EKG changes (peaked T-waves, widened QRS, ectopy) - weakness and paralysis may occur

Hyperkalemia Mnemonic

"Murder" Muscle cramps Urine abnormalities Respiratory distress Decreased cardiac contractility EKG changes Reflexes

Hypophosphatemia Symptoms

- irritability - fatigue - weakness - paresthesias - confusion - seizures - coma

Adrenal Cortical Regulation of Water Balance

(adurenal and kidneys are really close in lcoation) - Releases hormones to regulate water and electrolytes - (1)Glucocorticoids: - Have an anti-inflammatory effect and increase serum glucose Cortisol- most abundant- stress hormone, huge player in hospital if sick and has tones of stressors in the body- increases in response to stress --> cortisol levels fluctuate normally with circadian patterns day light --> night so if working nights, you cant help it you wake up to pee during the day- normal cortisol secretion is in circadian pattern - elevates glucose and anti-inflammatory effect in large doses - (2) Mineralocorticoids: - Enhance sodium retention and potassium excretion- when sodium is re-absorbed water follows Aldosterone- regulates sodium, and whenever sodium goes water goes - decreased renal perfusion or decreased sodium delivery to distal portions of the renal tubes activates renin-angiotensin-aldosterone-systen RAAS --> aldosterone secretion - Aldosterone is also stimulated by increased plasma potassium, decreased plasma sodium

D10W

(hardly give on the floor, very hypertonic and dangerous) - Hypertonic - Provides 340 kcal/L - Provides free water but NO electrolytes - Limit of dextrose concentration may be infused peripherally -

Regulation of Water Balance: Cardiac Reglation

(measures muscles cells in atrium- measures pressure. if fluid overloaded- lot of pressure give off peptides to stop ADH, renin, aldosterone) - Natriuretic peptides are antagonists to the RAAS - They are produced by cardiomyocytes in response to increased atrial pressure and high sodium levels - They suppress secretion of aldosterone, renin, and ADH to decrease blood volume and pressure --> stop holding onto fluid and excrete the fluid THERFORE promotes excretion of sodium and water --> decreased BP and blood volume - Lab work and someone is fluid overloaded -- BNP elevated brain neurotic peptide that will be elevated

Hyponatremia

- <135 mEq/L - low serum sodium - Results from loss of sodium-contain fluids and OR water excess- happens in hypervolemia or combo - causes from loss of sodium rich body fluids- profuse diaphoresis, draining wounds, excessive diarrhea and vomiting, trauma with sig blood loss - causes hypoosmolality with a shift of water INTO cells - causes from water excess: inappropriate use of sodium free or hypotonic IV fluids, after surgery patients or with renal failure, psychiatric disorders with excessive water intake, SIADH- syndrome of inappropriate antidiuretic hormone secretion- results in dilution hyponatremia caused by abnormal water retention

Nursing Assessment: Edema clinical manifestations and management/treatment

- Accumulation of fluids in interstitial spaces Clinical Manifestations - may be localized or generalized - usually associated with weight gain - Fluid trapped in "third space" Management and Treatment - Diagnose underlying cause - Treat symptomatically - Supportive measures (non-pitting edema you push on it and it goes right back)

Hyponatremia: nursing diagnoses

- Acute confusion - Risk for injury - Risk for electrolyte imbalances - Potential complication- severe neurologic changes

Atrial vs. Venous End

- Arterial end: capillary hydrostatic pressure > plasma oncotic pressure - fluid moves into interstitial space - Venous end: capillary hydrostatic pressure < plasma oncotic pressure, drawing fluid back into capillary- by the oncotic pressure created by plasma proteins

Sodium Potassium Pump

- As sodium (Na+) diffuses into the cell and potassium (K+) diffuses out of the cell, an active transport system supplied with energy (ATP) delivers Na+ back to the extracellular compartment and K+ to the intracellular compartment - At rest more K+ inside cell and more Na+ outside cell (check)

Hydrostatic Pressure

- Blood pressure generated by heart contraction - The force within a fluid compartment - In blood vessels, hydrostatic pressure is the BP by the heart - decreases as blood moves through arteries until it is about 30 mmHg in the capillary bed- at the capillary bed, hydrostatic pressure is the major force that pushes water out of the vascular system and into the interstitial space - The force exerted by the weight of a solution - When a difference exists in the hydrostatic pressure on two sides of the membrane, water and diffusible solutes move out of the solution that has the higher hydrostatic pressure by the process of filtration (high pressure to low pressure) - Arterial end: hydrostatic pressure is higher than osmotic pressure --> fluids and diffusible solutes move out of the capillary - Venous end: osmotic pressure or pull is greater than hydrostatic pressure, and fluids and some solutes move INTO the capillary

BUN and Body Builders

- Body builders taking a ton of protein supplements or cut out carbs can be damaging to your kidneys because working overtime from that waste product - if BUN is high best way of getting it down is to hydrate the patient - if BUN is low means body is caught up- can't really be too low - more so watch out for high elevated levels

Nursing Implementation Cardiovascular changes fluid volume excess vs. deficit

- Excess: pulse is full, bounding, not easily to obliterate --> JVD and increased BP - Deficit- compensatory mechanism - inc HR and vasoconstriction maintains BP in normal limits- if vasoconstriction and tachycardia provide inadequate compensation --> hypotension occurs-- flattened neck veins, weak, thready easily to obliterate pulse --> shock

Hyponatremia Symptoms

- CNS changes/delirium - irritability - confusion - lethargy - weakness - dizziness - seizures - coma - neurological damage from cerebral demyelination - tachycardia and hypotension if hypovolemic

Fluid Movement in capillaries determined by

- Capillary hydrostatic pressure : move water out of capillaries - Plasma oncotic pressure: move fluid into capillaries - Interstitial hydrostatic pressure: move fluid into capillaries - Interstitial oncotic pressure : move water out of capillaries

The amount and direction of movement is determined by

- Capillary hydrostatic pressure and interstitial oncotic pressure move water out of the capillaries - Plasma oncotic pressure and interstitial hydrostatic pressure move fluid into the capillaries (4 factors- capilary hydrostatic pressure, plsama oncotic pressure, interstital hydrostatic pressure, intersitital oncotic pressure) - Arterial end: capillary hydrostatic pressure > plasma oncotic pressure- fluid moves into interstitial space - Venous end: capillary hydrostatic pressure < plasma oncotic pressure, drawing fluid back into the capillary By the oncotic pressure created by plasma proteins

Disturbances in Fluid Balance

- Causes: Directly caused by illness or disease (burns or heart failure) OR - Result of therapeutic measures (IV fluid replacement or diuretics) - Preoperative patients at risk because of fluid restrictions, blood and fluid loss and stress

Hyponatremia: Clinical Manifestations

- Confusion - Irritability - Headache - Seizures and coma - a lot more life threatening than hypernatremia - athletes not having electrolytes with water for example - due to cellular swelling and first manifested in the CNS - excess water lowers plasma osmolality shifting fluid INTO brain cells --> irritability, headache, confusion, seizures and even coma or death

Gerontologic Considerations

- Decreased in renal blood flow- decreased glomerular filtration rate- decreased creatinine clearance- loss of ability to concentrate urine and conserve water - hormonal changes --> decreased renin and aldosterone and an increased in ADH and ANP - loss of subQ tissue and thinning dermis- increased loss of moisture from skin - aging --> decreased thirst mechanism- decreased fluid intake- increases osmolality and serum sodium level

Neurological Changes ECF deficit and excess

- ECF excess --> cerebral edema from increased hydrostatic pressure in cerebral vessels - Volume depletion --> alteration in sensorium secondary to reduced cerebral tissue perfusion - assess LOC, pupil response to light, degree of muscle strength and reflexes

Respiratory Changes Hypervolemia vs. hypo

- ECF excess --> pulmonary congestion, pulmonary edema as increased hydrostatic pressure in pulmonary vessels force fluid into alveoli --> SOB and crackles - ECF deficit --> increased RR because of decreased tissue perfusion --> hypoxia

Extracellular Fluid Volume Deficit

- ECF- plasma/blood AND interstitial- in the vessels and outside the vessels - Abnormal loss of normally body fluids: diarrhea, fistual drainage, hemorrhage, polyria - inadequate intake, or plasma-to interstitial fluid shift - Clinical manifestations related to loss of vascular volume as well as CNS effects - Treatment: replace water and electrolytes with balanced IV solutions - isotonic sodium chloride is used when rapid volume replacement is indicated- blood transfusion used when blood lost

Electrolyte Imbalances

- Electrolytes are normally gained and lost in relatively equal amounts - With abnormal loss through illness or treatment, the balance is disturbed - RN needs knowledge so careful and skilled monitoring can occur- sodium, potassium calcium, phosphate, magnesium

Hypernatremia general

- Elevated serum sodium occurring with water loss or sodium gain >145 mEq/L - Causes hyperosmolality leading to cellular dehydration because causes a shift of water out of the cells --> cellular dehydration - Primary protection is thirst from hypothalamus can be secondary to LOC because then cannot drink (cells lose fluid and they will shrink) - Water deficit can be produced from a deficiency in the synthesis or release of ADH from posterior pituitary gland OR a decrease in kidney responsiveness to ADH --> diuretics and water deficit - caused by excessive sweating, increased sensible loss from high fever, excessive sodium intake with inadequate water intake

Extracellular Fluid Imbalances: Flood Volume Excess- hypervolemia

- Excess intake of fluids, abnormal retention of fluids (heart failure, renal failure), or shifts from interstitial- to- plasma fluid shift does not alter ECF - Clinical manifestations related to excess volume - Treatment: Remove fluid without changing electrolyte composition or osmolality of ECF - shirking their cells - If excess fluids, usually because we did it to them in the hospital- we know it was common- doesn't happen as often as deficit - primary form of therapy = diuretics and fluid restriction or sodium intake restriction - if ascites or pleural effusion- abdominal paracentesis or thoracentesis

Hypernatremia: Nursing Management

- GOAL! Treat the cause of hypernatremia - Monitor serum Na+ levels - I/O and specific gravity of urine - assess LOC -goal for sodium excess is to dilute the sodium concentration with sodium free IV solution- use isotonic IV fluids (D5W) to rehydrate- because you want the fluid to stay outside of the cell therefore use D5W- closest thing to free water thats why you also give water to drink - in primary water defict, fluid replacement is provided orally or IV with isotonic or hypotonic solutino- 5% dextrose in water OR isotonic .45% NaCl saline solution - keep salt out of reach - give water or provide free water with tube-feedings - monitor levels quickly quickly reducing sodium can cause a rapid shift of water back into the cells --> cerebral edema and neuro complications

Variations in Fluid Content

- Healthy person: total body water is 50-60% of body weight - an infant has considerably more body fluid and ECF than an adult, 75%; more prone to fluid volume deficits - gender and amount of fat cells effects body water; women and obese people have less body water

Hyperkalemia

- High serum potassium >5.0mEq/L - caused by: 1. Impaired renal excretion 2. Shift from ICF to ECF 3. Massive intake - Most common in renal failure - best way is to make patient have diarrhea with high potassium

D5 1/2 NS

- Hypertonic - Common maintenance fluid - Replaces fluid loss - KCl added for maintenance or replacement - 1/2 amount of sodium and 1/2 amount of chloride therefore 0.45% NS - pull fluid out of cells initially when dextrose is present (in stress bodies get low potassium)

Hypokalemia Clinical Manifestations

- Hypokalemia alters resting membrane potential resulting in hyper-polarization (increased negative charge of cell) and impaired muscle contraction- therefore muscle function and cardiac changes - most serious are cardiac- impaired repolarization resulting in flattening of T wave and emergence of Y wave, P wave peaks QRS is prolonged, increased incidence of ventricular dysarthymias - GI smooth muscle slowing- constipation, ileus - Skeletal muscle weakness- and paralysis - Respiratory muscles maybe impaired - Cardiac arrhythmia - Polyuria related to decreased renal function + can impair function in non-muscle tissue by impairing insulin secretion --> hyperglycemia

Effects of IV tonicity on cells

- Hypotonic- cells swell - Isotonic cells stay the same - Hypertonic- cells shrink CHECK

Fluid Disturbances you should know

- Hypovolemia- Fluid Volume Deficit - Hypervolemia- Fluid Volume Excess - Dehydration *It is common for more that one imbalance to occur in the same patient- if they have both which one matters? The one that they are presenting symptoms with!

Fluid Compartments

- ICF: Intracellular fluid - 28L (majority of the fluids): inside the cells: 2/3 of body water or 40% of body weight in adults - ECF: Extracellular fluid- outside the cells- consists of 1/3 of body water mostly in the intravascular 1. Interstitial -10L: the fluid in the space between cells (sometimes called 3rd space) 2. Intravascular (plasma- same as serum= the same thing as plasma in the vessels- blood- the liquid part of blood)- 3L refers to fluid inside a blood vessel 3. Transcellular fluid- anything around the cells but not in the vessels- examples: pleural fluid, peritoneal fluid, CSF, pericardial, fluid in GI: very small amount of fluid contained within specialized cavities of the body

Hyperkalemia Clinical Manifestations

- Increases the concetration of potassium outside of the cell, atlering the normal ECF and ICF ratio and --> increased cellular excitiability - Are related to muscle dysfunction- leg gramping and weeakness followed by weakness or paralysis of other skeletal muscles including respiratory muscles - Hyperactivity of GI smooth muscle- cramping or diarrhea - Muscle weakness/paralysis (severe) - Cardiac arrhythmias- often bradycardia that may lead to V-fib- most clinically sig: cardiac depolarizatino is decreased flattening P wave and widening QRS - Apathy, lethargy, confusion or irritability - Anorexia, N/V, paralytic ileus, distention - Acid urine - Muscle cramps/tenderness

Elevation of Venous Hydrostatic Pressure

- Increasing presure at venous end of capillary inhibits fluid movement back into the capillary--> edema - caused by increased fluid overload, heart failure, liver failure, venous thrombosis, tourniquets

Measurement of Osmolality

- Indicate's body waters balance - Normal plasma osmolality is between 275-295 mOsm/kg >295 = indicates the concentration of particles is too great or water concentration is too little = water deficit <275= too little solute for the amount of water OR too much water for the amount of solute= water excess - measures concentration of a solution

Regulation of Water Balance- Insensible Water Loss

- Invisible vaporization from lungs and skin, assist regulating body temperature - Loss of approx. 600-900 mL/day - No electrolyte loss - accelerated metabolism (increased body temp and exercise) increases water loss ONLY WATER LOSS DO NOT CONFUSE WITH SWEAT- which is sensible water loss a natural way to cool off - Insensible water loss is normal moisture on the skin and NO loss of electrolytes

Lactated Ringer's Solution

- Isotonic - Similar in composition to plasma except contains no magnesium - Expands ECF- treat burns and GI losses - stays in ECF - Contraindicated with hyperkalemia and lactic acidosis - No free water or calories - has a lot of electrolytes except Mg- closets you will get to the serum composition - contains sodium, potassium chloride, calcium , and lactate (precursor to bicarbonate) in about the same concentration as those in ECF - contraindicated in patients with hyperkalemia and lactic acidosis because they have a decreased ability to convert lactate into bicarbonate

Hypovolemia- Nursing Interventions

- Monitor I&O's - Monitor VS- BP goes down with hypovolemia, HR goes up because less volume, pulse is thready and weak, RR inc - Weigh patient daily - Administer fluids as prescribed - Monitor for hidden fluid losses

Hypervolemia- Nursing Interventions

- Monitor I&O's -Observe for edema- has edema everywhere = anasarca = generalized edema - weigh patient daily- best way to evaluate fluid staus- this is always the best answer even better than I + Os - limit Na+ and fluids - Observe for sings of volume depletion - Monitor lab studies - Administer diuretics: furosemide- Lasix - Restrict fluids, monitor I and O - Provide skin care- especially for patients with edema - Semi Folwers - Low Na+ diet

Hyperkalemia: Nursing Management

- Monitor K+ levels - Monitor for and report arrhythmias - Monitor muscle weakness - Monitor I and Os especially adequate urine - Ensure safety - If giving blood, use freshest cells - Avoidance of K+ rich foods - Watch OTC medications containing K+

Hyponatremia nursing management/ implementation

- Monitor Na+ serum levels - Strict I and Os - Restriction of water intake if dilutional hyponatremia- allow kidneys time to excrete water- if caused by excess water - IV Hypertonic fluids SLOWLY - Use NS instead of distilled water for irrigations - Drugs- Vaprisol and Tolvaptan to block ADH and increase urine output without loss of electrolytes

Hypertonic IV Fluids

- More solutes and less fluids (more electrolytes?) - Initially expands and raises the osmolality of ECF- this is important when someone is dehydrated but must watch because they could get fluid overload - Require frequent monitoring of: BP, lung sounds, serum sodium levels - Initially raises osmolality of ECF and expands it- draws water out of the cells into ECF - useful in treating hypovolemia and hyponatremia examples: 10% dextrose (through peripheral line >10% must use central line), 3.0% Saline- used to treat hyponatremia- must be administered slowly, dextrose in saline: 5% in 0.45% saline or 5% in 0.9% saline...

Hypomagnesmia Causes

- NG suction - diarrhea - alcohol withdrawal - artifical nutrition administration - sepsis - burns

Should you allow patient with NG suction to drink water?

- NO because increase loss of electrolytes - occasionally given ice chips - irrigate NG tube with isotonic solutino not with WATER

Sodium: Hypernatremia

- Na+ > 145 is hypernatremia (normal value 135-145) - occurs with either water loss or sodium gain - usually elderly persons with acute infection, unable to replace fluids due to impaired thirst and/or restricted access to fluids. Also: diuretic use, salt water drowning, DI in brain injured patients, Cushing's syndrome - leads to a hyperosmolar state in the body which causes cell shrinkage and can lead to brain injury - treat by replacing volume loss with NS - decrease sodium intake in diet - assess CNS/neurological changes - treat any disease state or underlying cause - monitor urine output, urine specific gravity, BUN

Creatinine

- Normal value: 0.5-1.5 mg/dl - Reflects breakdown of muscle and protein - Is a very sensitive indicator of renal glomerular function - BUN/ Creatinine ratio normal = 10:1 --> = GRF filtration rate of glomerulus - Works with BUN to create filtration rate up - In acute renal failure it will shoot way up! - Renal failure is measured mainly by creatinine because BUN fluctuates so much, you could just be high because you are dehydrated - If creatinine stay relatively the same, your kidneys are functioning fine

Regulation of Water Balance: Hypothalamic- Pituitary Regulation

- Osmoreceptors in hypothalamus sense fluid deficit or increase: osmoreceptors figure out osmolality- pressure of body fluids and for example a deficit stimulates thirst - Osmoreceptors sense a body fluid deficit OR increase in plasma osmolality--> Deficit stimulates thirst and antidiuretic hormone ADH release: ADH stops kidneys from making urine; holds water in and urine output goes down: - the distal tubules and collecting ducts in the kidneys respond to ADH by becoming more permeable to water --> increased water reabsorption and decreased excretion of urine - Decreased plasma osmolality (water excess) suppresses ADH release - increases urine output- stops release of ADH allowing it to get rid of the fluid - post-operative patient have lower plasma osmolality due to anxiety and opioid analgesic --> drink more

Oncotic Pressure

- Osmotic pressure caused by plasma proteins - osmotic pressure caused by plasma colloids in solution - major colloid in vascular system is protein - plasma has substantial amounts of protein yet interstitial space has very little - plasma protein molecules attract water, pulling fluid from the tissue space to the vascular space

Hypervolemia- Clinical Findings

- Physical assessment (trouble breathing, CHF- fluid in space pushing up against lungs, cardiac tamponade, murmur heart sounds- if muffled means theres something in between you and it is usually fluid, JVD) - Lab values - Hct, BUN (decreases), Na+, Serum osmolality, Urine specific gravity, chest x-ray

Sources of Fluids for the Body

- ingested liquids - food - metabolism

Hypotonic IV Fluids

- Provides more water than electrolytes, diluting the ECF - pure water lyses RBCs - Osmosis then produces a movement of water from ECF to ICF- both ICF and ECF have same osmolality - Water moves from ECF to ICF by osmosis- pulls water into cells - usually maintenance fluids- do not want to run these very fast and additional electrolytes may be added - Monitor for changes in mentation: monitor LOC because cells can swell --> brain that increases pressure and can lead to confusion and can worsen to seizures - Although 5% dextrose is considered isotonic, dextrose is quickly metabolized and the net administration of free water hypotonic with proportionally = expansion of ECF and ICT - other example = 0.45% Saline- used to replace hypotonic fluid loss, used as maintence although does not replace daily loss of other electrolytes, no calories

Renin-Angiotensin-Aldosterone System

- Renin: secreted by juxtaglomerular cells produces angiotensin II - Angiotensin II causes vasoconstriction and stimulates the production of aldosterone = increased BP - Decreased blood flow to kidneys (as in hemorrhage), or decreased sodium reaching the glomerulus = more renin secreted - Causes vasoconstriction and increases BP - Increased blood flow to kidneys or increased sodium reaching the glomerulus = less renin secreted = reduced vasoconstriction - Decreased BP

Hypovolemia- Collaborative Management

- Restoration of fluid balance - Concentration of acid-base - Correction of electrolyte disturbances TREATMENT OF UNDERLYING CAUSE (could also be blood loss in this case get blood transfusion)

Hypokalemia Nursing Diagnoses

- Risk for activity intolerance - Risk for electrolyte imbalance - Risk for injury - Potential Complications- dysrhythmias

Nursing Diagnoses Hyperkalemia

- Risk for activity intolerance - Risk for electrolyte imbalance - Risk for injury - potentital complication: dysrhythmias

Hypernatremia: Nursing Diagnoses

- Risk for injury - Risk for fluid volume deficit - Risk for electrolyte imbalance - potential complications: seizures, and coma leading to irreversible brain damage

ECG Effects of Hypokalemia

- Slightly peaked P wave - Slightly prolonged PR interval - ST segment depression - Shallow T wave - Prominent U wave

Major Electrolytes and Their Chief Functions

- Sodium (Na+): control and regulates volume of body fluids - Potassium (K+): chief regulator of cellular enzyme activity and water content - Calcium (Ca2+): nerve impulse, blood clotting, muscle contraction, B12 absorption - Magnesium (Mg2+): metabolism of carbohydrates and proteins, vital actions involving enzymes - Chloride (Cl-): maintains osmotic pressure in blood, produces hydrochloric acid - Bicarbonate (HCo3-): body's primary buffer system - Phosphate (PO4-): involved in important chemical reactions in the body, cell division, and hereditary traits

Plasma Expanders

- Stay in vascular space and increase osmotic pressure - includes colloids, dextran, and hetastarch - Colloids (protein solutions): plasma, albumin, commercial plasmas used for hypovolemic patients - Dextran, Hetastarch- hardly every used because expensive - Dextran: complex synthetic sugar metabolizes slowly remains in vascular system for a longer period of time but not as long as colloids - Hetastarch- synthetic colloid that works smiliar to dextran to expand plasma volume - Blood expand it because they are solutes they will pull fluid out of the cells into the plasma and expand the volume - if patient has lost blood, whole blood or packaged RBCs are necessary

Electrolytes

- Substances whose molecules dissociate into ions when placed into water - ions are electrively charged particles - Cation: positively charged (Na+, K+, Ca2+. Mg+) - Anions: negatively charged (HCO3-, Cl-)- most proteins are anions Measurement of electrolytes: mEq

Elevation of Interstitial Oncotic Pressure

- Trauma, burns, inflammation damage capillary walls allow plasma proteins to accumulate in the interstitial space --> increased interstitial oncotic pressure - draws fluid into interstitial space and holds it there

Hypervolemia- Collaborative Management

- Treat underling cause - Restriction of Na+ and water - restrict sodium because water follows sodium - Diuretics - Dialysis

Hyperkalemia: Clinical Management

- Treat underlying condition - Treatments to remove K+ from plasma: 1. Peritoneal or hemodialysis 2. K+ wasting diuretics 3. K-excelate given PO or rectally 4. IV sodium bicarbonate, IV regular insulin, followed by D 50 IV - you know its working when patient has diarrhea - eliminate oral and parenteral potassium intake - increase potassium elimination- diuretics, dialysis - force potassium from ECF to ICF- IV of regular insulin or IV sodium bicarbonate for acidosis - IV calcium gluconate - patient experiencing dangerous cardiac cycles should receive IV calcium gluconate immediately- monitor BP because rapid administration of calcium --> hypotension

Fluid Volume Deficit: Assessment Findings

- Weight loss= best way to monitor it - Poor skin turgor (when punched skin released, skin remains elevated- should go right back) - Urine: decrease in volume, dark, odorous, increased specific gravity (1.03-1.30 more concentrated) - Increased RR - Dry mucous membranes - Increased HR: trying to increase blood flow - Increased hematocrit****- either dilute or increased RBC production to make up for loss and transport more O2 - Decreased CVP (central venous pressure) -inc HR and vasoconstriction maintains BP- if vasoconstriction and tachycardia provide inadequate compensation --> hypotension occurs- flattened neck veins weak thready pulse, eventually shock

Fluid Changes Skin assessment

- crucial - note older people have decreased turgor and is less predictive of fluid deficit because of loss of tissue elasticity - in ECF deficit turgor is diminished lag or tenting if skin remains wrinkled for 20-30s = poor skin turgor - vasoconstriction to compensate for decreased fluid volume --> skin may be COOL- YET mild hypovolemia usually does NOT stimulate this compensatory response and skin may still be warm and dry BUT volume deficit may cause skin to appear dry and wrinkled - edematous skin may feel cool because of fluid accumulation and a dec in blood flow secondary to the pressure of the fluid- fluid can also stretch the skin-- taut and hard feeling apply creams or oils- increases moisture retention and stimulates circulation

Regulation of Water Balance: Gastrointestinal Regulation

- daily water intake and output noramlly between 2000-3000mL - water intake can also caccount for food - but, Oral intake accounts for most water - Small amounts of water are eliminated by GI tract in feces - Diarrhea and vomiting can lead to significant fluid electrolyte loss

Hypercalcemia Treatment

- depends upon the severity of symptoms and the underlying cause - replace volume and encourage weight bearing mobilization if indicated

Implementing

- dietary modifications - modifications of fluid intake - medication administration - IV therapy - blood and blood products replacement - TPN/adequate nutrition/tube feeding - allaying patient anxiety as needed - appropriate patient and family teaching

Hyperkalemia Treatment

- diuretic therapy - decrease dietary intake - Kayexalate - IV insulin/dextrose/glucose - dialysis if renal failure or in severe cases

Nursing Diagnoses Related to Imbalances

- excess fluid volume - deficient fluid volume - risk for imbalanced fluid volume

Hypokalemia Symptoms

- fatigue - decreased deep tendon reflexes - muscle weakness - weak, thready pulse - cardiac dysrhythmias - lethargy - shallow respirations and dyspnea - anxiety/depression

Decrease in Plasma Oncotic Pressure

- fluid remains in interstitial space if plasma oncotic pressure is too low - results from excessive protein loss with renal disorders, deficit protein synthesis- liver disease, deficient protein intake- malnutrition - results from low plasma protein content

Hypertonic Solutions

- higher solute concentration than another solution - has less fluid relative to an adjacent fluid - fluid from less concentration will move to higher concentration, causing cells to shrink - indicated in hyponatremia, brain injury, severe swelling - hypertonic saline solution (2%-23.4%) - D5LR, D10, D5NS all hypertonic solutions - irritating to veins, may need central access - closely monitor electrolytes, glucose levels

Chloride: Hyperchloremia

- hyperchloremia is > 106 mEq/L (normal value: 97-107) - can result from metabolic acidosis, head trauma, increased perspiration, excess ACH production, decreased kidney function - almost always iatrogenic in hospital patients: administration of sodium chloride IV solution - symptoms include tachypnea, weakness, lethargy, diminished cognitive ability, hypertension, decreased cardiac output, dysrhythmias, and coma - treatment: determine and treat cause, monitor

Hypochloremia Symptoms

- hyperexcitability of muscles - tetany - hyperactive DTRs - weakness - muscle cramps

Fluid Volume Excess/Overload

- hypervolemia - overhydration - edema - interstitial-to-plasma shift

Hypotonic Solutions

- hypotonic solutions have lower volume of solute than surrounding fluid, will be indicated in severe dehydration, volume depletion - half-normal saline (1/2 NS, 0.45% NaCl) - Dextrose 2.5% in water (D2.5W) - Dextrose 5% in water (D5W) (isotonic fluid that becomes hypotonic when glucose is metabolized in the body) - NEVER for infants or brain-injured patients, risk of cerebral edema - closely monitor vital signs, LOC, electrolytes, glucose levels, fluid volume status, urine output

Nursing Assessments

- identify patients at risk for imbalances - determine that a specific imbalance is present and its severity, etiology, and characteristics - determine the plan of care, nursing diagnoses, or collaborative problems - identify specific outcomes and associated interventions - determine effectiveness of the plan of care

Hypocalcemia Causes

- inadequate intake - impaired absorption - excessive calcium loss

Hypokalemia Treatment

- increase dietary intake - replace potassium per protocol and per provider's order - monitor lab values closely - use caution with IV K+

Sodium: SIADH

- increased ADH secretion due to malignancies, CNS disorders, pulmonary disorders, medications - plasma osmolality and sodium are decreased secondary to water retention - creates a dilutional hyponatremia due to retention of water in ECF - treat by identifying and correcting the underlying problem

Blood gas values - pH, PO2, HCO3, PCO2

1)7.35-7.45 2) 80-100 mm Hg 3) 22-27 mEq/L 4)35-45 mm Hg

Fluid Regulation of Kidneys

1)Filters blood 2)Excretes urine 3)Secretes aldosterone - reabsorbs Na, H2O and Cl and exceretes K.

S&S of Fluid Volume Deficit

1)Increased pulse and respirations 2)decreased BP 3)output > intake 4)dry oral mucosa 5)increased thirst 6)weight loss (5lbs.) 7)scanty or concentrated urine 8)collapsed neck veins

examples of Isotonic solutions

1)Lactaid Ringers 2) NS (0.9% NaCl) 3) 5% Dextrose

Fluid Regulation of Lungs

1)Regulates O2 and CO2 2)Eliminates H 3)Acid/Base Balance

causes of Fluid Volume Deficit

1)decreased intake 2)increased excretion 3)fluid shift 4)strenuous exercise 5)extreme heat/dryness 6)fever (increased metabolic rate)

Signs and symptoms of Fluid volume excess

1)weight gain 2)High BP 3)shallow, rapid respirations 4)crackles 5)Fluid intake > outake 6)weakness, fatigue, dyspnea 7)edema, taut shiny skin 8)JVD 9)bounding pulse

S&S of Fluid Volume Excess

1)weight gain 2)weakness, fatigue 3)dyspnea with exertion 4)pitting edema 4)JVD 5)taut, shiny skin 6)bounding pulse 7)shallow, rapid respiration 8)crackles 9)high BP 10)fluid intake > outake

I. Concepts of Fluid and Electrolyte Balance C. Third Spacing 1. description 2. effect 3. possible locations 4. clinical assessment

1. The accumulation and sequestration of trapped extracellular fluid in an actual or potential body space as a result of injury 2. Trapped fluid represents fluid loss and is not available for normal physiologic processes 3. Fluid may be trapped in spaces like pericardial, pleural, peritoneal, or joint cavities, the bowel, or within soft tissues after burn or trauma 4. Assessing intravascular fluid loss is hard, it may not reflect on daily weight, intake and output records, and may only become apparent after organ malfunction.

1. Sodium normal value 2. Common food sources

1. 135-145 mEq/L 2. bacon butter canned foods cheese lunch meats processed foods milk white and whole wheat bread snack foods

VI. HYPOKALEMIA E. Normal value and food sources

1. 3.5-5.0 mEq/L 2. Banana Strawberry Cantaloupe Orange Raisin Avocado Carrot Spinach Mushroom Tomato Fish Potato Pork, Beef, Veal

VI. HYPOKALEMIA B. Causes 1. Actual potassium loss 2. Fasting 3. Movement from ECF to ICF 4. Dilution

1. Actual total body potassium loss Potassium primarily lost through kidney, GI. a. excessive medication use like DIURETICS or CORTICOSTEROIDS b. increased secretion of aldosterone from kidney like in Cushing's Syndrome (aldosterone is released when blood volume is low, causes kidney to retain Na+ but excrete K+in urine) c. vomiting, diarrhea d. wound drainage (gastrointestinal, ileostomy drainage) e. Prolonged NG suction f. kidney disease impairing potassium reabsorption g. Excessive diaphoresis 2. Inadequate potassium intake (fasting, NPO) 3. Potassium shift from ECF to ICF a. alkalosis b. hyperinsulinism 4. Dilution a. water intoxication b. IV therapy with potassium-deficient solutions

causes of hypocalcemia

hypoarathyroidism, malabsorption, pancreatitis, alkalosis, massive transfusion of citrated blood, renal failure, medications

Calcium Imbalances 1. Calcium entrance to body 2. Calcium balance mechanisms (3) 3. Function of calcium in body

1. Calcium obtained through ingested food. Only 30% of ingested calcium is absorbed. More than 99% of calcium in body is combined with phosphorus in skeletal system. Calcium primarily bound to albumin. Changes in albumin affect total calcium level but not ionized level. 2. A. Parathyroid Hormone (PTH). PTH release is stimulated by low calcium levels. PTH increased bone resorption (release of calcium), increases GI absorption, and increases renal tubule reabsorption of calcium. B. Calcitonin- Produced by thyroid gland, calcitonin release is stimulated by high levels of calcium. It opposes PTH by increasing calcium bone deposition (movement into bone), decreases GI absorption, and promoting renal excretion. C. Vitamin D- formed through action of UV light on skin and ingested through diet. Vitamin D is important for GI absorption of calcium. 3. Functions of calcium - transmission of nerve impulses -muscle contraction -myocardial contractions -blood clotting -formation of teeth and bone

VI. HYPOKALEMIA C. Assessment Hypokalemia alters resting membrane potential, reducing repolarization and cell excitability.

1. Cardiovascular- A. weak, irregular pulses. B. Thready peripheral pulses. C. Orthostatic hypotension (related to smooth muscle) 2. Respiratory- A. shallow respirations (related to skeletal muscle weakness) B. Diminished breath sounds. 3. Neuromuscular- A. anxiety, lethargy, confusion, coma. B. Skeletal muscle weakness. C. Paresthesia (tingling, numbness) D. Deep tendon hyporeflexia 4. Gastrointestinal- A. Decreased motility B. Hypoactive bowel sounds C. Nauseas, vomiting, constipation, abdominal distention. D. Paralytic ileum (intestinal blockage without physical obstruction)

Assessment of patients on IV solutions

1. Daily weight (gain or loss of 1 kg is roughly equivalent to 1 liter of fluid) 2. Vital signs (BP may decrease with hypovolemia and HR may increase) 3. I&O (0.5 mL/kg/hour output)

VII. Hyperkalemia B. Causes 1. Decreased excretion 2. Movement from ICF to ECF 3. Excessive K+ intake

1. Decreased excretion A. Potassium-retaining diuretics (spironolactone [Aldactone], triamterene [Dyrenium]) B. ACE inhibitors (enalapril [Vasotec], lisinopril [Prinivil]) Both med types reduce kidney K+ excretion C. Kidney disease D. Adrenal insufficiency (aldosterone deficiency), Addison's disease 2. K+ from ICF to ECF A. Acidosis, H+ move into cell and K+ moves out B. Tissue damage/cell destruction- burn, crush injury, tumor lysis. C. Hypercatabolism- severe infection, sepsis. D. Hyperuricemia- excessive uric acid (breakdown product of purines) 3. Excessive intake A. Too much K+ foods, salt substitutes B. Rapid infusion of K+ IV solutions (greater than 5-10 mEq/hr)

V. HYPERNATREMIA (NCLEX) B. Causes

1. Decreased sodium excretion a. Corticosteroids b. Cushing's syndrome c. Kidney disease d. hyperaldosteronism 2. Increased sodium intake orally or by sodium IV infusions 3. Decreased water intake a. Fasting, NPO status 4. Increased water loss a. increased metabolism, infection, excessive diaphoresis, diarrhea, diabetes insipidus

II. Fluid Volume Deficit A. Description 1. Cause of dehydration 2. Goal of treatment

1. Dehydration occurs when fluid intake is not sufficient to meet body needs. 2. Goal of treatment is to restore fluid volume, replace electrolytes, and eliminate cause of volume deficit (NCLEX)

IV. HYPONATREMIA D. Interventions

1. Monitor cardio, respiratory, neuromuscular, cerebral, renal, and GI status related to assessment 2. If hyponatremia is accompanied by hypovolemia, IV sodium chloride infusions are given to increase NaCl 3. In hyponatremia is accompanied hypervolemia, osmotic diuretics are given to excrete water and preserve sodium 4. If caused by inappropriate ADH secretion, meds that antagonize ADH are given 5. Instruct client to increase sodium intake and teach which foods are high 6. (NCLEX) if client is taking lithium, monitor lithium level because hyponatremia causes diminished lithium excretion causing toxicity !! Hyponatremia precipitates lithium toxicity in a client taking lithium !!

I. Concepts of Fluid and Electrolyte Balance D. Edema 1. description 2. Possible causes 3. Localized 4. Generalized

1. Excess accumulation of fluid in the interstitial space. 2. Results from changes in oncotic pressure, hydrostatic pressure, capillary permeability, and lymphatic obstruction 3. Localized edema results from trauma, inflammatory processes, or burns. 4. Generalized edema, or 'anasarca' is excessive fluid in the interstitial space throughout the body resulting from cardiac, renal or liver failure.

How the kidneys help in maintaining fluid & electrolyte balance

1. Filter plasma 2. Regulate ECF volume and osmolality 3. Regulate electrolyte levels 4. Regulate pH (acid-base balance) 5. Excrete metabolic wastes

VII. Hyperkalemia C. Assessment- EKG

1. Flat, wide P wave 2. Prolonged PR interval 3. Wide QRS complex 4. ST depression 5. TALL PEAKED T wave

III. Fluid Volume Excess A. Description 1. what it is 2. AKA 3. Goal of Tx

1. Fluid intake or retention exceeds needs of body 2. also called over hydration or fluid overload 3. (NCLEX) Goal of Tx is to restore fluid balance, correct electrolyte imbalances, and eliminate cause of over hydration.

Function of potassium

1. Helps with nerve conduction 2. Contraction of myocardium, as well as skeletal & smooth muscle 3. Instrumental in CHO and protein metabolism 4. Helps to deposit glycogen in liver cells

IV. HYPONATREMIA B. Causes

1. Increased sodium excretion a. excessive diaphoresis b. diuretics c.vomiting d. diarrhea e. wound drainage, especially GI f. kidney disease g. decreased secretion of aldosterone from kidneys 2. Inadequate sodium intake a. fasting, NPO b. low-salt diet 3. Dilution of serum sodium a. excessive ingestion of hypotonic fluids or irrigation with hypotonic fluids b. kidney disease c. freshwater drowning d. syndrome of inappripriate ADH secretion from pituitary e. hyperglycemia f. heart failure

3 types of IV solutions and their range

1. Isotonic: 250-375 mOs/liter (same as our body fluid) 2. Hypotonic: any solution less than 250 mOs/L 3. Hypertonic: osmolarity greater than 375 mOs/L

Functions of water in the body

1. Lubricates-joints & lungs so there's no friction 2. Transports-nutrients, hormones, enzymes, waste products and other substances 3. Cellular metabolism and holds their structure 4. Thermoregulator-maintains normal body temp 5. Insulator and shock absorber-spine & joints 6. Allows electrolytes and non-electrolytes to dissolve 7. Aids in digestion and elimination

V. HYPERNATREMIA D. Interventions

1. Monitor body systems looking for assessment findings 2. If cause if fluid loss, give IV infusions 3. (NCLEX) If cause is inadequate renal excretion, give diuretic that promote sodium loss 4. Restrict sodium intake

calcium electrolyte imbalances

hypocalcemia & hypercalcemia

Four mechanisms responsible for regulating the shift of fluids in the body (how fluids transport in our body)

1. OSMOSIS: movement of water across semi-permeable membrane, from less concentrated solution to higher con. sol. 2. DIFFUSION: movement of solutes or gases from higher conc. to lower conc. 3. ACTIVE TRANSPORT: used to move larger particles into and out of cells (protein & glucose); often uses energy from cellular respiration (substances move from less conc. sol. to higher conc. sol. 4. FILTRATION: movement of fluid and solutes through permeable membrane (kidneys) from an area of higher pressure to lower pressure

How to Hydrate your patient (2)

1. Oral Hydration - Provide for mild to moderate dehydration - Remember- sugar facilitates absorption in oral re-hydration therefore, do not give diet or sugar free oral fluids 2. IV Management - IV fluids 1/2 of the 24 hour total in first 6-8 hours slower rate for the rest of the 24 hours - assess for acute renal failure, hypotension

VI. HYPOKALEMIA C. Assessment- EKG

1. Prolonged PR interval 2. ST depression 3. Flat or inverted T wave 4. Prominent U wave 5. Bradycardia 6. Enhanced digitalis effect!!

How the lungs help in maintaining fluid & electrolyte balance

1. Remove about 400 mL of water daily through respiration 2. Play a major role in acid-base balance

How the adrenal glands in the endocrine system help in maintaining homeostasis

1. Secretes ALDOSTERONE - increased secretion of aldosterone causes sodium retention (and water retention) as well as potassium loss 3. CORTISOL has a lesser action, but when secreted in large quantities can produce sodium and water retention (Both aldosterone and cortisol play a role in sodium and water retention balance, but aldosterone plays a bigger role and controls potassium loss)

VII. Hyperkalemia A. 1. Description 2. Pseudohyperkalemia

1. Serum potassium level greater than 5.0 mEq/L 2. Increased serum value due to methods of blood collection, lysis of cells causes ICF to leak and potassium to rise. If levels increased with no clinical symptoms, redraw blood.

V. HYPERNATREMIA A. Description

1. Serum sodium levels greater than 145 mEq/L

VII. Hyperkalemia D. Interventions 1. Stop K+ intake 2. Increase K+ excretion 3. Move K+ from ECF to ICF 4. Reverse membrane potential, reduce excitability

1. Stop IV K+ infusions, initiate potassium-restriced diet, teach K+ foods to avoid, no salt-substitute. 2. Administer medications A. fluids, B. Loop diuretics if renal function not impaired. C. Kayexalate via GI tract if renal function impaired. Binds potassium in exchange for sodium and excretes K+ in feces. D. Insulin with glucose. Insulin moves K+ into cells, glucose prevents hypoglycemia. E. Give calcium gluconate to reverse cardiac dysrhythmias and reduce cardiac excitability F. Hemodialysis- for patients with renal failure or extremely high levels G. Patients receiving transfusions should get fresh blood. Stored blood may elevate K+ levels from cell breakdown and released potassium.

How the pituitary gland in the brain helps in maintaining homeostasis

1. Stores ADH (antidiuretic hormone) that was manufactured by hypothalamus until it's needed 2. ADH causes body to reserve or retain water by controlling the kidneys (when sodium content increases, fluid volume increases)

VI. HYPOKALEMIA A. Description

1. serum potassium level less than 3.5 mEq/L 2. (NCLEX) Potassium deficit is potentially life threatening because every body system is affected!

Specific gravity normal value

1.005-1.030 sp. grav.

urine specific gravity

1.010-1.025

Normal Values: Mg

1.3-2.3

Extracellular Fluid (ECF)

1/3 body fluid in adults; 20% of body weight Includes Interstitial compartment (between cells) or tissue spaces & blood vessels Contains large amounts of Na+ Plasma compartment = 5% of body weight % of ECF=transcellular space - includes cerebrospinal fluid, peritoneal, pleural, pericardial cavities & joint spaces. Interstitial fluid compartment=14% of body weight

Normal Values: HGB

12-18

serum Sodium level

135 - 145 mEq/L

sodium levels

135 to 145 mEg/L

Normal Values: Na

135-145

Na

135-145 mEq/L

Normal serum values for sodium

135-145 mEq/L

Sodium

135-145 mEq/L

Sodium (Na)

135-145 mEq/L ---------------------------------------------------------------------------------------------------------- most abundant cation in ECF and major contributor to serum osmolality ---------------------------------------------------------------------------------------------------------- controls and regulates water balance

Sodium normal value

135-145; in the ECF

Hypernatremia occurs when serum sodium levels are greater than ______ mEq/L, and critical values occur at levels greater than _____ mEq/L.

145 mEq/L; 160 mEq/L

Normal Values: Platelets

150-450k

Extracellular fluids make up what percent of body weight?

20% -Interstitial: in spaces between the body cells -Intravascular: plasma with the blood -Transcellular: specialized fluid such as CSF

What are causes of hypocalcemia?

CRF, increase in phosphorus, vitamin D deficiency, magnesium deficiency, acute pancreatitis, loop diuretics, chronic alcoholism, diarrhea, decrease albumin, alcoholism

Normal Values: Hct

35-52

serum Potassium level

3.5 - 5 mEq/ L

Potassium (K+) value

3.5 to 5.1 mEq/L

Normal Values: K

3.5-5

K

3.5-5.0 mEq/L

Potassium

3.5-5.0 mEq/L

Potassium (K)

3.5-5.0 mEq/L ---------------------------------------------------------------------------------------------------------- vital for skeletal, cardiac, and smooth muscle activity ---------------------------------------------------------------------------------------------------------- major cation in ICF ---------------------------------------------------------------------------------------------------------- must be ingested daily

Potassium normal value

3.5-5.2; in the ICF

Normal range of serum potassium

3.5-5.3 mEq/liter

Normal Values: Albumin

3.5-5.5

Renal system (kidneys)

3rd line of defense for acid base balance.

serum Calcium level

4.5 - 5.5 mEq/L

Normal Values: WBC

4.5-11k

Intracellular fluid makes up what percentage of body weight?

40% -within the cells

How can hyponatremia happen?

Less sodium with less loss of water excess sodium with more excess water normal sodium with excess water

Distribution considerations

60% of an adults body weight( More in a child, less in the elderly) Men Have more TBW than women d/t fewer fat cells Fat cells hold little water, hydrophobic African Americans have a larger amount of fat cells therefore less TBW Pregnancy- IVF increases 45-50% of total body fluids

Normal Values: Glucose

60-110

potassium electrolyte imbalances

hypokalemia & hyperkalemia

Hyponatremia

A concentration (water) imbalance A serum sodium concentration below the lower limit of normal (135 to 145 mEq/L) < 135 mEq/L When present the extracellular fluid contains relatively too much water for the amount of sodium ions present Extracellular fluid is more dilute than normal Etiology Factors that produce a relative excess of water in proportion to salt in the extracellular fluid Cells swell Also called: Hypotonic syndrome Hypo-osmolality Water intoxication 2 primary causes - A gain of relatively more water than salt Too much ADH, or Too much water intake - A loss of relatively more salt than water

Solvent(water)

A liquid that holds another substance and dissolves it also considered as water

What is hyPOkalemia?

A low serum potassium level.

What does Aldosterone do?

A mineralcorticoid, its secretion causes sodium retention and potassium excretion.

sodium electrolyte imbalances

hyponatremia & hypernatremia

VIII. Hypocalcemia A. Normal Ca levels

A. Calcium 8.6-10 mg/dL

VII. Hyperkalemia C. Assessment Symptoms related to excess ECF K+ and increased cellular excitability. Initial cramping leg pain.

A. Cardiovascular- Slow, weak, irregular pulse. Decreased BP. B. Respiratory- respiratory failure at high levels related to skeletal muscle weakness C. Neuromuscular- early-muscle twitches, cramps, paresthesia (tingling followed by numbness). Late- profound muscle weakness, ascending flaccid paralysis starting in extremities. D. GI- INCREASED motility. Hyperactive bowel sounds. Diarrhea.

VIII. Hypocalcemia Causes

A. Reduced GI absorption - Inadequate intake -Lactose intolerance - Malabsorption diseases like celiac sprue, Crohn's disease -Inadequate vitamin D - End-stage kidney disease B. Increased excretion -Kidney disease -Diarrhea -steatorrhea (excretion of excess fat in feces) -GI wound drainage C. Conditions decreasing ionized fraction of calcium -Removal/destruction of parathyroid -Alkolosis (increases calcium binding to protein) -Medications, calcium chelators or binders -Acute pancreatitis (lipolysis from pancreatitis releases fatty acids that bind to calcium) -Increased phosphate

A hypertonic solution has a greater osmolarity, causing water to move out of the cells and to be drawn into the intravascular compartment, causing the cell to shrink. A. True B. False

A. True Rationale: A hypertonic solution has a greater osmolarity, causing water to move out of the cells and to be drawn into the intravascular compartment, causing the cell to shrink

ADH vs Aldosterone

ADH tap water hormone > dilutes body fluids hypothalamaus/pituitary Causes reabsorption of water, which: - Decreases urine volume and fluid excretion - Concentrates the urine If ADH release is increased > smaller volume urine (anti-diuretic) If ADH release is decreased > large volume of dilute urine - Decreased osmolality of extracellular fluid Aldosterone adrenal cortex salt water hormone - it expands extracellular fluid volume Renal tubules to reabsorb sodium & water Decreases fluid excretion, although by a different mechanism than ADH When more aldosterone is secreted > urine volume is smaller Decreased secretion of aldosterone > larger urine volume

CLINICAL MANIFESTATIONS OF SODIUM LOSS AND WATER GAIN

ANOREXIA, MUSCLE CRAMPS, EXHAUSTION. WHEN IT DROPS BELOW 115, INTERCRANIAL PRESSURE INCREASES, LETHARGY, CONFUSION, MUSCLE TWITCHING, FOCAL WEAKNESS, SEIZURES

Fluid Regulation of GI tract

Absorbs nutrients H2O.

Hypophosphatemia symptoms

Altered LOC Renal dysfunction muscle weakness resp deficiency cardia arrhythmias osteomalacia

Hypokalemia Clinical manifestations

Altered smooth, skeletal, cardiac muscle function due to changes in resting membrane potential (hyperpolarization) Cardiac symptoms Ectopic beats Alterations in conduction Dysrhythmias may be severe enough to cause sudden cardiac death Abdominal symptoms Distention Diminished bowel sounds Paralytic ileus Skeletal muscle symptoms Bilateral muscle weakness; usually begins in legs Respiratory paralysis Renal Polyuria

Diffusion is...

The movement of molecules of a solute through a cell membrane from an area of higher concentration to an area of lower concentration.

What should you do when caring for a patient with IV fluids?

ASSESS: IV site, solution, rate, labs-lytes, lungs, cardiovascular, I&O

Nursing Management of Hyponatremia:

Abnormal losses or gains of water are noted. GI manifestations such as anorexia, nausea, vomiting, and abdominal cramping are noted. Nurse should be aware of CNS changes, lethargy, confusion, muscle twitching, and seizures.

What is the most common cause of hyPOkalemia?

Abnormal losses via either the kidneys or the gastrointestinal tract.

What causes potassium to move from the ICF to the ECF?

Acidosis, trauma to cells (as in massive soft tissue damage or in tumor lysis), and exercise.

Clinical Significance: Osmosis and Filtration

Act together at capillary membrane to maintain normal ECF and ICF volumes The thirst mechanism is an example of how osmosis helps maintain homeostasis. the feeling of thirst is caused by the actiivation of cells in the brain that respond to changes in ECG osmolarity

Phosphorous Excess: > 4.5 "Hyper"

Acute and chronic renal failure, excessive intake of phosphorus, vitamin D excess, respiratory acidosis, hypoparathyroidism, volume depletion, leukemia/ lymphoma treated with cytotoxic agents, increased tissue breakdown, rhabdomyolysis

hypocalcemia causes (ACDC LIE DIE IE)

Acute pancreatitis Crohn's disease Diarrhea Calcium excreting medications (diuretics, caffiene, anticonvulsants, heparin, laxatives, nicotine_ Long term immobilization and bone demineralization Inadequate Vit. D consumption End stage renal disease Decreased secretion of parathyroid hormone Inhibited absorption of calcium from the intestinal tract Excessive GI losses from diarrhea or wound draining Inadequate intake of calcium Excessive adm. of blood

Chloride Deficit Contributing Factors : Hypochloremia < 96 mEq/L

Addison's disease, reduced chloride intake or absorp- tion, untreated diabetic ketoacidosis, chronic respira- tory acidosis, excessive sweating, vomiting, gastric suction, diarrhea, sodium and potassium deficiency, metabolic alkalosis, loop, osmotic, or thiazide diuretic use, overuse of bicarbonate, rapid removal of ascitic fluid with a high sodium content, intravenous fluids that lack chloride (dextrose and water), draining fistulas and ileostomies, heart failure, cystic fibrosis

Water intoxication can be caused by:

Administering too much hypotonic fluid

Signs and symptoms of chloride deficit:

Agitation, irritability, tremors, muscle cramps, hyperactive deep tendon reflexes, hypertonicity, tetany, slow, shallow respirations, seizures, dysrhythmias, coma Labs indicate: ↓ serum chloride, ↓ serum sodium, ↑ pH, ↑ serum bicarbonate, ↑ total carbon dioxide content, ↓ urine chloride level

Composition and balance of fluid by Adrenal Functions:

Aldosterone, a mineralcorticoid secreted by the zona glomerulosa (outer zone) of the adrenal cortex. Increased secretion of Aldosterone--> causes Na+ retention and thus H2O retention and K+ loss. Decreased secretion of Aldosterone--> causes Na+ and H2O loss and K+ retention. Cortisol (adrenocortical hormone) has to be secreted in LARGE quantities in order to act as Aldosterone.

What is second spacing?

An abnormal accumulation of interstitial fluid (i.e., edema).

What is hyPERkalemia?

An elevated serum potassium level.

What is hyPERnatremia?

An elevated serum sodium that may occur with water loss or sodium gain.

How is ADH secretion stimulated?

An increase in plasma osmolality (concentration) or lowered blood volume.

Explain Tonicity.

Another term for osmolality. A fluid which is of the same osmolality as blood is called isotonic. -Isotonic: same as blood -hypotonic: lower than blood -Hypertonic: higher than blood (water to ECF)

Physical Assessment- Weighing

Any change in daily weight (loss in dehydration, gain in overload) When weighing: Same time of day Same clothing Same scale

Respiratory acidosis

Any condition that causes an excess of carbonic acid Caused by impaired removal of carbonic acid by the lungs Impaired gas exchange Chronic obstructive pulmonary disease (COPD) Pneumonia Severe asthma Pulmonary edema Inadequate neuromuscular function Guillain-Barré syndrome Chest injury or surgery (pain limits breathing) Hypokalemic respiratory muscle weakness Impairment of respiratory control in the brainstem Respiratory-depressants drugs (opioids, barbiturates) Decrease the normal 20:1 ratio of bicarbonate

Uses for isotonic solutions

Fluid loss and dehydration, Hypernatremia, Blood transfusion, fluid challenges, resuscitation, shock, metabolic alkalosis, hypercalcemia, hyponatremia, Acute blood loss, burns, dehydration, hypovolemia

Physical Assessment

Assess VS: Tachycardia, decrease BP, diminished pulses, flat neck veins can indicate fluid volume deficit, dehydration or hypovolemia Increased BP, bounding pulses, distended neck veins and hand veins can indicate fluid volume excess or overhydration

Osmolarity, ADH and urine

High osmolarity causes: Thirst > increased water intake ADH release >water reabsorbed from urine Low osmolarity causes: Lack of thirst > decreased water intake Decreased ADH release > water lost in urine

Considerations for older adults

At risk for most electrolyte imbalances from age related organ changes have less total body water than younger adults; more at risk for fluid imbalances; more likely to be taking drugs affecting fluid or electrolyte balance

What is azotemia? when can it occur?

Azotemia is increased nitrogen levels in the blood and can occur with FVE when urea and creatinine are not excreted due to DECREASED perfusion by the kidneys and DECREASED EXCRETION of wastes. High uric acid levels (hyperuricemia) can also occur from increased reabsorption and decreased excretion of uric acid by the kidneys.

Molecules in the body's chemical compounds that remain intact are called electrolytes. A. True B. False

B. False Rationale: Molecules in the body's chemical compounds that remain intact are called nonelectrolytes. Examples: glucose and urea

BUN- range and indicators

BLOOD UREA NITROGEN - Fluctuates a lot more than creatinine - monitored in serum or urine- generally serum - Building up means kidneys are not filtering - Normal value: 10-20 mg/dl - is a waste product of protein breakdown - Elevated levels can indicate dehydration, a high protein diet, renal insufficiency, or failure - Indicates hydration status - Indicator of glomerular function

For a patient with hypovolemia they're BP may ________ and their HR may _________.

BP decrease; HR increase

Metabolic Imbalance

Bicarbonate (PCO2) concentration corresponds with pH.

Respiratory Imbalance

Bicarbonate (PCO2) has opposite response of pH.

Hypovolemia causes (BIF VIC)

Blood loss (internal/external) Insufficient fluid intake Fever (sweat and increased metabolic rate) Vomiting or diarrhea Increased urine output from use of diuretics Continuous GI irrigation

Clinical Significance:blood pressure

Blood pressure is an example of hydrostatic filtering forces. It moves whole blood from the heart to capillaries where filtration can occur to exchange water, nutrients, and waste products between the blood and the tissues.

Acid Base regulatory mechanisms

Blood, Lungs, Kidneys

Homeostasis

Body fluids are in constant motion transporting nutrients, electrolytes, and oxygen to cells while carrying away waste products. Many diseases and treatments affect this balance.

Hypovolemia

Body loses both water and electrolytes from the ECF.

Physical Assessment-Fluid Volume Excess

Bounding Pulse, Distended Neck Veins (JVD), Edema, Hypertension, Crackles

HYPOKALEMIA MNEMONIC ASSESSMENT "CRAMP"

C-CONSTIPATION R-REFLEXES DERCREASED A-ARRYTHMIAS/ANOREXIA M-MUSCLE CRAMPS P-IRREGULAR PULSES

Electrolyte imbalance

Can occur in healthy people as result of changes in fluid intake and output Can be life threatening if severe; can occur in any setting

Capillary Forces

Capillary Filtration Pressure (Capillary hydrostatic pressure) - pushes water out of the capillary; into the interstitial compartment Interstitial fluid colloidal osmotic pressure: inward-pulling force of particles in the interstitial fluid (pulls water out of the capillary into the interstitial spaces) Capillary Colloidal Osmotic Pressure - pulls water back into the capillary from the interstitial compartment into capillaries Capillary osmotic pressure: inward-pulling force of particles in vascular fluid Interstitial fluid hydrostatic pressure: outward push of interstitial fluid against outside of capillary walls Interstitial or tissue hydrostatic pressure -opposes the movement of water out of the capillary

If serum potassium level is less than 2.5 mEq/L or greater than 7 mEq/liter what could happen and why?

Cardiac arrest; hypokalemia changes the conduction rate of nerve impulses to the heart (causes dysrhythmia) and hyperkalemia can cause irritability of the heart muscle, increasing and then decreasing the HR (could lead to dysrhythmia)

VIII. Hypocalcemia Assessment

Cardiovascular -Decreased heart rate -Hypotension -Diminished peripheral pulses Respiratory -not directly affected, but tetany and seizures could cause arrest Neuromuscular -Positive Chvostek's (facial twitch from tapping facial nerve by ear) and Trousseas's (hand spasm from BP cuff) -irritable skeletal muscles-twitch, cramp, tetany, seizure -Paresthesias (pins and needles) around mouth, limbs GI -increased motility, hyperactive bowel sounds -cramping, diarrhea EKG -prolonged QT interval, -prolonged ST interval

Cations and Anions

Cations: + charge -Na+, K+, Ca++, Mg++ Anions: - charge -Cl-, PO4, HCO3, SO4

Cations vs anions

Cations: Ions that carry a positive charge Anions: Ions that carry a negative charge The # of cations and anions should be equal.

Respiration fluid loss

Changes in rate/depth of respirations

Hypovolemia interventions (CLM^4T)

Check mucous membranes, skin turgor Lactated ringers solutions 0.9% NS as prescribed Monitor VS, I&O, daily weight, hematocrit & electrolyte level Test urine for specific gravity

calcium food sources (CCSS MARTY)

Cheese Collard greens Sardines Spinach Milk and soy milk Rhubarb Tofu Yogurt

Contributing Factors of Magnesium Deficit: < 1.8 mg/dL

Chronic alcoholism, hyperparathyroidism, hyper- aldo-steronism, diuretic phase of renal failure, mal- absorptive disorders, diabetic ketoacidosis, refeeding after starvation, parenteral nutrition, chronic laxative use, diarrhea, acute myocardial infarction, heart failure, decreased serum K+ and Ca++ and certain pharmacologic agents (such as gentamicin, cisplatin, and cyclosporine) *** DECREASED MAGNESIUM = DECREASED CALCIUM***

Signs indicating hypocalcemia

Chvosteck's sign - contraction of the facial muscles produced by tapping the facial nerve in front of the ear ---------------------------------------------------------------------------------------------------------- Trousseau's sign - carpal spasm that occurs by inflating a BP cuff on the upper arm to 20 mm Hg greater than systolic for 2-5 minutes

Fluid balance

Closely linked to/affected by electrolyte concentrations Fluid intake fluid loss -minimum urine amt needed to excrete toxic waste products=400 to 600ml -Insensible water loss-thru skin, lungs, stool

Clinical dehydration

Combination of two fluid disorders - Extracellular volume deficit - Hypernatremia Too small a volume of fluid in the extracellular compartment and too-concentrated body fluids Etiology - Vomiting - Diarrhea - Knowledge deficit about salt and fluid replacement

Considerations for infants

Infants have a higher proportionate value of fluid in brain, and are at greater risk for dehydration

Hyperkalemia treatment

D/C KCL per order Kayexalate(sodium polystyrene sulfonate)-decrease the serum K and increase the serum sodium Dietary restriction Monitor for arrhythmias Insulin administration Dialysis

Dextrose vs saline solution

D5W (260 mOsm/L) = 5W is 5% dextrose in water Isotonic Solution: Osmolarity about equal to serum, expands intravascular compartment. D5 NS (560 mOsm/L) = 5% dextrose in normal saline Hypertonic Solution: Osmolarity higher than serum, draws fluid into the intravascular compartment from cells and interstitial compartments.

Single most important indicator of fluid status

Daily Weights

What is Hyponatremia?

Decreased sodium, water excess, Na+<135mEq/L

Hyperkalemia

Definition: K+ >5.0 mEq/L Seldom occurs with normal renal function More serious than Hypokalemia

Hyponatremia

Definition: Serum Na <136 mEq/L Causes of hyponatremia: Excess body water, chronic use of diuretics, excess loss of sodium, Decreased Na+ diet

Hypokalemia

Definition: Serum Potassium < 3.5 meq/L Causes: -Inadequate intake of food -Intestinal suctioning -Recent ileostomy -Villus adenoma -Elderly -Pediatrics

What are symptoms of hyPERnatremia?

Dehydration and any accompanying ECF volume deficit, such as postural hypotension, weakness, and decreased skin turgor.

Dehydration vs. Hypovolemia

Dehydration: Loss of water ONLY Increased sodium levels Hypovolemia: Loss of ECF volume exceeds intake Loss of water AND electrolytes

Hypertonic solution examples

Dextrose 5% in normal saline solution

What's special about using the solution dextrose?

Dextrose, a.k.a. sugar, is an isotonic solution but the body will start using up the dextrose for energy, and then D5W starts acting more as a hypotonic solution.

hypokalemia causes (DEVI-US CRAP)

Diarrhea Excessive gastric suction, fistula draining Vomiting Inadequate intake of K+ Uncontrolled diabetes Syndrome(Cushing) Chronic use of corticosteroids Renal disease Alkalosis Parental nutrition

hyperkalemia s/s (DHPHM)

Diarrhea Hypotension Paresthesias Hyperactive bowel sounds Muscle weakness

Osmosis

Diffusion of water across a semipermeable membrane Lower concentration to higher concentration

Fluid Regulation of Cardiovascular system

Distributes nutrients and water throughout the body.

causes of Hypokalemia

Diuretics (Lasix), Diarrhea, GI loss, polyuria

Pharmacologic Therapy of FVE: DIURETICS!!

Diuretics are prescribed when dietary restriction alone is insufficient to reduce edema by inhibiting reabsorption of sodium and water by the kidneys: Choice of diuretic is based on the severity of the hypervolemic state, the degree of impairment of renal function, and potency of diuretic. "Thiazide" drugs block Na+ reabsorption in the distal tubule, where only 5-10% of filtered sodium is reabsorbed. (mild hypervolemia) Loop Diuretics (furosemide, bumetanide, or torsemide) can cause greater loss of both sodium and water because they block sodium reabsorption in the ascending limb of the loop of Henle, where 20-30 % of filtered sodium is normally reabsorbed. ( severe hypovolemia)

Hypervolemia

Documentaion: -vital signs -pulmonary status -oxygen therapy -intake and output -interventions(diuretics) -daily weights -lab results -dietary or fluid rstrictions -safety measures -teaching

Hypovolemia

Documentation: -Mental status -vital signs -strength of peripheral pulses -appearance and temp of skin -IV therapy -blood products infused -breath sounds and oxygen therapy used -hourly urine output -lab results -daily weights -patient teaching

Respiration fluid excess

Dyspnea, orthopnea, productive cough, moist breath sounds

Major electrolytes in the ECF and major electrolytes in ICF

ECF: sodium, chloride, calcium, bicarbonate ICF: potassium, magnesium, phosphate

Fluid Distribution- ECF

EXTRAcellular Fluid: Fluid OUTSIDE the cell 1/3 of TBW Na+ and Cl- Divided into 3 compartments

Plasma to interstitial fluid shift results in

Edema - accumulation of fluid in interstitial spaces- occurs if venous hydrostatic pressure rises, plasma oncotic pressure decreases, or interstitial oncotic pressure rises

Electrolyte distribution

Electrolyte composition differs in various compartments: Inside cells (ICF): higher concentrations of potassium, magnesium, and phosphate ions Outside cells (ECF): higher concentrations of sodium, chloride, and bicarbonate ions

What may result from the effect of a diuretic? How?

Electrolyte imbalances may result from a diuretic. Hypokalemia happens with ALL diuretics except for those that work in the distal tubule (Spironolactone) Hyperkalemia can occur with diuretics that work in the last distal tubule, especially in patients with DECREASED renal function. Hyponatremia occurs with diuresis due to increased release of ADH secondary to reduction in circulating volume. Decreased magnesium levels occur with administation of loop and "thiazide" diuretics due to decreased reabsorption and INCREASED excretion of magnesium by the kidney.

Electrolyte absorbtion

Essential if electrolyte is to be useful metabolically Depends on other factors Concentration gradients Binding proteins (may increase or decrease absorption) Contents of the GI tract pH of intestinal content Medications - Certain medications also influence electrolyte distribution Surgical removal of portions of GI tract

causes of Hypernatremia

Excess aldosterone secretion, water deprivation or increased water loss.

Edema

Excess fluid in interstitial compartment May be a manifestation of excess extracellular fluid volume Increased capillary hydrostatic pressure: too much volume; from inflammation Increased interstitial fluid osmotic pressure: inflammation causes protein to leak out from vascular permeability Blockage of lymphatic drainage: lymphedema; frequently localized Decreased capillary osmotic pressure: plasma proteins decreased; extensive edema

Electrolyte excess vs deficit

Excess may be caused by: Increased intake Increased absorption Shift into extracellular fluid Decreased excretion Deficit may be caused by: Decreased intake Decreased absorption Shift into electrolyte pools Increased excretion Loss through abnormal route

Fluid Volume Excess

Excess water and Na+ in the extracellular compartment Not a disease but a clinical sign

Fluid Volume Excess

Excessive retention of water and Na in extracellular fluid.

Chloride excess: Hyperchloremia: > 108 mEq/L

Excessive sodium chloride infusions with water loss, head injury (sodium retention), hypernatremia, renal failure, corticosteroid use, dehydration, severe diarrhea (loss of bicarbonate), respiratory alkalosis, administra- tion of diuretics, overdose of salicylates, Kayexalate, acetazolamide, phenylbutazone and ammonium chloride use, hyperparathyroidism, metabolic acidosis

Effects of Aldosterone

Excretes K and retains Na.

Electrolyte excretion

Excretion occurs through urine, feces, sweat Influenced by hormones Other factors Rate of renal tubular fluid flow Medications

How do the LUNGS keep the composition and balance of fluid?

Exhalation: Lungs remove 300mL Water in ADULT Hyperpnea (abnormally deep respirations) & continuous coughing increase the loss. Mechanical ventilation with excessive moisture decreases it. Lungs also have a major role in maintaining acid-base balance. ***CHANGES FROM NORMAL AGING RESULT IN DECREASED RESPIRATORY FUNCTION, CAUSING INCREASED DIFFICULTY IN pH REGULATION IN OLDER ADULTS WITH MAJOR ILLNESS OR TRAUMA.

Electrolyte loss through abnormal routes

Exit of electrolytes from the body through routes other than urine, feces, sweat May be uncontrollable or may result from therapeutic procedures Alters electrolyte homeostasis Examples Nasogastric suction Hemodialysis Emesis Drainage from fistulas, wounds Paracentesis

Istotonic solution

Expands ECF volume. (same concentrate as plasma.)

Pathophysiology of Fluid Volume Deficit:

FVD results from loss of body fluid and OCCURS MORE RAPIDLY when coupled with decreased fluid intake. Can happen from inadequate intake alone if the decreased intake is prolonged. Causes: abnormal fluid losses coming from diarrhea, GI suctioning, sweating, decreased intake, as in nausea or inability to gain access to fluids. Additional Risk factors: diabetes insipidus, adrenal insuffiency, osmotic diuresis, hemorrhage, and coma. Third space fluid shifts, or the movement of fluid from the vascular system to other body spaces ( EDEMA) formation in burns or ascites with liver dysfunction. ASCITES= ACCUMULATION OF FLUID IN PERITONEAL CAVITY

FVE pathophysiology:

FVE may be related to simple fluid overload or diminished function of the homeostatic mechanisms responsible for regulating fluid balance. Contributing factors: Heart failure, renal failure, cirrohosis of liver ( inflammation, degeneration, of cells and thickening of tissue caused by alcoholism or hepatitis); consumption amount of excessive amounts of table or other sodium salts

True or False: In an infant, a low percentage of their body weight is water.

False. Infants have the highest percentage of water for body weight: 70%

True or false: Water is lost though the kidneys, intestinal track, and skin. These are known as sensible fluid losses which we cannot measure.

False. Sensible fluid losses are those which can be measured.

True or false: The best place to check for skin turgor is the back of the hand.

False. The best place to check is the clavicle.

Fluid Spacing

First Spacing- Normal Second Spacing- Edema Third Spacing- Ascites, Burn Edema

Fluid Spacing

First spacing: fluid is inside vessel second spacing: fluid is outside vessel and within fluid compartments but may be abnormally distributed third spacing: fluid is in areas where fluid is not normally found(i.e. floating free within peritoneal cavity, between dermis &epidermis,etc) 2nd spacing will lead to edema 3rd spacing have more fluid then the body can redistribute quickly will see in patients with decreased liver function

Potassium (K+) food sources (FROM PAST BCC)

Fish Raisins Oranges Mushrooms Potatoes, pork Avocados Spinach & Strawberries Tomatoes Bananas Cantaloupes Carrots

FVD

Fluid Volume Deficit

Types of fluid imbalances

Fluid Volume Deficit -Dehydration -Hypovolemia Fluid Volume Excess -Hypervolemia -Overhydration

Fluid Loss Routes

Fluid output: 500-1000mL is normal Urine: at least 30cc/hr Insensible loss: Lungs (300ml/day) Skin( 500ml/day) Feces:(100-200 ml/day) Abnormal fluid output: diarrhea, emesis, hemorrhage, draining fistulas

Fluid Restrictions are for patients with...

Fluid retention or FVE

What is Hypervolemia and what are some causes? (PEK)

Fluid volume excess: exceeds the body's fluid need. Causes: (PEK) Poor pumping action of the heart Excessive salt intake Kidney or liver disease

Antidiurectic hormone(ADH)

Fluid volume falls Osmoreceptors sense increased serum osmolality hypothalamus stimulates release of ADH from posterior pit ADH stimulates kidneys to reabsorb water(urinary output decreases) fluid volume rises osmolality falls ADH secretion stops

Aldosterone

Fluid volume falls blood pressure falls kidneys secrete renin renin turns to angiotensin I in bloodstream angiotensin I turns to angiotensin II in lungs angiotensin II stimulates release of aldosterone from adrenal cortex aldosterone stimulates kidneys to reabsorb sodium water follows sodium fluid volume increases blood pressure rises

Signs and symptoms of magnesium excess:

Flushing, hypotension, drowsiness, hypoactive reflexes, de- pressed respirations, cardiac arrest and coma, diaphoresis. ECG: tachycardia → bradycardia, prolonged PR interval and QRS.

Water

Found in foods (but not in alcohol) Daily need is about 2,000mL 1 L of water weighs 1 kg (Important with daily weight measurement)

Diffusion

Free movement of particles(solute) across permeable membrane from area of higher to lower concentration Important in transport of most electrolytes; other particles diffuse thru cell membranes Sodium pumps glucose cannot enter most cell membranes witout help of insulin

Gerontologic Considerations:

Frequent use of meds in older adults also can affect renal and cardiac function and fluid balance. Thus increasing fluid and electrolyte disturbances. Routine procedures such as vigorous administration of laxatives before colon x ray studies, may reduce serious fluid volume deficit, necessitating the use of IV fluids to prevent hypotension and other effects of hypovolemia. Hyponatremia may cause CONFUSION in the ELDERLY person, where as in young adults may cause thirst. Rapid infusion of excessive volumes of IV fluids may produce fluid overload and cardiac failure.

Fluid deficit lab values

Hemoconcentration ↑ Hct, BUN, E+ levels ↑ Urine Specific Gravity

causes of Hyponatremia

GI loss - NG suction, vomit, diarrhea, Renal loss

hypokalemia causes

GI losses, medications, alterations of acid-base balance, hyperaldosteronism, poor dietary intake

Fluid excess lab values

Hemodilution ↓ Hct, BUN, E+ levels ↓ Urine Specific Gravity

Drugs Associated with Hyponatremia

Heparin, Acetazolamide, Carbamazepine, Chlorpropamide, Tolbutamide, Cyclophosphamide, Vincristine, Fluphenazine, Thioridazine, Thiothixene, Barbiturates, Morphine, Amiloride, Loop, Thiazides

hypokalemia interventions (GIM^5)

Give with food/juice (causes GI irritation) IV site (watch for phlebitis, infiltration) Monitor VS Monitor I&O Monitor neuromuscular activity Monitor cardiac changes Monitor electrolyte level

How is hyPOkalemia treated?

Giving potassium chloride supplements and increasing dietary intake of potassium.

Newborns

Goal: Restore appropriate fluid balance and prevent complications Dehydration occurs most in newborns and elderly Check for sunken fontanel when newborn laying down, shows dehydration

Diffusion

High concentration to low concentration Ex: Respirations, aveoli exchanging CO2, movement of glucose into cells

What does an extracellular contraction result from?

H2O deficiency (Hypernatremia), Na+ deficiency(Hyponatremia), Isotonic ECF deficit(normal Na+)

What does an extracellular expansion result from?

H2O excess(Hyponatremia Na+<135mEq/L), Na+ excess(Hypernatremia Na+ >145mEq/L), Isotonic ECF excess(normal Na+ 135-145mEq/L)

WHEN DOES HYPOKALEMIA AND HYPERKALEMIA HAPPEN IN REGARDS TO FVD

HYPOKALEMIA--> occurs with GI and renal losses Hyperkalemia:--> occurs with adrenal insufficiency

ADH AND THIRST:

Have important roles in maintaining sodium concentration and oral intake of fluids: Oral intake is controlled by the thirst center located in the hypothalamus. As serum concentration or OSMOLALITY increases, or BLOOD VOLUME DECREASES, neurons in the hypothalamus are stimulated by intracellular dehydration; thirst then occurs, and person increases oral intake of fluids. Water excretion is CONTROLLED by ADH, aldosterone, baroreceptors. Presence or absence of ****ADH is the MOST SIGNIFICANT**** factor whether determining whether the urine that is excreted is concentrated or dilute.

Metabolic acidosis clinical manifestations

Headache Abdominal pain Central nervous system depression Confusion Lethargy Stupor Coma Severe metabolic acidosis Tachycardia Ventricular dysrhythmias (from myocardial intracellular acidity) Decreased cardiac contractility Death from brainstem dysfunction usually occurs if pH falls below 6.9 Uncompensated Below-normal bicarbonate concentration pH below normal Normal Paco2

Respiratory acidosis clinical manifestations

Headache Tachycardia Cardiac dysrhythmias Neurologic abnormalities Blurred vision, tremors, vertigo, disorientation, lethargy, somnolence Severe respiratory acidosis Peripheral vasodilation with hypotension Uncompensated ABG PaCO2 above normal pH is below normal Bicarbonate normal Compensatory Response Increased renal excretion of metabolic acid (kidneys cannot excrete carbonic acid; this is solely a respiratory function) Increased PaCO2 (primary imbalance) Increased bicarbonate concentration (compensation) Decreased (somewhat low) or even normal pH, depending on degree of compensation Excretion of H+ and retention of HCO3− Results in increase of bicarbonate ion movement of pH toward normal Requires several days to be effective

Active Transport

Help move Na+ Na+ and K+ switch to maintain balance

Natriuretic peptides

Hormones secreted by special cells in atria of heart and ventricles of heart -Increased blood volume and B/P -stretches heart tissue -inhibited reabsorption of sodium and increased glomerular filtration -increased urine output -increased blood volume and decreased blood osmolarity

What two forces drive water movement?

Hydrostatic pressure and osmotic pressure.

Hypomagnesemia symptoms

Hyperactive deep tendon reflexes confusion tremors seizures ECG changes

Hypernatremia symptoms

Hypernatremia d/t water loss: -Intense thirst, swollen tongue, restlessness, agitation, twitching, weakness, postural hypotension, sezures, coma, weight loss Hypernatremia d/t sodium gain: Intense thirst, restlessness, agitation, twitching, flushed skin, peripheral & pulmonary edema, HTN, seizures, coma

Contributing Factors of Hypercalcemia > 10.5 mg/dL

Hyperparathyroidism, malignant neoplastic disease, pro- longed immobilization, overuse of calcium supple- ments, vitamin D excess, oliguric phase of renal failure, acidosis, corticosteroid therapy, thiazide diuretic use, increased parathyroid hormone, and digoxin toxicity

Hyponatremia treatment

Hypertonic saline fluid restriction if condition caused by overhydration fluid replacement with Na+ soulution if condition caused by fluid loss Reduce dose of diuretics

Fluid Volume Excess

Hypervolemia = excess of fluid and electrolytes in same proportion -Pt's with cardiac and kidney problems are at most risk

Hypokalemia Etiology

Hypokalemia Decreased potassium ion concentration in extracellular fluid Etiology Decreased intake: usually in conditions that cause a decreased oral intake Shift into the cell Increased excretion: usually renal but can be through feces, sweat, GI tract (emesis, diarrhea), diuretics

VI. HYPOKALEMIA D. Interventions

Hypokalemia is treated by giving KCl supplements PO or IV 1. Monitor systems related to assessment, place on cardiac monitor 2. Give KCl supplements as Rxd 3. Oral potassium supplements A. Oral supplements may cause nausea, vomiting, do not take on empty stomach. Discontinue if nausea, vomiting, pain, GI bleed, distention, diarrhea. B. Liquid potassium tastes nasty, give with juice. 4. IV potassium supplements A. Potassium NEVER given IV push or IM B. Administer at 5-10 mEq/hr MAX rate of 20mEq/hr C. Mix bag initially and periodically to ensure potassium distributed evenly in solution D. Monitor IV site for phlebitis hourly, infiltration can cause tissue necrosis. Use central IV for rapid infusion E. Assess renal function BEFORE giving potassium (urine output of at least 0.5ml/kg/hr) F. Teach about foods high in potassium

Contributing factors of Calcium Deficit: (Hypocalcemia) < 8.5 mg/dL

Hypoparathyroidism (may follow thyroid surgery or radical neck dissection), malabsorption, pancreatitis, alkalosis, vitamin D deficiency, massive subcutaneous infection, generalized peritonitis, massive transfusion of citrated blood, chronic diarrhea, decreased para- thyroid hormone, and diuretic phase of renal failure ** CALCIUM BINDS WITH ALBUMIN, IF ALBUMIN IS DOWN, CALCIUM IS DOWN= HYPOCALCEMIA***

hypocalcemia s/s (HHC TTT PPP )

Hypotension Hyperactive bowels Cramps Diarrhea Tachycardia Twitching Tetany Paresthesias Positive Chovestek's or Trousseau's sign Prolongation of QT interval

Fluid Regulation of Nervous System

Hypothalamus controls thirst - thirst center.

osmolarity (hypo/iso/hypertonic solutions)

Hypotonic - has lower osmotic pressure than ICF; lesser concentration of particles than plasma; causes water to move out of intravascular space & into cells causing "cells to swell"; Example: 0.45% NaCl (½ NS) Isotonic - has same osmotic pressure as ICF; same concentration of particles as plasma; remains in the vascular compartment; Example: 0.9% NaCl (NS), Lactated Ringers (LR) Hypertonic - has a higher osmotic pressure than ICF; greater concentration of particles than plasma; causes water to move out of cells & into intravascular compartment, so "cells shrink"; Examples: 3% NaCl (3% NS), 5% Dextrose in 0.45% Sodium Chloride(D5½ NS)

Checking for orthostatic hypotension allows the nurse to detect early signs of:

Hypovolemia

Nursing Diagnoses Hypovolemia vs. Hypervolemia

Hypovolemia: - Deficient fluid volume - Decreased Cardiac Output - Risk for deficient fluid volume - Potential complication- hypovolemic shock Hypervolemia - Excess fluid volume - Impaired gas exchange - Risk for impaired skin integrity - Activity intolerance - Disturbed body image - Potential complications- pulmonary edema, ascites

List nursing interventions for the client with sodium & volume imbalances...

I&O, cardiovascular changes, respiratory changes, neurologic changes, daily weights, skin assessment, IV fluids, functional status

Nursing Management of Fluid Volume Deficit

I&Os: measure all fluids that enter and leave the body Laboratory values: check electrolytes, CBC, and urine-specific gravity Cardiovascular: assess for hypotension and weak pulses Respiratory: Assess respiratory system and tissue perfusion Assess: Check orientation, vision, hearing, reflexes, and muscle strength Daily weights: check for weight changes Oral and skin care: check for skin breakdown and good oral care

Fluid Distribution- ICF

INTRAcellular Fluid: fluid WITHIN the cell 2/3 of Total Body Water skeletal muscle mass K+ & PO4-

Potassium (K+) fact

IV bolus of K+ is never administrated. Always diluted when administered. Is major cation of the ICF.

What is given to the hyPERkalemic patient experiencing dangerous cardiac dysrhythmias ?

IV calcium gluconate.

hypocalcemia medical management

IV of calcium gluconate; calcium and vitamin D supps; diet

If potassium is mostly found intracellularly, why do we measure and determine abnormalities based on serum results?

If cellular content is high, potassium will leak out into blood and cause hyperkalemia. (If there's not enough potassium in the cell, potassium will be pulled into cells from blood stream, decreasing serum potassium level and could cause hypokalemia.)

What is treatment for hyPOnatremia?

If from water excess, fluid restriction is often the only treatment. If fluid loss is the cause, replacement with sodium-containing solutions is indicated.

Physical assessment

If suspect dehydration, assess orthostatic changes Look for: Drop in BP Increased HR Orthostatic hypotension (sign of dehydration)

Concentration imbalances (vs. volume imbalances)

Imbalances are disorders of concentration and not the amount of extracellular fluid. Recognized by abnormal serum sodium concentration. Also called water imbalances Serum sodium concentration reflects osmolality of blood

How are electrolytes generally measured?

In milliequivalents per liter of water (mEq/L) Milliequivalents refers to the chemical combining power of the ion (measure of chemical makeup or activity so they bind together)

What is hypernatremia?

Increase in sodium levels, water deficit, Na+>145mEq/L

hypernatremia interventions (IM^3)

Increase water intake orally (provide water between meals and tube feedings, 8-10 glasses a day Monitor VS Monitor I&O Monitor electrolyte level

Thirst triggered by:

Increased concentration of extracellular fluid (osmolality) Decreased circulating blood volume In older adults, thirst diminishes; may have insufficient fluid intake

Hypomagnesemia treatment

Increased dietary intake oral supplements IM or IV mag administration -Caution: administering parenteral magnesium too rapidly can lead to respiratory or cardiac arrest!

ECV Excess (volume imbalance)

Increased extracellular volume (vascular and interstitial) but concentrations are normal Caused by addition or retention of isotonic saline (e.g. intravenous infusion); sometimes termed saline excess Renal retention of sodium and water Can be caused by excessive secretion of hormone aldosterone causing kidneys to retain saline Compensatory mechanism that can accompany chronic heart failure Clinical manifestations Manifestations of circulatory overload Bounding pulse Neck vein distention in upright position Crackles in dependent portions of lungs Dyspnea Orthopnea Sudden weight gain: a sensitive measure of extracellular volume excess Edema If advanced, frothy sputum of pulmonary edema In infant Bulging fontanel Assessment of neck veins is not effective in infants

Fluid Regulation of Thyroid Gland

Increases blood flow in the body and increases output.

Aldosterone

Increases reabsorption of Na and water and excretion of K in kidneys. Causes vasoconstriction, increases BP. (main Na-retaining hormone)

Body's two major fluid compartments

Intracellular (fluid within cell) and extracellular (fluid outside the cell)

Chloride and Bicarbonate relationship:

Inverse relationship. Bicarbonate= buffer for acid-base balance.

hyponatremia causes (IN BIG DIPER)

Irrigation of GI tubes with plain water Nausea and vomiting Burns Increased perspirations Gastrointestinal suction Draining skin lesions Inadequate sodium intake Potent diuretics Excessive intake of water Retention of fluids Syndrome of inappropriate antidiuretic hormone secretion

What is the concentration for Lactated ringer's(LS)?

Isotonic

what is the concentration for 0.9% sodium chloride(NS, 0.9%NS, 0.9%NaCl)?

Isotonic

Osmolarity of a Solution

Isotonic Hypertonic Hypotonic

What is/are the role(s) of water in the human body?

It is required for cellular metabolism. Affects blood volume. Solute transport. Assists with digesting and is the medium for digesting waste.

What is the importance of potassium?

It is the major ICF cation and is the major factor in the resting membrane potential of nerve and muscle cells. Potassium is critical for many cellular and metabolic functions, and disruptions cause a number of clinical problems.

How is hyPERnatremia treated?

It is treated by cause. In water deficits, volume is replaced. In sodium excess, dilution is accomplished with sodium-free IV fluids.

hyperkalemia serum

K greater than 5.0 mEq/L

What is the range of hypokalemia?

K+<3.5mEq/L

What is the range for hyperkalemia?

K+>5.0mEq/L

precautions for IV infusion of KCL

KCL should NOT be given unless Urine output is at least 0.5 ml/kg of body weight per hour. IV solutions should NOT contain more than 60 mEq/L of KCL. IV administration of KCL should NOT exceed 10-20 mEq per hour. KCL should Never be given IVPush Monitor IV sites frequently Potassium is a severe tissue irritant and is never given by IM or subcutaneous injection.

Loss

Kidney: urine output; skin loss: sensible and insensible losses; lungs; GI tract;

How do our bodies get rid of excess potassium?

Kidneys excrete excess potassium, as long as kidneys are healthy and we don't eat too many foods or supplements with potassium

How do the kidneys keep the composition and volume of body fluid:

Kidneys normally filter 170L of plasma in ADULT 1.5L of URINE. Kidneys act both autonomously and in response to blood-borne messengers, such as aldesterone and antidiuretic hormone. Maintaining fluid balance include the following: Regulation of ECF volume and osmolality by selective retention and excretion of body fluids Regulation of electrolyte levels in the ECF by selective retention of needed substances and excretion of unneeded substances Regulation of pH of the ECF by retention of hydrogen ions Excretion of metabolic wastes and toxic substances

What are good seasoning substitutes for salt?

Lemon juices, onions and garlic

Fluid Intake Sources

Liquids (1500 mL/day) Solid Foods (800mL/day) Metabolism (300 mL/day)

Intake

Liquids taken by mouth or feeding tube etc. All intravenous fluids, blood & components

In patients with SIADH, in which water restriction is difficult, and medication can antagonize the osmotic effect of ADH.

Lithium.

FVD contributing Factors:

Loss of water and electrolytes vomiting, diarrhea, fistulas, fever, excess sweating, burns, blood loss, gastrointestinal suctioning, and third space fluid shifts decreased intake, anorexia, nausea, inability to gain access to fluids, diabetes insipidus, and uncontrolled diabetes mellitus

What is hyPOnatremia?

Low serum sodium level.

Causes of Hyperkalemia

MACHINE: Medications Acidosis Cellular destruction Hypoaldosteromism Intake- excessive Nephrons- renal failure Excretion- impaired

Signs and symptoms of Hyperkalemia

MURDER: Muscle weakness Urine- olguria, anuria Respiratory distress Decreased cardiac contractility EKG changes Reflexes- hyperreflexia, areflexia

Potassium

Major cation of the ICF. Chief regulator of cellular enzyme activity and cellular water content The more K, the less Na. The less K, the more Na Plays a vital role in such processes such as transmission of electrical impulses, particularly in nerve, heart, skeletal, intestinal and lung tissue; CHON and CHO metabolism; and cellular building; and maintenance of cellular metabolism and excitation Assists in regulation of acid-base balance by cellular exchange with H RDA: not known precisely. 50-100 mEq Sources: bananas, peaches, kiwi, figs, dates, apricots, oranges, prunes, melons, raisins, broccoli, and potatoes, meat, dairy products Excreted primarily by the kidneys. No effective conserving mechanism Conserved by sodium pump and kidneys when levels are low Aldosterone triggers K excretion in urine Normal value: 3.5 - 5 mEq/L

Hypotonic fluids- Danger

Make low B/P worse Risk of water intoxication Cerebral edema

causes of Hypomagnesemia

Malnutrition, alcoholism, diarrhea, vomiting, polyuria

What are the manifestations of hyPERkalemia?

Manifestations include cramping leg pain, followed by weakness or paralysis of skeletal muscles.

What does fluid volume EXCESS result from?

May result from excessive intake of fluids, abnormal retention of fluids (e.g., heart failure, renal failure), or interstitial-to-plasma fluid shift.

Hypervolemia nursing interventions

Monitor fluid intake and output Monitor daily weight Monitor cardiopulmonary status Auscultate breathe sounds Assess for complaints of dyspnea Monitor chest x-ray results Monitor arterial blood gas values Assess for peripheral edema Inspect the patient for sacral edema Monitor infusion of I.V. solutions Monitor the effects of prescribed medications

Patient Teaching- Hyperkalemia

Medications Dietary Signs and Symptoms

Clinical Manifestations of Hypernatremia

Mild Thirst Oliguria Confusion Lethargy Muscle twitching & irregular muscle contractions Severe Seizures Coma Death The muscles and nerves are less able to respond to a stimulus & muscles become progressively weaker

Hyponatremia clinical manifestation

Mild central nervous system dysfunction Malaise Anorexia Nausea Vomiting Headache Thready, weak pulse with hypovolemia (decreased plasma volume) or full bounding pulse, normal or high BP with hypervolemia Severe central nervous system dysfunction Confusion Lethargy Seizures Coma

CAlcium sources

Milk cheese green leafy vegetables egg yolk whole grains(brown rice) legumes(dried peas) nuts

Sodium food sources (MMLK BBCCSS WTPL)

Milk Mustard Lunch meats Ketchup Bacon Butter Canned foods Cheese (american, cottage) Snack foods Soy sauce White/whole wheat bread Table salt Processed foods Lunch meats

Calcium Food Sources

Milk and soy milk Cheese Yogurt Spinach Collard greens Rhubarb Sardines Tofu

Phosphate sources

Milk, cheese fish & poultry cereals legumes nuts meats soft drinks

hyperkalemia intervention (M^5AP)

Monitor VS Monitor for cardiac changes Monitor I&O Monitor Lab values Monitor for calcium and magnesium loss when using Kayexalate Adm. sodium polystyrene sulfonate (Kayexalate) Prepare for peritoneal dialysis, hemodialysis (as prescribed)

Calcium

Normal level:9.0-10.5 mg/dL and 4.5-5.5 mEq/dl Functions: Maintaining bone strength and density Allowing skeletal and cardiac muscle contraction Controlling nerve impulse transmission Allowing blood clotting Needed for vitamin B12 absorption. stored in bones

Calcium

Most abundant electrolyte in the body. 99% in bones and teeth Close link between calcium and phosphorus. High PO4, Low Ca Necessary for nerve impulse transmission and blood clotting and is also a catalyst for muscle contraction and other cellular activities Needed for Vitamin B12 absorption and use Necessary for strong bones and teeth and thickness and strength of cell membranes RDA: 1g for adults. Higher for children and pregnant and lactating women according to body weight, older people, esp. post-menopausal Found in milk, cheese, and dried beans; some in meat and vegetables Use is stimulated by Vitamin D. Excreted in urine, feces, bile, digestive secretions, and perspiration Normal value 8.5 - 10.5 mg/dl

Filtration

Movement from an area of higher pressure to one of lower pressure

Filtration

Movement of fluid thru cell or blood vessel membrane becuz of difference in water volume pressing against confining walls

Simple Diffusoin

Movement of molecules from high to low concentration- assuming its permeable can move through - note molecules and solutes are interchangeable here- mixed in something- electrolytes, proteins

Active Transport

Movement of solute using carrier and energy from low concentration (ISF- interstitial fluid) to high concentration (cell) - move against concetration gradient - process in which molecules move against concentration gradient - External energy required: example sodium potassium pump to maintain difference use ATP - moves molecules against concretion AND osmotic pressure such as ions like sodium potassium calcium, and iron

Filtration

Movement of water and solutes from blood (high pressure) to ISF (interstitial fluid) (low pressure) area - Movement of solutes and solvents by hydrostatic pressure - movement is from an area of higher pressure to an area of lower pressure

Osmosis

Movement of water down a concentration gradient- from low solute concentration (ISF- interstitial fluid) to high concentration (blood) across semipermeable membrane - movement of water against the concentration gradient - can't move the molecules, move the fluid to achieve equilibrium trying to get pressure to be equal- requires no energy - water moves from less concentrated side (has more water) to more concentrated side (has less water) - the concentration determines the strength of the osmotic pull- higher the concentration, the greater the solution's pulling or greater oncotic pressure - measured in milliosmoles and can be expressed as osmolarity or osmolality

Solutions-Hypotonic

Moves fluids into the cells, causing them to enlarge 0.45% Sodium Chloride

Hyperkalemia Clinical Manifestations

Muscle dysfunction due to changes in resting membrane potential (hypopolarization) Early, mild Intestinal cramping, diarrhea Late, more severe Muscle weakness: ascending, beginning in lower extremities Cardiac dysrhythmias and even cardiac arrest

Hypokalemia symptoms

Muscle weakness leg cramps Potentially lethal arrhythmias -shallow or flat T wave, prominent U wave Rhabdomyolysis(muscle cell breakdown) Shallow respirations Thready and weak pulse to irregular heartbeat GI changes:hypoactive bowel movement

hypercalcemia s/s (MIND ABBCC)

Muscle weakness (hypotonicity) Increased HR & BP Nausea and vomiting Diminished deep tendon reflexes Abdominal distention Bounding pulse Bradycardia(late stage) Constipation Confusion, lethargy, and coma

Signs and symptoms of hypercalcemia:

Muscular weakness, constipation, anorexia, nausea and vomiting, polyuria and polydipsia, hypoactive deep ten- don reflexes, lethargy, deep bone pain, pathologic frac- tures, flank pain, and calcium stones. ECG: shortened QT interval, bradycardia, heart blocks.

Is Fluid Volume Deficit interchangeable with dehydration?

NO Dehydration is only the loss of water NOT sodium

GERONTOLOGIC CONSIDERATION

NORMAL PHYSIOLOGIC CHANGES OF AGING, INCLUDING REDUCED RENAL AND RESPIRATORY FUNCTION AND RESERVE ALTERATIONS IN THE RATIO OF BODY FLUIDS TO MUSCLE MASS MAY ALTER RESPONSES OF AN ELDERLY PERSON TO FLUID AND ELECTROLYTE CHANGES AND ACID-BASE DISTURBANCES IN ELDERLY PATIENTS. REACTIONS ARE LIKELY TO OCCUR MORE QUICKLY, AND WITH THE ADMINISTRATION OF SMALLER VOLUMES OF FLUID. INCREASED SENSITIVITY TO FLUID AND ELECTROLYTE CHANGES IN ELDERLY PATIENT REQUIRES CAREFUL ASSESSMENT, ATTENTIVE TO I&O, CHANGES IN WEIGHT, SIDE EFFECTS AND INTERACTIONS OF MEDS, AND PROMPT REPORTING

What type of drugs may cause edema?

NSAID's, estrogens, corticosteroids, or antihypertensives. [ metoprolol, lisinopril, furosemide, thiazide ]

Hypervolemia treatment

Na and fluid intake restriction Diuretics to promote excess fluid excretion Morphine and nitroglycerin (Nitro-Dur) for pulmonary edema Dilate blood vessels Reduce pulmonary congestion and amount of blood returning to the heart Digoxin for heart failure Strengthens cardiac contractions Supportive measures Oxygen administration Bed rest Hemodialysis or continuous renal replacement therapy for renal dysfunction

REMEMBER EXTRACELLULAR FLUID ELECTROLYTES LEVELS: Na+ ,Mg+, K+, Ca++, Cl-, P-

Na+= 135-145 K+= 3.5-5.0 Ca+= 8.3-10.2

Faciliated difusion

Needs hep, requires energy of the molecules or solutes - The use of a protein carrier in the cell membrane - Protein carrier combines with a molecule and assists in moving the molecule across the membrane from high to low- like glucose transported into the cell

Potassium Functions

Nerve impulse transmission Maintenance of cardiac rhythm Muscle contraction regulation of osmolarity contributes to acid base balance

Hyponatremia

Net gain of water or loss of Na-rich fluids.

Potassium

Normal: 3.5-5.0 mEq/L - major ICF cation 98% of body's potassium is intracellular -Crucial to vital organ function such as the heart - Major role in excitable tissues and cardiac function (therefore must be on telemetry) - Sodium Potassium pump removes Na+ and returns K+ to cells - Normally excreted through urine, feces, and sweat - Aldosterone increases K+ loss in urine - kidneys maor route of K+ loss- remainder lost in stool and sweat - regulates intracellular osmolality promoting cellular growth, required for glycogen to be deposited in muscle and liver and plays a role in acid base

Signs and Symptoms of Magnesium Deficit:

Neuromuscular irritability, positive Trousseau's and Chvostek's signs, insomnia, mood changes, anorexia, vomiting, increased tendon reflexes, and ↑ BP. ECG: PVCs, flat or inverted T waves, depressed ST segment.

Would oral potassium supplements be recommended for pt's with poor kidney function? Would salt substitutes be a good choice for pt's with poor kidney function?

No and No

Sodium: role and normal values

Normal 135-145 mEq/L - Most abundant ECF cation - Dictates the ECF volume - Osmotically very active -- imbalances typically associated with parallel changes in osmolality - serum sodium levels reflect ratio of sodium to water- therefore changes in sodium may reflect a primary water imbalance, a primary sodium imbalance or combo - plays a major role in 1. ECF concentration and volume 2. Generation and transmission of nerve impulses 3. Muscle contractility 4. Acid base balance - Gi tract absorbs sodium from foods- typically, daily intake of sodium far exceeds body's requirements - sodium leaves the body through urine, sweat and feces- primarily balanced by the kidneys with ADH and aldosterone which promotes sodium reabsorption

Acid base balance

Normal base to acid is 20:1 Salt and neutralization Acids react with bases to form water & salt (neutralization reaction) Carbonic acid = bicarbonate + hydrogen = carbon dioxide + water

Normal body pH

Normal body pH is 7.35 - 7.45 Below 7.25 or above 7.55 is considered life-threatening Above 7.8 (alkalosis) or below 6.8 (acidosis) usually is fatal 7.4 indicates a ratio of 1 part carbonic acid to 20 parts bicarbonate (base)

Plasma potassium

Normal concentration: 3.5 to 5 mEq/L (may vary slightly with different laboratories) Higher in neonates Most of potassium is inside the cell Potassium maintains the osmolality of the ICF

Magnesium

Normal level: 1.3 to 2.1 mg/dL Critical for skeletal muscle contraction, carbohydrate metabolism, ATP formation, vitamin activation, cell growth Hypomagnesemia hypermagnesemia

Potassium

Normal level: 3.5-5.0 mEq/L Some control over intracellular osmolarity and volume regulate protein synthesis, glucose use and storage Stomach contains large amounts of potassium It is excreted by the kidneys Makes skeletal and cardiac muscle work correctly.

Chloride

Normal level: 98 to 106 mEq/L Imbalance occurs resulting from other electrolyte imbalances treat underlying electrolyte imbalance or acid base problem

Sodium

Normal level:136-145 mmol/L or mEq/L Where sodium goes water follows Functions: -fluid volume maintenance -neural impulse transmission -muscle contraction

Phosphorus

Normal level:3.0-4.5 mg/dL found in bones Activates vitamins and enzymes; assists in cell growth and metabolism plasma levels of calcium and phosphorus exist in a balanced reciprocal relationship hypophosphatemia hyperphosphatemia

Nursing management of FVD:

Nurse monitors I&O Q8H sometimes hourly. loss may come from polyuria; diarrhea; vomiting; when FVD develops, kidneys conserve body fluids, leading to urine output <30mL/hr, urine in this INSTANCE is concentrated and represents a healthy response. monitor daily body weights Vital signs monitored. Nurse monitors weak, rapid pulse and postural hypotension (systolic drop pressure exceeding 15 mmHg when p/t moves from a lying to sitting) Decrease in body temp skin turgor ( flattens slowly with FVD) severe if skin is elevated for many seconds , skin turgor best measured by pinching the skin over the sternum, inner aspects of thigh, or forehead. ( skin turgor test should be avoided in elderly patients because of loss of elasticity) *****Inspect the tongue ( more valid than skin turgor)*** Normal person has 1 longitudal furrow on the tongue, in FVD, additional furrows are presented, and tongue is smaller because of fluid loss. Dry oral mucosa may imply FVD or mouth breathing Check urinary concentration: Specific gravity should be above 1.020 in a FVD patient in order to indicate HEALTHY RENAL CONSERVATION OF FLUID. Mental function- eventually affected in severe FVD as a result of decreasing cerebral perfusion. Decreased peripheral perfusion can result in cold extremities. In patients with a NORMAL cardiopulmonary function, A LOW CENTRAL VENOUS PRESSURE IS INDICATIVE OF HYPOVOLEMIA.

Fluid Output

Occurs through kidneys, skin, lungs and GI tract.

Magnesium Excess contributing Factors: > 2.7 mg/dL (Hypermagnesemia)

Oliguric phase of renal failure (particularly when mag- nesium-containing medications are administered), adrenal insufficiency, excessive IV magnesium administration, and DKA

Foods high in Potassium

Orange juice, strawberries, bananas, broccoli, carrots, spinach, beef, pork, cod, chocolate, nuts, seeds.

Potassium Sources

Oranges, bananas, avocados dried fruits potatoes, sweet potatoes, butterbeans, lima beans Milk & Meats Cereals

Osmolality vs osmolarity

Osmolality - the number of osmoles per kilogram of water; tonicity is sometimes used instead of this term Osmolarity - the number of osmoles per liter of solution

What is the importance of the osmolality?

Osmolality controls water movement and the body fluid distribution in the intracellular and extracellular compartments Potassium maintains the osmolality of the ICF Sodium controls the osmolality of the ECF Normal: 280-294 mOsm/kg

_______ refers to the loss or gain of only water so the osmolality is altered (electrolytes proportionately are greater). _______ refers to the loss or gain of water and electrolytes in equal proportions.

Osmolar; Isotonic

Hypertonic fluids

Osmolarity is greater than that of human serum >400mOm/L Cell dropped into solution will shrivel& shrink Uses: correction of severe electrolyte imbalances(i.e.sever electrolyte imbalances/losses: acute cerebral edema) Ex: of IV fluides: 10% (or greater) dextrose:D5NS:D5LR

Isotonic Solution

Osmolarity is identical to that of human serum 200-400 mOsm/L Cell dropped into solution will remain unchanged. Uses: volume expansion & fluid maintenance IV fluid Ex: 0.9% saline(NS), lactated Ringer's(LR or RL)

Hypotonic solution

Osmolarity is less than that of human serum <200 mOsm/L Cell dropped in solution will swell & burst Uses: Dilution of excess serum electrolytes (i.e.hyperglycemia) IV fluid EX: 0.45% saline (1/2 NS)

Movement of Body Fluid

Osmosis Filtration Diffusion Active Transport

Isotonic Solutions

Osmotic pressure EQUAL to plasma. There is NO osmotic movement. Cells will remain unchanged Isotonic IV Solutions: Normal Saline (0.9% NaCl) Lactated Ringer's solution (LR) (Most used) 5% dextrose in water (D5W) Uses: If someone is bleeding out Risks of giving: fluid overload

Hypertonic Solutions

Osmotic pressure HIGHER than plasma due to increased concentration of solutes. Cells will shrink Maintenance IV Solutions: 3% NS 5% NS Blood Products Albumin Uses: to stabilize B/P, increase urine output, reduce edema before surgery Carry greater concentration of solute than plasma and thus have a higher osmolality CAUTION: Hypertonic! 3% and 5% Saline- B/P should be monitored Give SLOW to prevent circulatory overload Also Hypertonic: 10% and 50% Dextrose Must give in peripheral veins

Hypotonic Solutions

Osmotic pressure LOWER than plasma due to a decreased concentration of solutes. Fluid will move into cells, cells will swell Hypotonic IV Solutions: 0.45% saline (1/2 NS) D5 1/2 Normal Saline Uses: Replaces cellular fluids Treat high sodium (hyperneutremia)- pushes sodium into cells to push out into body, to give cells enough sodium Can rupture if too much fluid moves in Fluid moves from low to high concentration

What is oncotic pressure?

Osmotic pressure exerted by colloids in solution.

causes of Hypercalcemia

Osteoperosis, hyperparathyroidism, immobilization

hyperkalemia reading

P waves- flat T waves- peaked ST segment- depressed QRS widened complex PR prolonged interval

hypokalemia reading

P waves- peaked T waves- flat ST segment- depressed U waves- depressed

CLINICAL MANIFESTATIONS OF HYPONATREMIA

POOR SKIN TURGOR, DRY MUCOSA, DECREASED SALIVA PRODUCTION, ORTHOSTATIC FALL IN BLOOD PRESSURE, NAUSEA, ABDOMINAL CRAMPING, NEUROLOGICAL CHANGES, ALTERED MENTAL STATUS,

Dilutional Hyponatremia:

Patient's serum sodium level is diluted by an increase in the ratio of water to sodium. Causes water to move into the cell, so that the patient develops an ECF volume excess, because they will be more thirsty to replenish the fluid lost.

With what kind of patients would you give a hypertonic solution?

Patients who have been vomiting or had diarrhea for the past couple of days or are hypoglycemic

Body Fluid content

Percentage of body weight that is water is: -approximately 60% in adults -greater in men than women -45-55% in the elderly -70-80% in infants

Total Body Water

Percentage of body weight that is water varies according to a person's age & in proportion to body fat In infant - 75% In men - 60% In women - 50% 1 L of water weighs 2.2 lbs or 1 kg

Oxygen Saturation

Point at which hemoglobin is saturated by O2.

Fluid Volume Deficit Causes

Polyuria Fever Profuse Sweating Third-space fluid shifts Draining wound or fistula Confusion GI suctioning Meds Diseases Decreased intake as in the following conditions: Anorexia Nausea Depression Inability to gain access to fluids Diarrhea Vomiting

fluid volume excess (Hypervolemia) interventions (PAM^4 CPR)

Position client in Semi Fowlers Administer diuretics as prescribed Monitor I&0 Monitor weight Monitor VS Monitor hematocrit and electrolyte levels Check for edema Provide low sodium diet (as prescribed) Restrict fluids (as prescribed)

Edema pitting scale

Press skin over bony prominences for 5+ seconds 1+ Mild pitting - slight indentation with no swelling 2+ Moderate pitting - indentation subsides quickly 3+ Deep pitting - indentation remains for a short time; area looks swollen 4+ Very deep pitting - indentation lasts a long time; area is very swollen 5+ Brawny - skin so taut & shiny that palpation is impossible

Nursing History Assessment

Primary Concern Chronic/ acute disease and conditions Meds/ Treatments: Diuretics, steroids, chemo Diet/ Fluid Output

Glucocorticoids

Primary effects: Antiinflammatory action & increase in serum glucose Effects of Cortisol: Acts during stress as a mineralocorticoid: Promotes sodium retention water follows sodium fluid volume rises

Renal System (kidneys)

Primary system in regulating fluid and electrolyte balance.

Regulation of Water Balance- RAAS

Problem in cycle can effect output Medications can block- Ex: B/P meds

Homeostasis

Proper functioning of all body systems; requires fluid and electrolyte balance -extracellular fluid-outside of cell -intracellular fluid-inside cell -interstitial fluid-between cells &outside blood vessels -transcellular fluids-

What is the major colloid in the vascular system that contributes to total oncotic pressure?

Protein

Colloid Osmotic Pressure

Protein (colloid) present in blood vessels increases osmotic pressure and "pulls" fluid in from the interstitium

Calcium regulation

PtH(Parathyroid gland) -responds to LOW calcium levels -brings CA++ out of bone (resorption which raises blood calcium ThyroCalcitonin-Thyroid gland -responds to high calcium levels -take Ca++ into bone(deposition) which lowers blood calcium Vitamin D-Skin -promotes intestinal Ca++ absorption

Solutions-Hypertonic

Pulls fluids from cells, causing them to shrink. 3% Sodium Chloride.

Signs of and changes with FVE

Pulse volume will increase ---------------------------------------------------------------------------------------------------------- BP will increase

How the heart helps in maintaining fluid & electrolyte balance

Pumping action of the heart circulates blood through the kidneys

hyponatremia s/s (RAW MAPP)

Rapid, thready pulse Abdominal cramping Weakness Muscle twitching and seizures Apprehension Poor skin turgor Postural BP changes

Solutions-Isotonic

Same osmolarity as blood plasma. Expands body fluid volume without causing a fluid shift. 0.9% Normal Saline.

Phosphorous Deficit: <2.5 mg/dL Hyposphatemia:

Refeeding after starvation, alcohol withdrawal, diabetic ketoacidosis, respiratory alkalosis, ↓ magnesium, ↓ potassium, hyperparathyroidism, vomiting, diar- rhea, hyperventilation, vitamin D deficiency associ- ated with malabsorptive disorders, burns, acid-base disorders, parenteral nutrition, and diuretic use

Tonicity

Refers to osmotic pressure of a solution Measurement is determined by: Osmolality/ osmolarity, particle concentration, molecular weight

Fluid Regulation of Lungs

Regulates O2 and CO2, Acid/Base Balance and eliminates H+.

ECV deficit (volume imbalance)

Removal of a sodium-containing fluid from the extracellular compartment d/t: - GI excretion - Renal excretion -In some instances, fluid is sequestered in a "third space" in the body, outside the extracellular compartment, i.e., ascites Caused by removal of a sodium-containing fluid from the body Volume of extracellular fluid is abnormally decreased but concentration of serum sodium and extracellular fluid is normal Sometimes termed saline deficit Clinical manifestation Thirst/dehydration Sudden weight loss (1 kg lost in 24 hours = excretion of 1 L of fluid) Postural hypotension with concurrent increased heart rate; another sensitive indicator>SHOCK Flat neck veins (collapsing with inspiration) when patient is supine Lightheadedness Dizziness Syncope Oliguria or small volume of concentrated urine (if kidneys are responding normally) Decreased skin turgor Dryness of oral mucous membranes Hard stools Soft sunken eyeballs Longitudinal furrows in the tongue In infants Fontanel may be sunken Neck veins are not reliably assessed in infants

hypercalcemia causes (RH AEIU)

Renal failure Hyperparathyroidism Adrenal insufficiency Excessive intake of Vit. D Increased bone resorption of destruction from conditions (tumors, fractures, osteoporosis, & immobility) Use of thiazide, lithium, glucocorticoids

causes of Hypermagnesemia

Renal failure, excess intake

Describe renin-angiotensin-aldosterone system:

Renin is an enzyme that converts angiotensin I (inactive substance formed by the liver) into angiotensin II. Renin is released by juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin converting enzyme (ACE) drugs converts angiotensin I to angiotensin II. Angiotensin II, with vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin. Aldosterone is a VOLUME regulator and is also released as serum POTASSIUM INCREASES, serum SODIUM DECREASES, OR ADRENOCORTICOTROPIC HORMONE INCREASES

hyponatremia interventions (RAM^3S)

Restrict water intake and avoid tap water enemas Assess skin turgor and mucous membranes Monitor VS Monitor I&O Monitor weight Saline is used for irrigation rather than sterile water.

Respiratory Alkalosis

Result of hyperventilation.

Metabolic Acidosis

Results from severe diarrhea or renal disease.

Hyperkalemia etiology

Rise of serum potassium above 5 mEq/L (depending on lab) Etiology Increased potassium intake: rapid or excessive IV infusion Shift of potassium from cells to extracellular fluid: acidosis, crushing injuries Decreased potassium excretion: oliguria, potassium-sparing diuretics, drugs that reduce aldosterone effects or are nephrotoxic

Hypertonic Fluids- Danger

Risk of Fluid Volume Overload!

Predisposing factors of hyponatremia:

SIADH ( syndrome of inappropriate antidiuretic hormone); hyperglycemia, and increased water intake through the administration of electrolyte poor parenteral fluids, tap water enemas, irrigation of NG tubes with water instead of normal saline

Clinical Signs & Symptoms of Hypokalemia

SUCTION: Skeletal muscle weakness U wave (EKG changes) Constipation Toxic effects of digoxin Irregular weak pulse Orthostatic hypotension Numbness (parathesis)

Isotonic solutions

Same osmolality as plasma: Destrose 5% in water, Normal Saline, Lactated Ringers

What are three processes of movement of water and electrolytes between ECF and ICF?

Simple diffusion, facilitated diffusion, and active transport.

Thirst

Simplest mechanism for maintaining fluid balance Occurs as a result of even small losses of fluid. Thirst center located in the hypothalamus Elderly at risk due to decreased thirst mechanism as a result of aging. -Confusion, subnormal temperature, tachycardiea, pinched facial expression

Greastest determinate of serum osmolality

Sodium

What is the most abundant electrolyte in the ECF and what is it's normal concentration range?

Sodium (Na+) and the range is 135-145 mmol/L Sodium is the primary determinant of ECF osmolality. Sodium accounts for its primary role in controlling water distribution throughout the body. Primary regulator of ECF volume. A loss/gain of sodium is accompanied by a loss/gain of water. Sodium establishes electro-chemical state necessary for muscle contraction and transmission of nerve impulses.

Hyponatremia Symptoms

Sodium Loss: -Cerebral changes:alteration in LOC(irritability, confusion) -neuromuscular changes: general muscle weakness -intestinal changes: increased motility, nausea, diarrhea, abdominal cramping -Cardiovascular changes: rapid, weak, thready pulse, decreased B/P, orthostatic hypotension Water gain: -headache, lassitude, apathy, weakness, confusion,N&V, weight gain, muscle spasm, seizures, coma

Hypernatremia treatment

Sodium free IVF (i.e. D5W) Diurectics(possibly) Restriction of sodium intake Prevention

What are causes of Hyponatremia?

Sodium loss: Diarrhea, vomiting, NG suction, diuretics, adrenal insufficiency, burns, wound drainage. Water Gain: SIADH, CHF, excessive hypotonic IV fluids, poliydipsia( excessive thirst)

What is the frequent cause of ECF volume?

Sodium retention

Major Cations

Sodium-Na+ Potassium-K+ Calcium-Ca++ Magnesium-Mg++

Electrolyte Imbalances

Sodium: hyper/hyponatremia Potassium: hyper/hypokalemia Calcium: hyper/hypocalemia Magnesium: hyper/hypermagnesemia Phosphorus: hyper/hypophosphatemia Chloride: hyper/hypochloremia

Chloride sources, Deficiencies & excess

Sources: table salt & foods containing salt Deficiency: -Rare, but can occur with sever vomiting, excessive use diuretics, sodium restricted diets, excessive nasogastric or fistula drainage -Tx: use of alternative sources of chloride Excess: Causes: Alkalosis, hypernatremia

hypercalcemia reading

T wave- widened QT interval shortened

Average Total Water Percentages

TBW- 55-60% Adult male- Approx. 60% Adult Female- 50-55% Newborns 75-77% Young child- 2 year old 60% Dehydration harder on elderly and newborns( more on elderly)

Signs and Symptoms of Chloride Excess:

Tachypnea, lethargy, weakness, deep rapid respirations, decline in cognitive status, decreased cardiac output, dys- pnea, tachycardia, pitting edema, dysrhythmias, coma Labs indicate: increased serum chloride, increased serum sodium, decreased serum pH, decreased serum bicarbon- ate, normal anion gap, increased urinary chloride level

hypocalcemia interventions (TIM AAMP KIM)

Teach client proper use of antacids or laxative Instruct client taking calcium excreting meds to check CA levels periodically Monitor calcium levels closely Adm. Vit. D (AP) to aid in the digestion of calcium from the intestinal tract Adm. CA 1-2 hours after meal to max. intestinal absorption Monitor VS Provide quiet environment, avoid over stimulation Keep 10% calcium gluconate for acute calcium deficit Initiate seizure precautions Monitor for Chvostek's (contraction of facial muscles in response to a light tap over the facial nerve in front of the ear) Trousseau's )carpal spasm induced by inflating a BP cuff above systolic pressure for a few minutes.)

Hypocalcemia signs & synptoms

Tetany -Trousseau's sign-carpal spasms induced by inflating BP cuff above systolic pressure Chvostek's sign-contraction of facial muscles in response to tap over the facial nerve in front of the ear. -fatigue -depression, anxiety, confusion -muscle cramps, hyperreflexia -seizures -laryngeal stridor -dysphasia -numbness & tingling around mouth -parasthesias in extremities -ECG changes

Signs and Symptoms of Phosph. Excess

Tetany, tachycardia, anorexia, nausea and vomiting, mus- cle weakness, signs and symptoms of hypocalcemia

What is the primary organ for regulating fluid and electrolyte balance?

The kidney

Diffusion

The movement of solutes or molecules (Na+ or glucose for example) from high concentration to low concentration - occurs in liquids, gases and solids- stops when = on both sides - membranes must be permeable - simple diffusion requires NO energy

Osmosis is...

The movement of water across a membrane from an area of a less concentrated solution to a more concentrated solution.

Third spacing

The accumulation of trapped extracellular fluid in a body space due to disease or injury

Filtration

The action or process of filtering something Capillaries Ex: Blood Pressure

What is osmotic pressure?

The amount of pressure required to stop the osmotic flow of water.

Compensation

The body attempts to correct changes in blood pH.

What is a concern for some elderly patients that deliberately restrict their fluid intake?

The concern is that elderly patients may restrict fluid intake to avoid embarrassing episodes of incontinence. In this situation, nurse should identify interventions to deal with incontinence such as encouraging patients to wear protective clothing or devices, or have a urinal accessible.

What is hydrostatic pressure?

The force within a fluid compartment and is the major force that pushes water out of the vascular system at the capillary level.

What occurs in cases of hyPOkalemia?

The incidence of potentially lethal ventricular dysrhythmias is increased in hypokalemia. Skeletal muscle weakness and paralysis, including the respiratory muscles, leading to shallow respirations and respiratory arrest, can occur.

What happens with impaired kidneys?

The kidneys cannot maintain fluid and electrolyte balance, resulting in edema and electrolyte imbalances.

What causes hyPERkalemia?

The most common cause is renal failure. Hyperkalemia is also common with massive cell destruction (e.g., burn or crush injury, tumor lysis); rapid transfusion of stored, hemolyzed blood; and catabolic states (e.g., severe infections).

What is first spacing?

The normal distribution of fluid in the ICF and ECF compartments.

Composition and balance of fluid by the HEART AND BLOOD VESSELS

The pumping action of the heart circulates blood through the kidneys under sufficient pressure to allow for urine formation. Failure of this pumping action interferes with renal perfusion and thus with water and electrolyte regulation.

What is homeostasis?

The state of equilibrium in the internal environment of the body, naturally maintained by adaptive responses that promote healthy survival.

What happens to patients on digoxin?

They experience increased digoxin toxicity if their serum potassium level is low.

Drug Therapy

Thiazides: Chlorothiazide, Hydrochlorothiazide (HCTZ) Loop Diuretics: Furosemide, Bumetanide Potassium Sparing Diuretics: Spironolactone, Triamterene, Amiloride

Hypovolemia s/s (THIRDD FPIC)

Thirst (dehydration) HR increases, thready pulse,and postural hypotension Increased specific gravity of urine Rapid weight loss Dizziness or weakness Decrease in urine and B/P Flat neck and hand vein Poor skin turgor and dry mucous membranes Increased hematocrit level Confusion

Clinical Signs

Thirst- very first sign of dehydration Weight loss over a short period Decreased skin and tongue turgor Dry mucous membranes Urine output <30ml/hr in adult Marked oliguria- late sign May lead to elevated: HCT( 35-50%) Na, BUN Serum Osmo Urine Osmo SG

causes Hypervolemia - crackles, SOB

Too much fluid to patient with kidney failure or CHF.

hyperkalemia causes (TEAM RICE)

Tranfusion of stored blood (the breakdown of older RBC releases K+) Excessive use of K+ based salt substitutes Addisons disease Metabolic acidosis Renal failure Intestinal obstruction Cell damage Excessive oral and parenteral adm. of K+

Hypokalemia

Treatment: -PO replacement -IV replacement; careful, know your guidelines; central line vs. peripheral

Tests to elicit signs of Ca deficiency

Trousseau's sign Chvostek's sign

True or False: A patient with poor kidney function may not be able to get rid of excess electrolytes as needed: therefore, those electolytes are built up in the blood.

True

True or false: Edema occurs when there is too much fluid in the intravascular space which causes the fluid to leak out into the tissue

True

True or false: Magnesium causes vasodilation, which decreases the blood pressure.

True

True or false: Plasma proteins such as albumin, help us hold fluid in the intravascular space.

True

True or false: The adrenal glands secrete aldosterone. Aldosterone helps us retain sodium and water.

True

True or false: The kidney is the major organ for keeping our sodium and water in balance.

True

True or false: Too little fluid in your vascular space makes your blood pressure go down.

True

Osmolarity *CHECK

URINE NOT SERUM - Normal value: 300-1300 mOsm/kg - Ratio of solute to water in serum - Excellent indicator of fluid balance - One of the bodies most carefully guarded parameters - Shows ability to concentrate or dilute urine (measurement of the pressure- how much solutes are in it) < 300 means that not much pressure meaning there is not much solutes it is diluted - really light urine has low osmolarity - Dark amber urine will be >1300- need the numbers can just go by color

Fluid excretion

Urinary tract Largest volume excreted Highly dependent on: Adequate blood pressure to perfuse the kidneys Glomerular filtration rate (GFR) Bowels Normal bowel function Increases with diarrhea Lungs Exhalation Skin Visible sweat Insensible perspiration

Will specific gravity be higher or lower in regards to FVD? Why?

Urine specific gravity will be increased in relation to the kidneys attempt to conserve water. Specific gravity will be decreased in regards to diabetes insipidus--> (deficiency in pituitary hormone vasopressin which regulates kidney function) vasopressin= pituitary hormone that promotes water retention and increases blood pressure.

Volume imbalance vs Concentration imbalance

Volume imbalance (Sometimes termed saline imbalance) - Volume of extracellular fluid is abnormally decreased but concentration of serum sodium and extracellular fluid is normal Fluid Concentration imbalances (Also called water imbalances) - disorders of concentration and not the amount of extracellular fluid

Damaging Diseases

Vomiting, diarrhea Hepatic diseases Hyperaldosteronism Acute ETOH Heart failure Malabsorption Syndrome Nephritis Acute Leukemia's

Fluid Excretion

Vomiting, diarrhea, abnormal drainage, excessive use of laxatives, enema, diuretics, blood loss, diaphoresis, burns

Fluid Replacement-Oral Fluid Contraindications

Vomiting, obstruction, risk for aspiration, impaired swallowing

When caring for an adult client diagnosed with hyponatremia, the nurse plans to restrict...

Water

Fluid Volume excess

Water & Na+ retained in isotonic proportions Etiology: CHF, renal failure, cirrhosis, excessive serum sodium, aldosterone, or steroids Sx: rapid wt gain, edema, HTN, poluria, neck vein distention, increases blood pressure, crackles, dyspnea, periorbital edema, pitting edema Labs:decreases HcT, BUN <10mg/100ml

Fluid Volume deficit

Water & electrolytes lost in equal (isotonic) proportions Etiology: GI distrubances, blood/plasma loss (hemorrhage), excessive perspiration, fever, decreases fluid intake, diuretics Sx: postural hypotension, tachycardia, dry mucous membranes, poor skin turgor, thirst, confusion, rapid wt. loss, lethargy, decreases urine output (10-30ml/hr), weak pulse, decreases blood pressure Labs: urine specific gravity >1.030, decreases HcT, decreases hemaglobin, increases BUN

Sodium Excess >145 mEq/L (hypernatremia) contributing factors:

Water deprivation in patients unable to drink at will, hypertonic tube feedings without adequate water supplements, diabetes insipidus, heatstroke, hyperventilation, watery stool, Excess corticosteroid, sodium bicarbonate, and sodium chloride administration, and salt wear near drowning victims

What are common causes of hyPOnatremia?

Water excess from inappropriate use of sodium-free or hypotonic IV fluids.

Osmolality

Water moves freely back and forth across the membrane in response to the osmolar pressure being exerted by the molecules of solute in the intracellular and extracellular fluids. serum osmolality a measure of the number of dissolved particles per unit of water in serum. In a solution, the fewer the particles of solute in proportion to the number of units of water (solvent), the less concentrated the solution. A low serum osmolality means a higher than usual amount of water in relation to the amount of particles dissolved in it, and accompanies overhydration, or edema. An increased serum osmolality indicates deficient fluid volume. Measurement of the serum osmolality gives information about the hydration status within the cells. Serum osmolality reflects the status of hydration of the intracellular as well as the extracellular compartments and thus describes total body hydration. The normal value for serum osmolality is 270-300 mOsm/kg water. Urine osmolality a measure of the number of dissolved particles per unit of water in the urine. Useful in diagnosing renal disorders of urinary concentration and dilution and in assessing status of hydration. The normal value is 500 to 800 mOsm/L.

How water moves in hypotonic solutions

Water moves from less conc. sol. to more conc. sol. - will move from intravascular space (vein) into the ICF (cell)

How water moves in hypertonic solutions

Water moves from less concentrated solution to more concentrated sol.- will move from intracellular and interstitial compartments (cell) to the intravascular space (vein) *Crenation can happen here; would initially see weight gain first

Hypotonic solution

Water moves into cell and causes cell to swell. Fluid shift out of blood vessels into interstitial spaces.

Hypertonic solution

Water moves out of cell and causes cell to shrink.

Hydrostatic pressure

Water pushing pressure Force that pushes water outward from a confined space thru a membrane amt of water in any body fluid space determines pressure

Uses for hypertonic solutions

Water replacement

What is the primary component of the body?

Water, accounting for approximately 60% of the body weight in the adult.

hypernatremia causes (WE DECIDED CHF)

Watery diarrhea Enteral and parental nutrition depletes the cells of water Dehydration Excessive perspiration Cushing Syndrome Impaired renal function Diabetes inspidus Excessive adm. if sodium bicarbonate Decreased water intake Corticosteroids Hyperventilation Fever

Physical Assessment-Fluid Volume Deficit

Weak Pulse, Sunken Eyes, Dry Conjunctivae, Hypotension, Oliguria or Anuria

More clinical signs

Weak, rapid pulse Slow capillary refill Increase body temp Elevated urine specific gravity Altered sensorium Cold extremities- Late sign Low B/P Sunken eye balls

fluid volume excess (Hypervolemia) s/s (WIND CCLPP)

Weight gain Increased B/P & HR, bounding pulse Neck and hand vein distention Decreased hematocrit level Confusion Cough and dyspnea Lung Crackles Pale, cool skin Pitting edema

Clincal Signs of Fluid Volume Excess

Weight gain, peripheral edema, distended neck veins (JVD), Moist rales in lungs(crackles), Polyuria, Ascites, Pleural effusion, Decreased BUN, Decreased HCT, Bounding full pulse, Pulmonary eddema, Bulging fontanel (infant), Dyspnea, Tachypnea

what does fluid volume DEFICIT result from?

With abnormal loss of body fluids (e.g., diarrhea, fistula drainage, hemorrhage, polyuria), inadequate intake, or a plasma-to-interstitial fluid shift.

What are some examples of increased interstitial volume?

Wounds and infections obstruction to lymphatic flow a plasma albumin level less than 1.5 to 2 g/dl decrease in oncotic pressure

All patients with hyPERkalemia should be ___

___monitored electrocardiographically to detect potentially fatal dysrhythmias and to monitor the effects of therapy.

I. Concepts of Fluid and Electrolyte Balance F. Body Fluid Transport 4. Hydrostatic Pressure a. definitions b. action c. arterial side of cap. d. venous side of cap. e. excess fluid return summary

a. Hydrostatic pressure is the force exerted by the weight of a solution. OR The pressure that a fluid exerts on the walls of its container. Greatest cause of hydrostatic pressure in cardiovascular system is the force of blood on vessel walls from heart pump. b. When a difference exists in the hydrostatic pressure on two sides of a semipermeable membrane, water and diffusible solutes move out of the solution with higher hydrostatic pressure by the process of filtration. c. At the arterial end of the capillary, the hydrostatic pressure is higher than the osmotic pressure, therefore fluids and diffusible solutes move out of the capillary. d. At the venous end, osmotic pressure is higher than hydrostatic pressure, and fluids and some solutes move into the capillary e. The excess fluid and solutes remaining in the interstitial spaces are returned to the intravascular compartment by the lymph channels. SO- the artery side 'pushes' solutes out through hydrostatic pressure, and the vein side 'pulls' fluid/solutes back in through osmotic pressure.

I. Concepts of Fluid and Electrolyte Balance F. Body Fluid Transport 5. Osmolality a. definition b. how its measured c. normal plasma osmolality

a. Osmolality refers to the number of osmotically active particles per kilogram of water; it is the CONCENTRATION of a solution. b. In the body, osmolality is measures in milliosmoles (mOsm) c. The normal osmolality of plasma is 270 to 300 mOsm/kg water

I. Concepts of Fluid and Electrolyte Balance F. Body Fluid Transport 2. Osmosis a. osmotic pressure definiton b. semipermeable membrane def. c. osmosis def. d. osmotic pressure def.

a. Osmotic pressure is the force that draws the SOLVENT from a less concentrated solute through a semipermeable membrane into a more concentrated solute, thus tending to equalize the concentration of the solvent. b. If a membrane is permeable to water but not all solutes present, it is a selective or semipermeable membrane. c. Osmosis is the movement of solvent molecules across a membrane in response to a concentration gradient, usually from a solution of lower to one of higher solute concentration. d. When a more concentrated solution is on one side of a semipermeable membrane and less concentrated solution on the other, a pull called OSMOTIC PRESSURE draws the water through the membrane to the more concentrated side to equal the concentration gradient across the membrane.

I. Concepts of Fluid and Electrolyte Balance B. Body fluid compartments 3. Intracellular compartment

a. Refers to all fluid inside cells b. Most body fluid (70%) is within cells

I. Concepts of Fluid and Electrolyte Balance B. Body fluid compartments 2. Intravascular compartment

a. Refers to fluid inside a blood vessel

I. Concepts of Fluid and Electrolyte Balance B. Body fluid compartments 4. Extracellular compartment

a. Refers to fluid outside cells b. Includes interstitial fluid (fluid between cells, commits called 'third space'), blood, lymph, bone, connective tissue, water, everything other than intracellular

I. Concepts of Fluid and Electrolyte Balance G. Movement of Body Fluid 2. Isotonic solutions a. definition b. relation to body fluids c. examples of isotonic solutions

a. When solutions on both sides or semipermeable membrane have equal concentration or have reached equilibrium. b. Isotonic solutions have the same osmolality (concentration, mOsm) as body fluids. They expand only the extracellular fluid. c. 0.9% Sodium Chloride (Normal Saline) - 5% Dextrose in water (D5W)(physiologically hypotonic, dextrose quickly metabolized leaving free water) - 5% Dextrose in 0.225% saline (D5 1/4NS) - Lactated Ringer's (LR)- contains sodium, potassium, chloride, calcium. Contraindicated for hyperkalemia and lactic acidosis

III. Fluid Volume Excess (NCLEX) D. Assessment Fluid Volume Excess a. cardio b. respiratory c. neuro d. renal e. integumentary f. GI g. Labs

a. bounding increased HR, elevated BP, distended neck/hand veins, dysrhythmias b. increased RR, shallow, dyspnea, crackles c. ALOC, headache, visual disturbances, muscle weakness, paresthesias (abnormal sensation, tingling "pins and needles" d. increased urine output if kidneys can compensate, decreased urine output if kidney damage is cause e. pitting edema in dependent areas, pale cool skin f. increased motility, diarrhea, increased body weight, liver enlargement (hepatomegaly), ascites (fluid accumulation in peritoneal cavity causing swelling) g. Decreased osmolality, hematocrit, BUN, Na, specific gravity

III. Fluid Volume Excess (NCLEX) C. Causes 3. Hypotonic overhydration

a. early kidney disease b. heart failure c. Inappropriate antidiuretic hormone secretion d. poorly controlled IV therapy e. Replacement of isotonic fluid loss with hypotonic fluids f. irrigation of wounds and body cavities with hypotonic fluids

Crenation

contraction of a cell after exposure to a hypertonic solution, due to the loss of water through osmosis (water flows out of cell into vein with hypertonic solutions)

I. Concepts of Fluid and Electrolyte Balance A. Electrolytes 2. Measurement (milliequivalent)

a. the milliequivalent (mEq) is the unit of measurement that expresses the combining ability of an electrolyte. b. one mEq of any cation always reacts with one mEq of any anion c. milliequivalent provides information about the number of ions available to combine with other ions

II. Fluid Volume Deficit (NCLEX) D. Assessment 1. Fluid Volume Deficit a. cardio b. respiratory c. neuro d. renal e. integumentary f. GI g. Labs

a. thready increased HR, decreased BP, orthostatic hypotension, flat neck and hand veins in dependent positions, decreased peripheral pulses, dysrhythmias b. increased RR and depth, dyspnea c. decreased CNS activity from lethargy to coma, fever, muscle weakness d. decreased urine output e. dry skin, dry mouth, tenting f. decreased motility, diminished sounds, constipation, thirst, decreased body weight g. Increased osmolality, hematocrit, BUN, Na, specific gravity

IV. HYPONATREMIA C. Assessment a. cardio b. respiratory c. neuromuscular d. CNS e. GI f. Renal g. Integumentary h. Lab

a. vary related to vascular volume. Normovolemic- rapid HR, normal BP. Hypovolemic- thready weak pulse, rapid HR, flat veins, decreased BP. Hypervolemic- rapid bounding pulse, increase BP b. Shallow ineffective respirations is late manifestation related to muscle weakness c.diminished deep tendon reflexes, generalized muscle weakness thats worse in extremities d. headache, confusion, seizures, coma e. increased motility and hyperactive bowel sounds, nausea, abdominal cramping, diarrhea f. increased urine output g. dry mucous membranes f. serum sodium less than 135, decreased specific gravity

I. Concepts of Fluid and Electrolyte Balance (NCLEX) H. Body fluid Intake and Output 1. Body fluid intake a. ways water enters body b. amount of water from foods

a. water enters body through three sources 1. orally ingested liquid 2. water in food 3. water formed by oxidation of food b. ~10mL of water is released by metabolism of 100 calories

II. Fluid Volume Deficit B. Types if Fluid Volume Deficits 2. Hypertonic Dehydration a. description b. what happens c. what causes clinical problems

a. water loss exceeds electrolyte loss b. fluid moves from cells to ECF causing cellular dehydration and shrinkage c. Clinical problems result from alterations in concentrations of plasma/ECF electrolytes

How many lbs or kg's does a patient need to gain in a day for their doctor to be concerned?

about 3 lbs or a little over 1 kg

Overhydration

above-normal amounts of water in extracellular spaces

GI tract

absorbs water and nutrients that enter the body through this route

Ascites

accumulation of fluid in the peritoneal cavity, causing abdominal swelling

requires ATP

active transport requires what for energy

Signs?symptoms of FVE:

acute weight gain, edema, distended jugular veins, crackles, elevated CVP, shortness of breath, increased BP, bounding pulse and cough

Signs/Symptoms and Lab Findings:

acute weight loss, decreased skin turgor, oliguria, concentrated urine, weak rapid pulse, capillary filling time prolonged, low central venous pressure, low BP, flattened neck veins, dizziness, weakness, thirst, confusion, increased pulse, muscle cramps

causes of hyponatremia

adrenal insufficiency, water intoxication, SIADH, and losses by vomiting, diarrhea, sweating, and diuretics

Sources of sodium

bacon, ham, processed cheese, table salt

Sources of potassium - meats and fish

beef , cod, pork, veal

transcellular

cerebrospinal pleural peritoneal, & synovial fluids

What are the 3 ways edema can happen?

change in capillary membrane formation of interstitial fluid decreasing removal of interstitial fluid

electrolytes

charged ions capable of conducting electricity, in various concentrations and combinations (Ex: Na+Cl-, Sodium Chloride, or "salt")

Example of anions

chloride (Cl-), bicarbonate (HCO3-), phosphate (PO4-)

major anions

chloride, bicarbonate, phosphate, sulfate, proteinate ions

causes of Hypocalcemia

chronic alcoholism, chronic renal failure, Vitamin D deficiency

dysphagia

common in magnesium-depleted patients; important in assessing ability to swallo

FVE contributing factors:

compromised regulatory mechanisms, such as renal failure, heart failure, cirrhosis, over adminstration of sodium fluids, prolonged corticosteroid therapy, severe stress,

Osmolality

concentration of solutes in a solution.

FVE risk factors

heart failure, renal failure, and cirrhosis of the liver

Adrenal Glands

help the body conserve sodium, save chloride and water, and excrete potassium

Metabolic Acidosis

high potassium -low pH <7.35 -low bicarb <22 -causes: --most commonly due to renal failure -renal losses of HCO3 --GI loss of HCO3-dirrhea --indigestion -Aspirin -ETOH

The movement of fluid through capillary walls depends on

hydrostatic pressure and osmotic pressure

Hyper-osmolar imbalance is a.k.a. _________, and hypo-osmolar imbalance is a.k.a. _________.

hyper-osmolar- dehydration hypo-osmolar: over-hydration

S&S of Hypomagnesemia

hyperactive deep tendon reflexes, muscle tremors

In what IV solution does water flow out of a cell and into a vein?

hypertonic

With a hypotensive patient, what kind of solution would you want to give?

hypertonic or isotonic solution

Tonicity:

the measure of the osmotic pressure of a solution; another term for osmolality.

Active transport is...

the movement of electrolytes against a concentration gradient. For movement to occur, active transport requires energy expenditure.

Filtration is...

the movement of water and smaller particles from an area of high pressure to an area of low pressure. Hydrostatic pressure- the forces created by fluid within a closed system; it is responsible for normal circulation. Osmotic pressure- the power of a solution to draw water.

Define osmolality:

the number of osmoles (standard unit of osmotic pressure) per kg of solution. Expressed as mOsm/kg. Used more often in clinical practice than the term osmolarity to evaluate serum and urine. In addition to urea and glucose, sodium contributes the largest number of particles to osmolality.

Define Osmolarity:

the number of osmoles, the standard unit of osmotic pressure per liter of solution. It is expressed as milliosmoles per liter; describes the concentration of solutes or dissolved particles.

Define Hydrostatic Pressure:

the pressure created by the weight of fluid against the wall that contains it. In the body, hydrostatic pressure in blood vessels results from the weight of fluid itself and the force resulting from cardiac contraction.

Define Osmosis:

the process by which fluid moves across a semipermeable membrane from an area from LOW SOLUTE CONCENTRATION to an area of HIGH SOLUTE CONCENTRATION. The process continues until the solute concentrations are equal on both sides of the membrane.

hypertonic

the result of water loss greater than sodium loss -dehydration of cells

hemostasis

the stopping of blood flow, ex. clotting

causes of hyperkalemia

usually treatment related, impaired renal function, hypoaldosteronism, tissue trauma, and acidosis

Signs and symptoms of Hyperkalemia:

vague muscular weakness, tachycarda----> bradycardia, dysrhythmias, flaccid paralysis, paresthesias, intestinal colic, cramps, irritability, anxiety ECG: Tall tented T waves, prolonged PR interval and QRS duration, absent P waves, ST depression

causes of fluid volume deficit

vomiting, diarrhea, GI suctioning, sweating, decreased intake, and inability to gain access to fluid

How can sodium be lost?

vomiting, diarrhea, fistulas, or sweating, use of diuretics, low salt diet, and a deficiency of aldosterone (adrenal deficiency)

Osmosis

water passes from an area of lesser solute concentration to greater concentration until equilibrium is established

hyponatremia intervention

water restriction, sodium replacement