Ch 13 Fluid & Electrolyte SO 21 questions - Adult Nursing 2 Test 4 Thursday 4/20/2017

how do you get fluid off?

1. insulin 2. dextrose 3. calcium gluconate 4. then IV Lasix LAST

partially compensated

ALL out of range

*Know the ranges for serum electrolytes as indicated in your Brunner Textbook. Please know the serum ranges that are listed on page 246 in TABLE 13-4 Major Fluid and Electrolyte Imbalances. Some of the ranges in the chapter contradict what is in the table.*

Na: 135-145 - Sodium deficit (hyponatremia) Serum sodium <135 mEq/L - Sodium excess (hypernatremia) Serum sodium >145 mEq/L K: 3.5-5 - Potassium deficit (hypokalemia) Serum potassium <3.5 mEq/L - Potassium excess (hyperkalemia) Serum potassium >5.0 mEq/L Ca: 8.5-10.5 - Calcium deficit (hypocalcemia) Serum calcium <8.5 mg/dL - Calcium excess (hypercalcemia) Serum calcium >10.5 mg/dL Mg: 1.8-2.7 - Magnesium deficit (hypomagnesemia) Serum magnesium <1.8 mg/dL - Magnesium excess (hypermagnesemia) Serum magnesium >2.7 mg/dL P: 2.5-4.5 - Phosphorus deficit (hypophosphatemia) Serum phosphorus <2.5 mg/dL - Phosphorus excess (hyperphosphatemia) Serum phosphorus >4.5 mg/dL Cl: 96-108 - Chloride deficit (hypochloremia) Serum chloride <96 mEq/L - Chloride excess (hyperchloremia) Serum chloride >108 mEq/L

the pts K is 2.2 what should the nurse do?

Nurse should check pts EKG/ECG Also check Mg level bc it also affects the heart

Mg normal

*1.8-2.7*

Na normal

*135-145*

P normal

*2.5-4.5*

3. An 85-year-old man is brought to the hospital with a decreased fluid intake for the past 4 days and weakness. He is unable to tolerate oral fluids, so IV fluids are prescribed. What is the evidence for selecting a site for IV placement and selecting a stabilization device for this patient? What criteria would you use to assess the strength of the evidence? What is the evidence for when to change the IV site? a. What is the evidence for selecting a site for IV placement and selecting a stabilization device for this patient? Health care research is the evidence base for more comprehensive evaluation of IV placement. Current nursing research should be cited as supporting evidence. Students should review the IV guidelines, which include clinical management of complications. Students should include in their answers current nursing research regarding IV site placement and selecting a stabilization device as the evidence base and be able to discuss results, such as the following paragraphs.

- In many settings, venipuncture is an expected nursing skill, which includes selecting the appropriate venipuncture site and type of cannula and being proficient in the technique of vein entry. - The nurse should demonstrate competency in, and knowledge of, catheter placement according to the Nurse Practice Act applicable in his or her state, as well as follow organizational policies and practice guidelines of that state's board of nursing. - *The metacarpal, cephalic, basilic, and median veins and their branches are recommended sites because of their size and ease of access*. - Ideally, both arms and hands are carefully inspected before choosing a specific venipuncture site that does not interfere with mobility. - For this reason, the antecubital fossa is avoided, except as a last resort. - Cannula tips should not rest in a flexion area (e.g., the antecubital fossa), because this could inhibit the IV flow. - *The most distal site of the arm or hand is generally used first so that subsequent IV access sites can be moved progressively upward.* - Leg veins should rarely, if ever, be used because of the high risk of thromboembolism. - The patient is unable to take oral fluids; after 4 days, IV placement may be difficult. - The physician may order a PICC or midline catheter vascular access devices. - To select the ideal product for use, the nurse must consider the patient's age and condition, the setting, and the prescribed therapy. - Firmly anchoring the IV cannula to prevent to-and-fro motion (e.g., a catheter stabilization device will help). - Sutureless securement devices avoid disruption around the catheter entry site and may decrease the degree of bacterial contamination.

*Heart and Blood Vessel Functions*

- 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

*know the difference b/w fluids*

1. ICF (fluid in the cells): 2/3 of body fluid, is located primarily in the skeletal muscle mass 2. ECF (fluid outside the cells): 1/3 of body fluid is in this compartment; plasma [intravascular fluid] & interstitial fluid

d. How would your priorities, approach, and techniques differ if the patient is in *metabolic alkalosis*?

As with the previous examples, the priority for acute and chronic metabolic alkalosis is aimed at correcting the underlying acid-base disorder - Because of volume depletion from GI loss, the nurse needs to monitor the patient's fluid I&O carefully. - The nurse would assist with restoring normal fluid volume by administering sodium chloride fluids and KCl. - H2 receptor antagonists, such as cimetidine (Tagamet), may be administered to reduce the production of gastric HCl. - Carbonic anhydrase inhibitors are useful in treating metabolic alkalosis in patients who cannot tolerate rapid volume expansion (e.g., patients with heart failure).

major anions in body fluid

Cl Bicarbonate P Sulfate Proteinate ions

*Extravasation!*

Caustic damage to tissue - is similar to infiltration, with an inadvertent administration of vesicant or irritant solution or medication into the surrounding tissue. Medications such as vasopressors, potassium and calcium preparations, and chemotherapeutic agents can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis of tissues can occur. Older patients, comatose or anesthetized patients, patients with diabetes, and patients with peripheral vascular or cardiovascular disease are at greater risk for extravasation; other risk factors include high pressure infusion pumps, palpable cording of vein, and fluid leakage from the insertion site. The extent of tissue damage is determined by the concentration of the medication, the quantity that extravasated, the location of the infusion site, the tissue response, and the duration of the process of extravasation. - when this occurs, the infusion must be stopped and the provider notified promptly. The agency's protocol to treat extravasation is initiated; the protocol may specify specific treatments, including antidotes specific to the medication that extravasated, and may indicate whether the IV line should remain in place or be removed before treatment. The protocol often specifies infiltration of the infusion site with an antidote prescribed after assessment by the provider, removal of the cannula, and application of warm compresses to sites of extravasation from alkaloids or cold compresses to sites of extravasation from alkylating and antibiotic vesicants. The affected extremity should not be used for further cannula placement. Thorough neurovascular assessments of the affected extremity must be performed frequently. - Reviewing the institution's IV policy and procedures and incompatibility charts and checking with the pharmacist before administering any IV medication, whether peripherally or centrally, are recommended to determine incompatibilities and vesicant potential to prevent extravasation. Careful, frequent monitoring of the IV site, avoiding insertion of IV devices in areas of flexion, securing the IV line, and using the smallest catheter possible that accommodates the vein help minimize the incidence and severity of this complication. In addition, when vesicant medication is administered by IV push, it should be given through a side port of an infusing IV solution to dilute the medication and decrease the severity of tissue damage if extravasation occurs. Extravasation is rated as grade 4 on the infiltration scale. Complications of an extravasation may include blister formation, skin sloughing and tissue necrosis, functional or sensory loss in the injured area, and disfigurement or loss of

Detecting and Controlling Hypervolemia

It is important to detect FVE before the condition becomes severe - Interventions include promoting rest, restricting Na intake, monitoring parenteral fluid therapy, and administering appropriate medications. - Regular rest periods may be beneficial, because bed rest favors diuresis of fluid. - The mechanism is related to diminished venous pooling and the subsequent increase in effective circulating blood volume and renal perfusion. - *Sodium and fluid restriction* should be instituted as indicated. - Because most patients with FVE require diuretics, the patient's response to these agents is monitored. - The rate of parenteral fluids and the patient's response to these fluids are also closely monitored. - If dyspnea or orthopnea is present, the patient is placed in a *semi-Fowler's position* to promote lung expansion. - *The patient is turned and repositioned at regular intervals because edematous tissue is more prone to skin breakdown than normal tissue!* - Because conditions predisposing to FVE are likely to be chronic, patients are taught to monitor their response to therapy by documenting fluid I&O and body weight changes. The importance of adhering to the treatment regimen is emphasized.

major cations in body fluid

Na K Ca Mg H ions

*Hypotonic Fluids* - 0.45% NaCl

One purpose of hypotonic solutions is to replace cellular fluid, because it is hypotonic compared with plasma. - Another is to provide free water for excretion of body wastes. - At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. - Half-strength saline (0.45% sodium chloride) solution is frequently used - Multiple-electrolyte solutions are also available - Excessive infusions of hypotonic solutions can lead to intravascular fluid depletion, decreased blood pressure, cellular edema, and cell damage. These solutions exert less osmotic pressure than the ECF.

*I have also added to the enrichment the information on the hypertonic, hypotonic, and isotonic fluids. The information I gave in class was incorrect. Since I am correcting that information you will be responsible for the information attached on the enrichment. Pg. 273*

Solutions are often categorized as isotonic, hypotonic, or hypertonic, according to whether their total osmolality is the same as, less than, or greater than that of blood, respectively (see earlier discussion of osmolality). - Electrolyte solutions are considered isotonic if the total electrolyte content (anions + cations) is between 250 and 375 mEq/L hypotonic if the total electrolyte content is less than 250 mEq/L hypertonic if the total electrolyte content is greater than 375 mEq/. - The nurse must also consider a solution's osmolality, keeping in mind that the osmolality of plasma is approximately 300 mOsm/L (300 mmol/L). - Example: a 10% dextrose solution has an osmolality of approximately 505 mOsm/L.

When planning care for adult patients, which oral intake is adequate to meet daily fluid needs of a stable patient? a. 500 to 1500 mL b. 1200 to 2200 mL c. 2000 to 3000 mL d. 3000 to 4000 mL

c. 2000 to 3000 mL Daily fluid intake and output is usually 2000 to 3000 mL. This is sufficient to meet the needs of the body and replace both sensible and insensible fluid losses. These would include urine output and fluids lost through the respiratory system, skin, and GI tract.

diffusion

the process by which solutes move from an area of HIGHER concentration to one of LOWER concentration; does not require expenditure of energy

K normal

*3.5-5*

Ca normal

*8.5-10.5*

Cl normal

*96-108*

*Identify the normal values for arterial and mixed venous bloods in an Arterial Blood Gas. See Pg 271 TABLE 13-7 Normal Values for Arterial and Mixed Venous Bloods.* Parameter - Arterial Blood - Mixed Venous Blood

*pH: 7.35-7.45* ...........................................7.32-7.42 *PCO2: 35-45 mm Hg*...............38-52 mm Hg *HCO3- : 22-26 mEq/L*................19-25 mEq/L PO2 *: >80 mm Hg....................24-48 mm Hg Base excess/deficit : ±2 mEq/L.......±5 mEq/L Oxygen saturation (SaO2%): >94% 65%-75%

*Pituitary Functions* hypothalamus-ADh

- The *hypothalamus manufactures ADH*, which is *stored in the posterior pituitary gland* and released as needed to *conserve water* - Functions of ADH include maintaining the osmotic pressure of the cells by controlling the retention or excretion of water by the kidneys and by regulating blood volume. - *Pt will be really thirsty with even just 2% weight loss!*

ECF compartment divisions

1. intravascular space 2. interstitial space 3. transcellular space

What nursing interventions are implemented for patients with fluid volume deficit (FVD) and fluid volume excess (FVE)?

Monitor *I & Os* & daily weights

d. What IV fluids would you anticipate being prescribed? Give the rationale for their use.

The nurse could anticipate *isotonic electrolyte solutions (e.g., lactated Ringer's solution, 0.9% sodium chloride)* are frequently prescribed as the first-line choice to treat the hypotensive patient with FVD because they expand plasma volume - As soon as the patient becomes normotensive, a *hypotonic electrolyte solution (e.g., 0.45% sodium chloride)* is often used to provide both electrolytes and water for renal excretion of metabolic wastes. - Clinicians consider a hypotonic sodium solution to be safer than D5W, because it allows a gradual reduction in the serum sodium level, thereby decreasing the risk of cerebral edema. - *It is the solution of choice in severe hyperglycemia with hypernatremia!* - In this scenario, the patient might receive a hypotonic solution, such as 0.45 normal saline solution initially; the aim would be to improve her BP while not increasing her serum sodium or potassium levels using 0.9 NS or lactated Ringer's. Her glucose is already high, so a dextrose solution should be avoided. She may also need a colloid solution if she has significant blood loss.

b. How would your priorities, approach, and techniques differ if the patient is in *respiratory acidosis*?

The nursing priority is to improve the patient's ventilation. For example, the nurse might administer pharmacologic agents, such as bronchodilators, to help reduce bronchial spasm, antibiotics for respiratory infections, and thrombolytics or anticoagulants for pulmonary emboli. The nurse would encourage pulmonary hygiene and adequate hydration. Supplemental oxygen is administered; mechanical ventilation may be necessary. Placing the patient in a semi-Fowler's position facilitates expansion of the chest wall.

ascites

a type of edema in which fluid accumulates in the peritoneal cavity

Which serum potassium result best supports the rationale for administering a stat dose of potassium chloride 20 mEq in 250 mL of normal saline over 2 hours? a. 3.1 mEq/L b. 3.9 mEq/L c. 4.6 mEq/L d. 5.3 mEq/L

a. 3.1 mEq/L The normal range for serum potassium is 3.5 to 5.0 mEq/L. This IV order provides a substantial amount of potassium. Thus the patient's potassium level must be low. The only low value shown is 3.1 mEq/L.

When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress, and the vital signs show hypotension and tachycardia. What is the nurse's priority action? a. Administer oxygen. b. Notify the physician. c. Rapidly administer more IV fluid. d. Reposition the patient to the right side.

a. Administer oxygen. The cap off the central line could allow entry of air into the circulation. For an air emboli, oxygen is administered; the catheter is clamped; the patient is positioned on the left side with the head down. Then the physician is notified.

*The dehydrated patient is receiving a hypertonic solution. What assessments must be done to avoid risk factors of these solutions (select all that apply)?* a. Lung sounds b. Bowel sounds c. Blood pressure d. Serum sodium level e. Serum potassium level

a. Lung sounds c. Blood pressure d. Serum sodium level BP, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions.

*The patient has chronic kidney disease and ate a lot of nuts, bananas, peanut butter, and chocolate. The patient is admitted with loss of deep tendon reflexes, somnolence, and altered respiratory status. What treatment should the nurse expect for this patient?* a. Renal dialysis b. IV potassium chloride c. IV furosemide (Lasix) d. IV normal saline at 250 mL per hour

a. Renal dialysis Renal dialysis will need to be administered to remove the excess magnesium that is in the blood from the increased intake of foods high in magnesium. If renal function was adequate, IV potassium chloride would oppose the effects of magnesium on the cardiac muscle. IV furosemide and increased fluid would increase urinary output which is the major route of excretion for magnesium.

*While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient?* a. Weakness b. Paresthesia c. Facial spasms d. Muscle tremors

a. Weakness *Signs of hypercalcemia are lethargy, headache, weakness, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.*

*geri considerations R/T FVD!*

assessment of *skin turgor is NOT as valid in older adults because the skin has lost some of its elasticity*; therefore, other assessment measures (e.g., slowness in filling of veins of the hands and feet) become more useful in detecting FVD - *nurse should recognize that some older patients deliberately restrict their fluid intake to avoid embarrassing episodes of incontinence!* - nurse identifies interventions to deal with the incontinence, such as *encouraging the patient to wear protective clothing or devices, to carry a urinal in the car, or to pace fluid intake to allow access to toilet facilities during the day*. - Older people without cardiovascular or renal dysfunction should be reminded to drink adequate fluids, particularly in very warm or humid weather.

*A 22-year-old male is admitted to the emergency department with a stab wound to the abdomen. The patient's vital signs are blood pressure 82/56 mm Hg, pulse 132 beats/minute, respirations 28 breaths/minute, and temperature 97.9° F (36.6° C). Which fluid, if ordered by the health care provider, should the nurse question?* a. 0.9% saline b. 0.45% saline c. Packed red blood cells d. Lactated Ringer's solution

b. 0.45% saline IV administration of 0.45% saline is hypotonic and is used for maintenance fluid replacement and dilutes the extracellular fluid. Intravenous solutions used for volume expansion for hypovolemic shock include lactated Ringer's solution and 0.9% saline. If hypovolemia is due to blood loss, blood may be administered.

The patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. What IV solution may be used to pull fluid into the intravascular space after the paracentesis? a. 0.9% sodium chloride b. 25% albumin solution c. Lactated Ringer's solution d. 5% dextrose in 0.45% saline

b. 25% albumin solution After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer's, and 5% dextrose in 0.45% saline will not be effective for this action.

*A 50-year-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should be questioned by the nurse?* a. Limit foods high in potassium b. Spironolactone (Aldactone) daily c. Calcium gluconate IV piggyback d. Administer intravenous insulin and glucose

b. Spironolactone (Aldactone) daily Spironolactone (Aldactone) is a potassium-sparing diuretic that inhibits the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss. Spironolactone is contraindicated in a patient with hyperkalemia (serum potassium >5.0 mEq/L). Collaborative management for patients with hyperkalemia may include *limiting foods high in potassium, IV insulin and glucose, administration of calcium gluconate, potassium-wasting diuretics (e.g., furosemide [Lasix]), hemodialysis, sodium polystyrene sulfonate (Kayexalate), and IV fluid administration.*

Hematoma

results when blood leaks into tissues surrounding the IV insertion site. - Leakage can result if the opposite vein wall is perforated during venipuncture, the needle slips out of the vein, a cannula is too large for the vessel, or insufficient pressure is applied to the site after removal of the needle or cannula. - s/s: *ecchymosis, immediate swelling at the site, and leakage of blood at the insertion site* - Treatment includes removing the needle or cannula and applying light pressure with a sterile, dry dressing; applying ice for 24 hours to the site to avoid extension of the hematoma; elevating the extremity to maximize venous return, if tolerated; assessing the extremity for any circulatory, neurologic, or motor dysfunction; and restarting the line in the other extremity if indicated. - can be prevented by carefully inserting the needle and by using diligent care with patients who have a bleeding disorder, are taking anticoagulant medication, or have advanced liver disease.

Potassium Deficit (Hypokalemia)

serum potassium level below 3.5 mEq/L [3.5 mmol/L], usually indicates a deficit in total potassium stores. However, it may occur in patients with normal potassium stores: When alkalosis is present, a temporary shift of serum potassium into the cells occurs - Potassium-losing diuretics, such as the thiazides and loop diuretics, can induce hypokalemia. Other medications that can lead to hypokalemia include corticosteroids, sodium penicillin, carbenicillin, and amphotericin B. GI loss of potassium is another common cause of potassium depletion. Vomiting and gastric suction frequently lead to hypokalemia, partly because potassium is actually lost when gastric fluid is lost and because potassium is lost through the kidneys in response to metabolic alkalosis. Because relatively large amounts of potassium are contained in intestinal fluids, potassium deficit occurs frequently with diarrhea, which may contain as much potassium as 30 mEq/L. Potassium deficit also occurs from prolonged intestinal suctioning, recent ileostomy, and villous adenoma (a tumor of the intestinal tract characterized by excretion of potassium-rich mucus). - Patients who do not eat a normal diet for a prolonged period are at risk for hypokalemia. This may occur in debilitated older people and in patients with alcoholism or anorexia nervosa. In addition to poor intake, people with bulimia frequently suffer increased potassium loss through self-induced vomiting, misuse of laxatives, diuretics, and enemas. Magnesium depletion causes renal potassium loss and must be corrected first; otherwise, urine loss of potassium will continue. - Potassium deficiency can result in widespread derangements in physiologic function. Severe hypokalemia can cause death through cardiac or respiratory arrest. Clinical signs develop when the potassium level decreases to less than 3 mEq/L (3 mmol/L). If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine (resulting in polyuria, nocturia) and excessive thirst. Potassium depletion suppresses the release of insulin and results in glucose intolerance. - Hypokalemia increases sensitivity to digitalis, predisposing the patient to digitalis toxicity at lower digitalis levels. Metabolic alkalosis is commonly associated with hypokalemia. This is discussed further in the section on acid-base disturbances in this chapter. - The source of the potassium loss is usually evident from a careful history. However, if the cause of the loss is unclear, a 24-hour urinary potassium excretion test can be performed to distinguish between renal and extrarenal loss. Urinary potassium excretion exceeding 20 mEq/day with hypokalemia suggests that renal potassium loss is the cause. - If hypokalemia cannot be prevented by conventional measures such as increased intake in the daily diet or by oral potassium supplements for deficiencies, then it is treated cautiously with IV replacement therapy. Potassium loss must be corrected daily; administration of 40 to 80 mEq/day of potassium is adequate in the adult if there are no abnormal losses of potassium. h. For patients who are at risk for hypokalemia, a diet containing sufficient potassium should be provided. Dietary intake of potassium in the average adult is 50 to 100 mEq/day. Foods high in potassium include most fruits and vegetables, legumes, whole grains, milk, and meat - When dietary intake is inadequate for any reason, oral or IV potassium supplements may be prescribed. Many salt substitutes contain 50 to 60 mEq of potassium per teaspoon and may be sufficient to prevent hypokalemia. If oral administration of potassium is not feasible, the IV route is indicated. The IV route is mandatory for patients with severe hypokalemia (e.g., serum level of 2 mEq/L). Although potassium chloride (KCl) is usually used to correct potassium deficits, potassium acetate or potassium phosphate may be prescribed. - Because hypokalemia can be life threatening, the nurse needs to monitor for its early presence in patients at risk. Fatigue, anorexia, muscle weakness, decreased bowel motility, paresthesias, and dysrhythmias are signals that warrant assessing the serum potassium concentration. When available, the ECG may provide useful information. - Example: patients receiving digitalis who are at risk for potassium deficiency should be monitored closely for signs of digitalis toxicity, because hypokalemia potentiates the action of digitalis. - Prevention may involve encouraging the patient at risk to eat foods rich in potassium (when the diet allows). Sources of potassium include *fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains*. If the hypokalemia is caused by abuse of laxatives or diuretics, patient education may help alleviate the problem. Part of the health history and assessment should be directed at identifying problems that are amenable to prevention through education. Careful monitoring of fluid I&O is necessary, because 40 mEq of potassium is lost for every liter of urine output. The ECG is monitored for changes, and arterial blood gas values are checked for elevated bicarbonate and pH levels. - The oral route is ideal to treat mild to moderate hypokalemia because oral potassium supplements are absorbed well. Care should be exercised when administering potassium, particularly in older adults, who have lower lean body mass and total body potassium levels and therefore lower potassium requirements. In addition, because of the physiologic loss of renal function with advancing years, potassium may be retained more readily in older than in younger people. - Quality and Safety Nursing Alert: *Oral potassium supplements can produce small bowel lesions; therefore, the patient must be assessed for and cautioned about abdominal distention, pain, or GI bleeding.* - Potassium should be administered only after adequate urine output has been established. A decrease in urine volume to less than 20 mL per hour for 2 consecutive hours is an indication to stop the potassium infusion until the situation is evaluated. Potassium is primarily excreted by the kidneys; when oliguria occurs, potassium administration can cause the serum potassium concentration to rise dangerously. - Quality and Safety Nursing Alert: *Potassium is NEVER administered by IV push or intramuscularly to avoid replacing potassium too quickly. IV potassium must be administered using an infusion pump.* - Each health care facility has its own policy for the administration of potassium, which must be consulted. Administration of IV potassium is done with extreme caution using an infusion pump with the patient monitored by continuous ECG. Caution must be used when selecting a premixed solution of IV fluid containing KCl, as the concentrations range from 10 to 40 mEq/100 mL. Renal function should be monitored through BUN and creatinine levels and urine output if the patient is receiving potassium replacement. During replacement therapy, the patient is monitored for signs of worsening hypokalemia as well as hyperkalemia. *IV POTASSIUM BURNS!*

*osmosis!*

the process by which fluid moves across a semipermeable membrane from an area of 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 - When 2 different solutions are separated by a membrane that is impermeable to the dissolved substances, *fluid shifts through the membrane from the region of low solute concentration to the region of high solute concentration until the solutions are of equal concentration!* - The magnitude of this force depends on the # of particles dissolved in the solutions, NOT on their weights. - The number of dissolved particles contained in a unit of fluid determines the *osmolality* of a solution, which influences the movement of fluid b/w the fluid compartments - 3 other terms are associated with osmosis: osmotic pressure oncotic pressure osmotic diuresis

Educating Patients About Edema

*Avoid sweet or dry food because it increases thirst!!!* - Because edema is a common manifestation of FVE, patients need to recognize its symptoms and understand its importance. The nurse gives special attention to edema when instructing the patient with FVE. Edema can occur as a result of increased capillary fluid pressure, decreased capillary oncotic pressure, or increased interstitial oncotic pressure, causing expansion of the interstitial fluid compartment. Edema can be localized (e.g., in the ankle, as in rheumatoid arthritis) or generalized (as in cardiac and renal failure). Severe generalized edema is called anasarca. - Edema occurs when there is a change in the capillary membrane, increasing the formation of interstitial fluid or decreasing the removal of interstitial fluid. Sodium retention is a frequent cause of the increased ECF volume. Burns and infection are examples of conditions associated with increased interstitial fluid volume. Obstruction to lymphatic outflow, a plasma albumin level less than 1.5 to 2 g/dL, or a decrease in plasma oncotic pressure contributes to increased interstitial fluid volume. The kidneys retain sodium and water when there is decreased ECF volume as a result of decreased cardiac output from heart failure. A thorough medication history is necessary to identify any medications that could cause edema, such as nonsteroidal anti-inflammatory drugs (NSAIDs), estrogens, corticosteroids, and antihypertensive agents. - Ascites is a type of edema in which fluid accumulates in the peritoneal cavity; it results from nephrotic syndrome, cirrhosis, and some malignant tumors. The patient commonly reports shortness of breath and a sense of pressure because of pressure on the diaphragm. - The goal of treatment is to preserve or restore the circulating intravascular fluid volume. Thus, in addition to treating the cause of the edema, other treatments may include diuretic therapy, restriction of fluids and sodium, elevation of the extremities, application of anti-embolism stockings, paracentesis, dialysis, and continuous renal replacement therapy in cases of renal failure or life-threatening fluid volume overload

*Which electrolyte imbalance would require ECG/EKG monitoring*

*Hypokalemia* but also hyperkalemia, hypomagnesemia, hypermagnesemia, hypocalcemia, hypercalcemia

skin

*Sensible perspiration* refers to visible water and electrolyte loss through the skin (sweating) - The chief solutes in sweat are sodium, chloride, and potassium - Actual sweat losses can vary from 0 to 1,000 mL or more every hour, depending on factors such as the environmental temperature - Continuous water loss by evaporation (approximately 500 mL/day) occurs through the skin as insensible perspiration, a nonvisible form of water loss - Fever greatly increases insensible water loss through the lungs and the skin, as does the loss of the natural skin barrier (e.g., through major burns)

*kidney functions*

*Vital to the regulation of F & E balance!* - they normally filter 180 L of plasma every day in the adult and excrete 1 to 2 L of urine - They act both autonomously and in response to bloodborne messengers, such as aldosterone and antidiuretic hormone (ADH) - Major functions in maintaining normal fluid balance include the following: 1. Regulation of ECF volume and osmolality by selective retention and excretion of body fluids 2. Regulation of normal electrolyte levels in the ECF by selective electrolyte retention and excretion 3. Regulation of pH of the ECF by retention of hydrogen ions 4. Excretion of metabolic wastes and toxic substances - Given these functions, failure results in multiple fluid and electrolyte abnormalities - The usual daily urine volume in the adult is 1 to 2 L. - A general rule is that the output is approximately 1 mL of urine per kilogram of body weight per hour (1 mL/kg/h) in all age groups

*Identify how the body compensates for respiratory or metabolic disturbances*

- !The lungs compensate for metabolic disturbances by changing CO2 excretion!* - *The kidneys compensate for respiratory disturbances by altering bicarbonate retention and H+ secretion!* - The lungs, under the control of the medulla, control the CO2 and thus the carbonic acid content of the ECF. They do so by adjusting ventilation in response to the amount of CO2 in the blood. A rise in the partial pressure of CO2 in arterial blood (PaCO2) is a powerful stimulant to respiration. Of course, the partial pressure of oxygen in arterial blood (PaO2) also influences respiration. However, its effect is not as marked as that produced by the PaCO2. - The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. In respiratory and metabolic alkalosis, the kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. The kidneys obviously cannot compensate for the metabolic acidosis created by renal failure. Renal compensation for imbalances is relatively slow (a matter of hours or days). - In metabolic acidosis, the respiratory rate increases, causing greater elimination of CO2 (to reduce the acid load). - In metabolic alkalosis, the respiratory rate decreases, causing CO2 to be retained (to increase the acid load) - Plasma pH is an indicator of hydrogen ion (H+) concentration and measures the acidity or alkalinity of the blood. Homeostatic mechanisms keep pH within a normal range (7.35 to 7.45). These mechanisms consist of buffer systems, the kidneys, and the lungs. The H+ concentration is extremely important: The greater the concentration, the more acidic the solution and the lower the pH. The lower the H+ concentration, the more alkaline the solution and the higher the pH. The pH range compatible with life (6.8 to 7.8) represents a 10-fold difference in H+ concentration in plasma. - Buffer systems prevent major changes in the pH of body fluids by removing or releasing H+; they can act quickly to prevent excessive changes in H+ concentration. Hydrogen ions are buffered by both intracellular and extracellular buffers. The body's major extracellular buffer system is the bicarbonate-carbonic acid buffer system, which is assessed when arterial blood gases are measured. Normally, there are 20 parts of bicarbonate (HCO3-) to one part of carbonic acid (H2CO3). If this ratio is altered, the pH will change. It is the ratio of HCO3- to H2CO3 that is important in maintaining pH, not absolute values. CO2 is a potential acid; when dissolved in water, it becomes carbonic acid (CO2 + H2O = H2CO3). Therefore, when CO2 is increased, the carbonic acid content is also increased, and vice versa. If either bicarbonate or carbonic acid is increased or decreased so that the 20:1 ratio is no longer maintained, acid-base imbalance results. - Less important buffer systems in the ECF include the inorganic phosphates and the plasma proteins. Intracellular buffers include proteins, organic and inorganic phosphates, and, in red blood cells, hemoglobin.

*Adrenal Functions* Aldosterone, Cortisol

- *Aldosterone*, a mineralocorticoid secreted by the zona glomerulosa (outer zone) of the adrenal cortex, has a profound effect on fluid balance - Increased secretion of aldosterone causes sodium retention (and thus water retention) and potassium loss - Conversely, decreased secretion of aldosterone causes sodium and water loss and potassium retention. - *Cortisol*, another adrenocortical hormone, has less mineralocorticoid action. - However, when secreted in large quantities (or administered as corticosteroid therapy), it can also produce Na and fluid retention.

*Compartment Mechanisms*

- Changes in the volume of the interstitial compartment within the ECF can occur without affecting body function - However, the vascular compartment cannot tolerate change as readily and must be carefully maintained to ensure that tissues receive adequate nutrients.

pharm therapy R/T FVE

- Diuretics are prescribed when dietary restriction of Na alone is insufficient to reduce edema by inhibiting the 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 the potency of the diuretic - thiazide diuretics block Na reabsorption in the distal tubule, where only 5% to 10% of filtered Na is reabsorbed - loop diuretics, such as *furosemide (Lasix)!*, bumetanide (Bumex), or torsemide (Demadex), can cause a greater loss of both Na and water because they block sodium reabsorption in the ascending limb of Henle's loop, where 20% to 30% of filtered sodium is normally reabsorbed - generally, thiazide diuretics, such as hydrochlorothiazide (HydroDIURIL) or chlorthalidone (Thalitone), are prescribed for mild to moderate hypervolemia and loop diuretics for severe hypervolemia - K supplements

correcting hyperkalemia

- It is possible to exceed the tolerance for potassium if administered rapidly by the IV route. Therefore, care is taken to administer and monitor potassium solutions closely. Particular attention is paid to the solution's concentration and rate of administration. IV administration is via an infusion pump. - The nurse must caution patients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. In addition, potassium-conserving diuretics such as spironolactone (Aldactone), triamterene (Dyrenium), and amiloride (Midamor), potassium supplements, and salt substitutes should not be administered to patients with renal dysfunction. - Quality and Safety Nursing Alert: *Potassium supplements are extremely dangerous for patients who have impaired renal function and thus decreased ability to excrete potassium. Even more dangerous is the IV administration of potassium to such patients, because serum levels can rise very quickly. Aged (stored) blood should not be administered to patients with impaired renal function, because the serum potassium concentration of stored blood increases due to red blood cell deterioration. It is possible to exceed the renal tolerance of any patient with rapid IV potassium administration, as well as when large amounts of oral potassium supplements are ingested.*

mgmt of hyponatremia *VS are #1*

- Na replacement, water restriction, & pharm therapy - The nurse needs to identify and monitor patients at risk for hyponatremia. The nurse monitors fluid I&O as well as daily body weight. - Early detection and treatment are necessary to prevent serious consequences. For patients at risk, the nurse closely monitors *fluid I&O as well as daily body weight*. It is also necessary to monitor laboratory values (i.e., sodium) and be alert for GI manifestations such as anorexia, nausea, vomiting, and abdominal cramping. The nurse must be alert for *CNS changes*, such as lethargy, confusion, muscle twitching, and seizures. *Neurologic signs* are associated with very low sodium levels that have fallen rapidly because of fluid overloading. Serum sodium is monitored very closely in patients who are at risk for hyponatremia; when indicated, urine sodium and specific gravity are also monitored. - Quality and Safety Nursing Alert: *When administering fluids to patients with cardiovascular disease, the nurse assesses for signs of circulatory overload (e.g., cough, dyspnea, puffy eyelids, dependent edema, weight gain in 24 hours). The lungs are auscultated for crackles.* - Quality and Safety Nursing Alert: *Highly hypertonic sodium solutions (2% to 23% sodium chloride) should be administered slowly and the patient monitored closely, because only small volumes are needed to elevate the serum Na concentration from a dangerously low level*

Preventing Hypervolemia

- Specific interventions vary with the underlying condition and the degree of FVE. - However, most patients require *sodium-restricted diets* in some form, and adherence to the prescribed diet is encouraged. - Patients are instructed to avoid over-the-counter (OTC) medications without first checking with a health care provider, because these substances may contain sodium. - If fluid retention persists despite adherence to a prescribed diet, hidden sources of Na, such as the water supply or use of water softeners, should be considered.

*Parathyroid Functions* PTH

- The parathyroid glands, embedded in the thyroid gland, regulate *calcium and phosphate balance by means of parathyroid hormone (PTH)* - PTH influences *bone reabsorption, calcium absorption from the intestines, and calcium reabsorption from the renal tubules*

*Lung Functions*

- Through exhalation, the lungs remove approximately 300 mL of water daily in the normal adult. - Abnormal conditions, such as hyperpnea (abnormally deep respiration) or continuous coughing, increase this loss; mechanical ventilation with excessive moisture decreases it. - The lungs also play a major role in maintaining acid-base balance. - The lungs normally eliminate water vapor (insensible loss) at a rate of approximately 300 mL every day. - The loss is much greater with increased respiratory rate or depth, or in a dry climate.

ECF

- transports electrolytes such as enzymes and hormones - Na ions far outnumber other cations in the ECF bc of this *Na is important in regulating the volume of body fluid* - *has a low concentration of K and can tolerate only small changes in K concentrations*, so release of large stores of intracellular K (typically caused by trauma to the cells and tissues) can be extremely dangerous

CHART 13-6 Assessment Assessing for Phlebitis Grade - Clinical Criteria

0 - No clinical symptoms 1 - Erythema at access site with or without pain 2 - Pain at access site Erythema, edema, or both 3 - Pain at access site Erythema, edema, or both Streak formation Palpable venous cord (1 inch or shorter) 4 - *Pain at access site with erythema, Streak formation, Palpable venous cord (longer than 1 inch), Purulent drainage*

CHART 13-5 Assessment Assessing for Infiltration Grade - Clinical Criteria 4 is very bad

0 - No clinical symptoms 1 - Skin blanched, edema <1 inch in any direction, cool to touch, with or without pain 2 - Skin blanched, edema 1-6 inches in any direction, cool to touch, with or without pain 3 - Skin blanched, translucent, gross edema >6 inches in any direction, cool to touch, mild to moderate pain, possible numbness 4 - *Skin blanched, translucent, skin tight, leaking, skin discolored, bruised, swollen, gross edema >6 inches in any direction, deep pitting tissue edema, circulatory impairment, moderate to severe pain, infiltration of any amount of blood products, irritant, or vesicant*

c. Outline the nursing plan of care to address the patient's fluid and electrolyte or acid-base disorders. Give the rationale for the nursing interventions for this patient. The patient's oxygenation status is of primary concern, which impacts the acid-base balance. A nursing plan of care for this patient should address fluid and electrolyte status, as well as acid-base disorders. Possible nursing interventions with rationales include:

1. Assess the oxygenation status, including ABGs, pulse oximetry, respiratory rate and effort, as well as the level of consciousness. Rationale: Increasing hypoxemia and hypercapnia will eventually lead to respiratory failure. 2. Encourage adequate ventilation with pursed lip breathing. Rationale: The best solution to improve respiratory acidosis is to treat the cause for hypoventilation. 3. Administer bronchodilators as prescribed. Rationale: Improving the gas exchange will decrease the PaCO2, decrease H+, and increase oxygen. 4. Administer antibiotics, as prescribed. Rationale: The productive cough suggests a respiratory infection. 5. Administer supplemental oxygen as prescribed. Rationale: Although the drive to breathe by the patient with COPD is driven by CO2, oxygen is not withheld for hypoxemic patients. 6. Position the patient in a semi-Fowler's position. Rationale: This position facilitates chest wall expansion. 7. Ensure patent IV access. Rationale: In the event of an emergency, the nurse will need IV access to administer medications.

Ideally, both arms and hands are carefully inspected before a specific venipuncture site that does not interfere with mobility is chosen. For this reason, the antecubital fossa is avoided, except as a last resort. *The most distal site of the arm or hand is generally used first so that subsequent IV access sites can be moved progressively upward*. The following factors should be considered when selecting a site for venipuncture:

1. Condition of the vein 2. Type of fluid or medication to be infused 3. Duration of therapy 4. Patient's age, size, and activity level 5. Whether the patient is right- or left-handed 6. Patient's medical history and current health status 7. Setting in which the therapy will take place i. Hand veins are easiest to cannulate. Cannula tips should not rest in a flexion area (e.g., the antecubital fossa), because this could inhibit the IV flow j. Except in emergency situations, the patient should be prepared in advance for an IV infusion. The venipuncture, the expected length of infusion, and activity restrictions are explained. If the patient requires alternative formats (e.g., interpreter, large-print written materials) to understand the procedure, they should be provided. Then the patient should have an opportunity to ask questions and express concerns. For example, some patients believe that they will die if small bubbles in the tubing enter their veins. After acknowledging this fear, the nurse can explain that usually only relatively large volumes of air administered rapidly are dangerous. k. Quality and Safety Nursing Alert: The nurse must assess the patient for a history of allergic reactions to medications. Although obtaining drug allergy information is important when administering any medication, it is especially critical with IV administration, because the medication is delivered directly into the bloodstream.

b. What actions and interventions are indicated? Essential nursing actions and interventions include the following:

1. Hourly I&Os, vital signs every 15 to 30 minutes, central venous pressure monitoring, level of consciousness, and breath sounds should be performed to determine when IV therapy should be slowed to avoid volume overload. 2. Skin and tongue turgor are monitored on a regular basis to reflect perfusion and hydration. 3. A fluid challenge test might be helpful to determine fluid volume loss versus renal impairment. An example of a typical fluid challenge involves administering 100 to 200 mL of normal saline solution over 15 minutes. Rate of fluid administration is based on the severity of loss and the patient's hemodynamic response to volume replacement. 4. Cardiac monitoring would be important due to the patient's electrolyte imbalances (e.g., potassium). 5. ABG analysis may reveal both a metabolic and respiratory acidosis. Correcting the acidosis helps correct the hyperkalemia. 6. When measuring vital signs, an apical pulse should be taken (Crawford & Harris, 2011b). 7. The presence of paresthesias and GI symptoms, such as nausea and intestinal colic, are noted. 8. Serum potassium levels and glucose should be redrawn. If potassium continues to rise, a *cation exchange resins (e.g., sodium polystyrene sulfonate [Kayexalate]) may be necessary* 9. Renal function should be monitored through BUN and creatinine levels and urine output

*Gerontologic Considerations in fluid and electrolyte changes*

1. Normal physiologic changes of aging, including *reduced cardiac, renal, and respiratory function* and reserve and alterations in the ratio of body fluids to muscle mass, may alter the responses of older people to fluid and electrolyte changes and acid-base disturbances. 2. Decreased respiratory function can cause impaired pH regulation in older adults with major illness or trauma. 3. Renal function declines with age, as do muscle mass and daily exogenous creatinine production, so high-normal and minimally elevated serum Cr values may indicate substantially reduced renal function in older adults 3. Bc of a decrease in age-related muscle mass, older people have a lower concentration of body fluid that may alter physiologic responses. 4. use of multiple medications by older adults can affect renal and cardiac function, thereby increasing the likelihood of fluid and electrolyte disturbances 5. routine procedures, such as the vigorous administration of laxatives or enemas before colon x-ray studies, may produce a serious FVD, necessitating the use of IV fluids to prevent hypotension and effects of hypovolemia 6. *alterations in F & E balance that may produce minor changes in young and middle-aged adults may produce profound changes in older adults* 7. s/s of F &E disturbances may be subtle or atypical, rapid infusion of an excessive volume of IV fluids may produce fluid overload and cardiac failure in older patients, these reactions are likely to occur more quickly and with the administration of smaller volumes of fluid than in healthy young and middle-aged adults because of the decreased cardiac reserve and reduced renal function that accompany aging - Ex: FVD may cause delirium in the older person, whereas in the young or middle-aged person, the 1st sign commonly is increased thirst 8. dehydration is the rapid loss of more than 3% of body weight owing to the loss of either water or Na, common bc of decreased kidney mass, decreased glomerular filtration rate, decreased renal blood flow, decreased ability to concentrate urine, inability to conserve Na, decreased excretion of K, and a decrease of total body water. 9. loss of SQ tissue and resultant thinning of the skin occurs with aging; the dermis is dehydrated and loses strength and elasticity, these skin changes affect placement of peripheral IV catheters in geri

CHART 13-3 Guidelines for Starting a Peripheral Intravenous Infusion Equipment (as Needed) 1. Single-use tourniquet 2. Padded, appropriate-length arm board 3. Single use scissors or clippers for hair removal 4. Tape 5. IV solution, tubing, connector, and catheter 6. Topical analgesics 7. Chlorhexidine gluconate, povidone-iodine, or alcohol swabs 8. Preservative-free 0.9% NaCL flush solution Padded, appropriate-length arm board or finger splint 9. Nonlatex gloves 10. Electronic infusion pump 11. Transparent dressing, bandage, or sterile gauze Implementation - Nursing Action - Rationale

1. Verify prescription for IV therapy, check solution label, and identify patient. Check for allergies (i.e., latex, iodine). - Serious errors can be avoided by careful checking. Checking for allergies reduces risk of allergic reaction. 2. Explain procedure to patient. - Knowledge increases patient comfort and cooperation. 3. Perform hand hygiene, and put on disposable nonlatex gloves. - Asepsis is essential to prevent infection. The use of nonlatex gloves prevents exposure of nurse to patient's blood and of patient and nurse to latex. 4. Apply a tourniquet 4 to 6 inches above the site, and identify a suitable vein - This will distend the veins and allow them to be visualized. A new tourniquet should be used for each patient to prevent the transmission of microorganisms. A blood pressure cuff may be used for older patients to avoid rupture of the veins. 5. Choose site. *Use distal veins of hands and arms first.* - *Careful site selection will increase likelihood of successful venipuncture and preservation of vein. Using distal sites first preserves sites proximal to the previously cannulated site for subsequent venipunctures. Veins of feet and lower extremity should be avoided due to risk of thrombophlebitis. (In consultation with the physician, the saphenous vein of the ankle or dorsum of the foot may occasionally be used.)* 6. Choose IV cannula or catheter and inspect carefully. - *Length and gauge of cannula should be appropriate for both site and purpose of infusion. The shortest gauge and length needed to deliver prescribed therapy should be used. Inspect the needle or cannula to make sure there are no imperfections.* 7. Prepare equipment by connecting infusion bag and tubing, run solution through tubing to displace air, and cover end of tubing. - *This prevents delay; equipment must be ready to connect immediately after successful venipuncture to prevent clotting.* 8. Raise bed to comfortable working height and position for patient; adjust lighting. Position patient's arm below heart level to encourage capillary filling. Place protective pad on bed under patient's arm. - Proper positioning will increase likelihood of success and provide comfort for patient. 9. Depending on agency policy and procedure, lidocaine 1% (without epinephrine) 0.1 to 0.2 mL may be injected locally to the IV site or a transdermal analgesic cream (EMLA) may be applied to the site prior to IV placement. Alternatively, topical application of lidocaine (Numby Stuff) or an intradermal injection of bacteriostatic 0.9% sodium chloride may be used to produce a local anesthetic effect. - This reduces pain locally from procedure and decreases anxiety about pain. 10. Palpate for a pulse distal to the tourniquet. Ask patient to open and close fist several times, or position patient's arm in a dependent position to distend a vein. Warm packs can be applied for 10 to 20 minutes prior to venipuncture to promote vasodilation. - The tourniquet should never be tight enough to occlude arterial flow. If a radial pulse cannot be palpated distal to the tourniquet, it is too tight. A clenched fist encourages the vein to become round and turgid. Positioning the arm below the level of the patient's heart promotes capillary filling. 11. *Prepare site by scrubbing with chlorhexidine gluconate or povidone-iodine swabs for 2 to 3 minutes in circular motion, moving outward from injection site. Allow to dry. - Strict asepsis and careful site preparation are essential to prevent infection.* *If the site selected is excessively hairy, clip hair. (Check agency's policy and procedure about this practice.)* *Hair removal should be performed with scissors or electric clippers. Hair should not be shaved with a razor because of the potential for microabrasions, which increase the risk of infection. Depilatories should not be used due to the potential for dermal allergic reactions and/or irritation.* Isopropyl alcohol 70% is an alternative solution that may be used. 12. With the hand not holding the venous access device, steady patient's arm and use finger or thumb to pull skin taut over vessel. - Applying traction to the vein helps to stabilize it. 13. Holding needle bevel up and at 5- to 25-degree angle, depending on the depth of the vein, pierce skin to reach but not penetrate vein. Use bevel-down technique for small veins to prevent extravasation - One-step method of catheter insertion directly into vein with immediate thrust through the skin is excellent for large veins but may cause a hematoma if used in small veins. 14. Decrease angle of needle further until nearly parallel with skin, then enter vein either directly above or from the side in one quick motion. - Two-stage procedure decreases chance of thrusting needle through posterior wall of vein as skin is entered. *No attempt should be made to reinsert the stylet because of risk of severing or puncturing the catheter.* 15. If backflow of blood is visible, straighten angle and advance needle. Additional steps for catheter inserted over needle: [Backflow may not occur if vein is small; this position decreases chance of puncturing posterior wall of vein] - Advance needle 0.6 cm (1/4 to 1/2 inch) after successful venipuncture. Advancing the needle slightly makes certain the plastic catheter has entered the vein. - Hold needle hub, and slide catheter over the needle into the vein. Never reinsert needle into a plastic catheter or pull the catheter back into the needle. Reinsertion of the needle or pulling the catheter back can sever the catheter, causing catheter embolism. - Remove needle while pressing lightly on the skin over the catheter tip; hold catheter hub in place. Slight pressure prevents bleeding before tubing is attached. - Never reinsert a stylet back into a catheter. The stylet can shear off a piece of the plastic if reinserted. - Never reuse the same catheter. Reusing the same catheter can cause infection. 16. Release tourniquet and attach infusion tubing; open clamp enough to allow drip. - Releasing the tourniquet restores blood flow and avoids potential ischemic damage to the area distal to the IV insertion site. 17. Cover the insertion site with a transparent dressing, bandage, or sterile gauze according to hospital policy and procedure. Tape in place with nonallergenic tape but do not encircle extremity. Tape a small loop of IV tubing onto dressing. - Transparent dressings allow assessment of the insertion site for phlebitis, infiltration, and infection without removing the dressing. Tape applied around extremity can act as a tourniquet and impede blood flow and infusion of fluid. The loop decreases the chance of inadvertent cannula removal if the tubing is pulled. 18. Label with type and length of cannula, date, time, and initials. - Labeling facilitates assessment and safe discontinuation. 19. A padded, appropriate-length arm board may be applied to an area of flexion (neurovascular checks should be performed frequently). - This secures cannula placement and allows correct flow rate (neurovascular checks assess nerve, muscle, and vascular function to be sure function is not affected by immobilization). 20. Calculate infusion rate and regulate flow of infusion. For hourly IV rate, use the following formula: gtt/mL of infusion set/60 (minutes in an hour) × Total hourly vol = gtt/min - Infusion must be regulated carefully to prevent overinfusion or underinfusion. Calculation of the IV rate is essential for the safe delivery of fluids. Safe administration requires knowledge of the volume of fluid to be infused, total infusion time, and calibration of the administration set (found on the IV tubing package; 10, 12, 15, or 60 drops to deliver 1 mL of fluid). 21. Document date and time therapy initiated; type and amount of solution; additives and dosages; flow rate; gauge, length, and type of vascular access device; catheter insertion site; type of dressing applied; patient response to procedure; patient education and name and title of the health care provider who inserted the catheter. - Documentation is essential to promote continuity of care. 22. Discard needles, stylets, or guidewires into a puncture-resistant needle container that meets OSHA guidelines. Remove gloves and perform hand hygiene. - Proper disposal of sharps decreases risk of needlesticks.

FVE s/s, lab, assessment

1. acute weight gain 2. peripheral edema & ascites 3. JVD 4. crackles 5. elevated CVP 6. SOB 7. HTN 8. bounding pulse & cough 9. increased RR 10. pulmonary congestion seen on X-ray 10. increased urine output 11. decreased Hgb, Hct, serum & urine osmolality, urine Na & specific gravity

hypovolemia s/s, lab, assessment

1. acute weight loss 2. decreased skin turgor 3. oliguria 4. concentrated urine 5. capillary filling time prolonged 6. low CVP 7. decreased BP 8. flattened neck veins 9. dizziness 10. weakness 11. thirst & confusion 12. increased pulse 13. muscle cramps 14. sunken eyes 15. nausea 16. increased temp 17. cool, clammy, pale skin 18. increased Hgb, Hct, serum urine osmolality, BUN, Cr, urine specific gravity 19. decreased urine Na - lab data useful in evaluating fluid volume status include *BUN* and its relation to *serum Cr concentration*: BUN elevated out of proportion to the serum creatinine (ratio greater than 20:1), BUN can be elevated because of dehydration or decreased renal perfusion and function - Hct level is greater than normal because there is a decreased plasma volume - increase in urine specific gravity - hypokalemia w/ GI & renal losses - hyperkalemia w/ adrenal insufficiency - hyponatremia w/ increased thirst & ADH release - hypernatremia w/ increased insensible losses and DI

hyponatremia S/S, lab, assessment

1. anorexia, n/v, abd cramping 2. HA, lethargy, dizziness, confusion, altered mental status, status epilepticus, coma 3. muscle cramps & focal weakness 4. muscular twitching 5. seizures 6. papilledema 7. dry skin, poor skin turgor, dry mucosa, decreased saliva production 8. increased pulse 9. decreased BP, orthostatic fall in BP 10. weight gain & edema (but NOT peripheral edema) 11. decreased serum & urine Na, urine specific gravity & osmolality

*nursing mgmt R/T FVD!*

1. nurse monitors and measures fluid I&O *at least every 8 hours*, and sometimes hourly,; as FVD develops, body fluid losses exceed fluid intake through *excessive urination (polyuria), diarrhea, vomiting, or other mechanisms*; once FVD has developed, the kidneys attempt to conserve body fluids, leading to a urine output of less than 1 mL/kg/h in an adult; urine in this instance is concentrated and represents a healthy renal response; daily body weights are monitored; an acute loss of 0.5 kg (1 lb) represents a fluid loss of approximately 500 mL (1L of fluid weighs approximately 1 kg, or 2.2 lb). 2. Vital signs are closely monitored. The nurse observes for a weak, rapid pulse and orthostatic hypotension (i.e., a decrease in systolic pressure exceeding 20 mm Hg when the patient moves from a lying to a sitting position). A decrease in body temperature often accompanies FVD, unless there is a concurrent infection. 3. *Skin and tongue turgor are monitored on a regular basis!!!* In a healthy person, pinched skin immediately returns to its normal position when released. This elastic property, referred to as turgor, is partially dependent on interstitial fluid volume. In a person with FVD, the skin flattens more slowly after the pinch is released. In a person with severe FVD, the skin may remain elevated for many seconds. Tissue turgor is best measured by pinching the skin over the sternum, inner aspects of the thighs, or forehead. *Tongue turgor is NOT affected by age and evaluating this may be more valid than evaluating skin turgor!* In a normal person, the tongue has one longitudinal furrow. In the person with FVD, there are additional longitudinal furrows and the tongue is smaller because of fluid loss. The degree of oral mucous membrane moisture is also assessed; a dry mouth may indicate either FVD or mouth breathing. 4. *Urine concentration* is monitored by measuring the urine specific gravity. In a volume-depleted patient, the urine specific gravity should be greater than 1.020, indicating healthy renal conservation of fluid. 5. *Mental function* is eventually affected, resulting in delirium in severe FVD as a result of decreasing cerebral perfusion. Decreased peripheral perfusion can result in cold extremities. In patients with relatively normal cardiopulmonary function, a low central venous pressure is indicative of hypovolemia. Patients with acute cardiopulmonary decompensation require more extensive hemodynamic monitoring of pressures in both sides of the heart to determine if hypovolemia exists.

hypernatremia s/s, lab, assessment

1. thirst 2. elevated body temp 3. swollen dry tongue and sticky mucous membranes 4. hallucinations 5. lethargy 6. restlessness 7. irritability 8. simple partial or tonic-clonic seizures 9. pulmonary edema 10. hyperreflexia 11. twitching 12. n/v 13. anorexia 14. increased pulse 15. HTN 16. increased serum Na, urine specific gravity & osmolality 17. decreased urine Na, CVP

hypernatremia causes

1. water deprivation in pts unable to drink at will 2. hypertonic tube feedings w/o adequate water supplements 3. DI 4. heatstroke 5. hyperventilation 6. watery diarrhea 7. burns 8. diaphoresis 9. excess corticosteroid, Na bicarb, Na CL admin 10. salt water near-drowning victims

c. Which electrolyte results should be followed?

Because the K is elevated, it should be closely monitored. Hyperkalemia (greater than 5.0 mEq/L [5 mmol/L]) seldom occurs in patients with normal renal function. - Medications have been identified as a probable contributing factor in more than 60% of hyperkalemic episodes. Medications commonly implicated are potassium chloride, heparin, ACE inhibitors, NSAIDs, beta-blockers, cyclosporine (Neoral), tacrolimus (Prograf), and potassium-sparing diuretics - The earliest changes, often occurring at a serum potassium level greater than 6 mEq/L (6 mmol/L), are peaked, narrow T waves; ST-segment depression; and a shortened QT interval. - If the serum potassium level continues to increase, the PR interval becomes prolonged and is followed by disappearance of the P waves. - Finally, there is decomposition and widening of the QRS complex. - *Ventricular dysrhythmias and cardiac arrest may occur!* - The sodium is also elevated and the chloride is low; they should be monitored, but are not the greatest concern. The nurse should assess large gains of sodium, as might occur with ingestion of OTC medications that have a high sodium content (e.g., Alka-Seltzer). In addition, the nurse obtains a medication history, because some prescription medications have a high sodium content.

Clotting and Obstruction

Blood clots may form in the IV line as a result of kinked IV tubing, a very slow infusion rate, an empty IV bag, or failure to flush the IV line after intermittent medication or solution administrations. - s/s: *decreased flow rate and blood backflow into the IV tubing* - the infusion must be discontinued and restarted in another site with a new cannula and administration set. - The tubing should NOT be irrigated or milked. - NEITHER the infusion rate nor the solution container should be raised, and the clot should not be aspirated from the tubing. - Clotting of the needle or cannula may be prevented by not allowing the IV solution bag to run dry, taping the tubing to prevent kinking and maintain patency, maintaining an adequate flow rate, and flushing the line after intermittent medication or other solution administration. - In some cases, a specially trained nurse or physician may inject a thrombolytic agent into the catheter to clear an occlusion resulting from fibrin or clotted blood.

Infiltration

Fluid leakage outside vein - is the unintentional administration of a nonvesicant solution or medication into surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate. When the solution is particularly irritating, sloughing of tissue may result. Close monitoring of the insertion site is necessary to detect infiltration before it becomes severe. - is usually easily recognized if the insertion area is larger than the same site of the opposite extremity but is not always so obvious. A common misconception is that a backflow of blood into the tubing proves that the catheter is properly placed within the vein. However, if the catheter tip has pierced the wall of the vessel, IV fluid will seep into tissues and flow into the vein. Although blood return occurs, infiltration may have occurred as well. A more reliable means of confirming infiltration is to apply a tourniquet above (or proximal to) the infusion site and tighten it enough to restrict venous flow. If the infusion continues to drip despite the venous obstruction, infiltration is present. - As soon as the nurse detects infiltration, the infusion should be stopped, the IV catheter discontinued, and a sterile dressing applied to the site after careful inspection to determine the extent of infiltration. The infiltration of any amount of blood product, irritant, or vesicant is considered the most severe. - *The IV infusion should be started in a new site or proximal to the infiltration site if the same extremity must be used again*. A warm compress may be applied to the site if small volumes of noncaustic solutions have infiltrated over a long period, or if the solution was isotonic with a normal pH; the affected extremity should be elevated to promote the absorption of fluid. If the infiltration is recent and the solution was hypertonic or had an increased pH, a cold compress may be applied to the area. Infiltration can be detected and treated early by inspecting the site every hour for redness, pain, edema, blood return, coolness at the site, and IV fluid leaking from the IV site. Using the appropriate size and type of cannula for the vein prevents this complication. The use of EIDs does not cause an infiltration or extravasation; however, these devices will exacerbate the problem until the infusion is turned off.

*Isotonic Fluids* D5W, NaCl, Lactated Ringer's

Fluids that are classified as isotonic have a total osmolality close to that of the ECF and do not cause red blood cells to shrink or swell. The composition of these fluids may or may not approximate that of the ECF. Isotonic fluids expand the ECF volume. One liter of isotonic fluid expands the ECF by 1 L; however, it expands the plasma by only 0.25 L because it is a crystalloid fluid and diffuses quickly into the ECF compartment. For the same reason, 3 L of isotonic fluid is needed to replace 1 L of blood loss. Because these fluids expand the intravascular space, patients with hypertension and heart failure should be carefully monitored for signs of fluid overload. *D5W* - A solution of D5W is unique in that it may be both isotonic and hypotonic. Once administered, the glucose is rapidly metabolized, and this initially isotonic solution (same osmolality as serum) then disperses as a hypotonic fluid—one third extracellular and two thirds intracellular. It is essential to consider this action of D5W, especially if the patient is at risk for increased intracranial pressure. During fluid resuscitation, this solution should not be used because hyperglycemia can result. Therefore, D5W is used mainly to supply water and to correct an increased serum osmolality. About 1 L of D5W provides fewer than 170 kcal and is a minor source of the body's daily caloric requirements. *Normal Saline Solution* - Normal saline (0.9% sodium chloride) solution contains water, salt, and chloride. Because the osmolality is entirely contributed by electrolytes, the solution remains within the ECF. For this reason, normal saline solution is often used to correct an extracellular volume deficit but is not identical to ECF. It is used with administration of blood transfusions and to replace large sodium losses, such as in burn injuries. It is not used for heart failure, pulmonary edema, renal impairment, or sodium retention. Normal saline does not supply calories. Other Isotonic Solutions Several other solutions contain ions in addition to sodium and chloride and are somewhat similar to the ECF in composition. *Lactated Ringer's* solution contains potassium and calcium in addition to sodium chloride. It is used to correct dehydration and sodium depletion and replace GI losses. Lactated Ringer's solution contains bicarbonate precursors as well. These solutions are marketed, with slight variations, under various trade names.

*Know the relationship between Calcium and Phosphorous*

Hypocalcemia is common in patients with renal failure, because these patients frequently have elevated serum phosphate levels. - *Hyperphosphatemia usually causes a reciprocal drop in the serum calcium level*. - Other causes of hypocalcemia include inadequate vitamin D consumption, magnesium deficiency, medullary thyroid carcinoma, low serum albumin levels, alkalosis, and alcohol abuse. - Medications predisposing to hypocalcemia include aluminum-containing antacids, aminoglycosides, caffeine, cisplatin, corticosteroids, mithramycin, phosphates, isoniazid, and loop diuretics. - A 0.9% sodium chloride solution should NOT be used with calcium because it increases renal calcium loss. Solutions containing phosphates or bicarbonate should NOT be used with calcium because they cause precipitation when calcium is added. - IV administration of 0.9% sodium chloride solution temporarily dilutes the serum calcium level and increases urinary calcium excretion by inhibiting tubular reabsorption of calcium. - *Administering IV phosphate can cause a reciprocal drop in serum calcium* - Calcitonin can be used to lower the serum calcium level and is particularly useful for patients with heart disease or renal failure who cannot tolerate large sodium loads. Calcitonin reduces bone resorption, increases the deposition of calcium and phosphorus in the bones, and increases urinary excretion of calcium and phosphorus. Although several forms are available, calcitonin derived from salmon is commonly used. Skin testing for allergy to salmon calcitonin is necessary before the hormone is administered. Systemic allergic reactions are possible because this hormone is a protein; resistance to the medication may develop later because of antibody formation. Calcitonin is administered by intramuscular injection rather than subcutaneously, because patients with hypercalcemia have poor perfusion of subcutaneous tissue. - Excess phosphorus binding by antacids may decrease the phosphorus available from the diet to an amount lower than required to maintain serum phosphorus balance. The degree of hypophosphatemia depends on the amount of phosphorus in the diet compared to the dose of antacid. Hypophosphatemia can occur with chronic diarrhea, Crohn's disease, vit.D deficiency, anorexia, alcoholism, malabsorption. Vitamin D regulates intestinal ion absorption; therefore, a *deficiency of vitamin D may cause decreased calcium and phosphorus levels, which may lead to osteomalacia (softened, brittle bones)*

*Treatment for Severe Emergent Hyperkalemia* Emergency Pharmacologic Therapy (for SEVERE Hyperkalemia)

If serum potassium levels are dangerously elevated, it may be necessary to administer *IV calcium gluconate*. Within minutes after administration, calcium antagonizes the action of hyperkalemia on the heart but does not reduce the serum potassium concentration. Calcium chloride and calcium gluconate are not interchangeable; calcium gluconate contains 4.5 mEq of calcium, and calcium chloride contains 13.6 mEq of calcium. Therefore, caution is required. - Monitoring the BP is essential to detect hypotension, which may result from the rapid IV administration of calcium gluconate. The ECG should be continuously monitored during administration; the appearance of *bradycardia* is an indication to stop the infusion. The myocardial protective effects of calcium last about 30 minutes. Extra caution is required if the patient has been "digitalized" (i.e., has received accelerated dosages of a digitalis-based cardiac glycoside to reach a desired serum digitalis level rapidly); parenteral administration of calcium sensitizes the heart to digitalis and may precipitate digitalis toxicity. - IV administration of *sodium bicarbonate* may be necessary in severe metabolic acidosis to alkalinize the plasma, shift potassium into the cells, and furnish sodium to antagonize the cardiac effects of potassium. Effects of this therapy begin within 30 to 60 minutes and may persist for hours; however, they are temporary. - Circulatory overload and hypernatremia can occur when large amounts of hypertonic sodium bicarbonate are given. Bicarbonate therapy should be guided by the bicarbonate concentration or calculated base deficit obtained from blood gas analysis or laboratory. - *IV administration of regular insulin and a hypertonic dextrose solution* causes a temporary shift of potassium into the cells. Glucose and insulin therapy has an onset of action within 30 minutes and lasts for several hours. - Loop diuretics, such as furosemide (Lasix), increase excretion of water by inhibiting sodium, potassium, and chloride reabsorption in the ascending loop of Henle and distal renal tubule. - Beta-2 agonists, such as albuterol (Proventil, Ventolin), are highly effective in decreasing potassium; however, their use remains controversial because they can cause tachycardia and chest discomfort. Beta-2 agonists move potassium into the cells and may be used in the absence of ischemic cardiac disease. Their use is a stopgap measure that only temporarily protects the patient from hyperkalemia. - If the hyperkalemic condition is not transient, actual removal of potassium from the body is required through cation exchange resins, peritoneal dialysis, hemodialysis, or other forms of renal replacement therapy.

After applying a tourniquet, the nurse palpates and inspects the vein. The vein should feel firm, elastic, engorged, and round—not hard, flat, or bumpy. Because arteries lie close to veins in the antecubital fossa, the vessel should be palpated for arterial pulsation (even with a tourniquet on), and cannulation of pulsating vessels should be avoided. General guidelines for selecting a cannula include the following:

Length: 0.75 to 1.25 inches long Diameter: Narrow diameter of the cannula to occupy minimal space within the vein Gauge: 1. 20 to 22 gauge for most IV fluids; a larger gauge for caustic or viscous solutions 2. 14 to 18 gauge for blood administration and for trauma patients and those undergoing surgery 3. 22 to 24 gauge for older patients

preventing hyperkalemia

Measures are taken to prevent hyperkalemia in patients at risk, when possible, by encouraging the patient to adhere to the prescribed potassium restriction. *Potassium-rich foods to be avoided include many fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa*. Conversely, foods with minimal potassium content include *butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey*. Labels of *cola* beverages must be checked carefully because some are high in potassium and some are not.

Phlebitis ( inflammation of a vein)

No caustic damage - can be categorized as chemical, mechanical, or bacterial; however, 2 or more of these types of irritation often occur simultaneously. Chemical phlebitis can be caused by an irritating medication or solution (increased pH or high osmolality of a solution), rapid infusion rates, and medication incompatibilities. Mechanical phlebitis results from long periods of cannulation, catheters in flexed areas, catheter gauges larger than the vein lumen, and poorly secured catheters. Bacterial phlebitis can develop from poor hand hygiene, lack of aseptic technique, failure to check all equipment before use, and failure to recognize early signs and symptoms of phlebitis. Other factors include poor venipuncture technique, catheter in place for a prolonged period, and failure to adequately secure the catheter. - is characterized by a reddened, warm area around the insertion site or along the path of the vein, pain or tenderness at the site or along the vein, and swelling. The incidence of phlebitis increases with the length of time the IV line is in place, the composition of the fluid or medication infused (especially its pH and tonicity), catheter material, emergency insertions, the size and site of the cannula inserted, ineffective filtration, inadequate anchoring of the line, and the introduction of microorganisms at the time of insertion. The INS has identified specific standards for assessing phlebitis. Phlebitis is graded according to the most severe presenting indication. - Treatment consists of discontinuing the IV line and restarting it in another site, and applying a warm, moist compress to the affected site. Phlebitis can be prevented by using aseptic technique during insertion, using the appropriate-size cannula or needle for the vein, considering the composition of fluids and medications when selecting a site, observing the site hourly for any complications, anchoring the cannula or needle well, and changing the IV site according to agency policy and procedures.

nursing mgmt hyperkalemia

Patients at risk for potassium excess (e.g., those with renal failure) need to be identified and closely monitored for signs of hyperkalemia. The nurse monitors I&O and observes for signs of muscle weakness and dysrhythmias. When measuring vital signs, an apical pulse should be taken. The presence of paresthesias and GI symptoms such as nausea and intestinal colic are noted. Serum potassium levels, as well as BUN, creatinine, glucose, and arterial blood gas values, are monitored for patients at risk for developing hyperkalemia.

*What action will the nurse take in preparing a site for intravenous injection? [parenteral fluid therapy]*

Pick the most distal veins Shave hair w/ men Before preparing the skin, the nurse should ask the patient if he or she is allergic to latex or iodine—products commonly used in preparing the skin for IV therapy. Excessive hair at the selected site may be removed by clipping to increase the visibility of the veins and to facilitate insertion of the cannula and adherence of dressings to the IV insertion site. Because infection can be a major complication of IV therapy, the IV device, the fluid, the container, and the tubing must be sterile. The nurse must perform hand hygiene and put on gloves. Gloves (nonsterile, disposable) must be worn during the venipuncture procedure because of the likelihood of coming into contact with bloodborne pathogens. The insertion site is prepared according to institutional policy - Before performing venipuncture, the nurse carries out hand hygiene, applies gloves, and informs the patient about the procedure. The nurse selects the most appropriate insertion site and type of cannula for a particular patient. - Many sites can be used for IV therapy, but ease of access and potential hazards vary. Veins of the extremities are designated as peripheral locations and are ordinarily the main sites used by nurses. Because they are relatively safe and easy to enter, arm veins are most commonly used. The *metacarpal, cephalic, basilic, and median veins* and their branches are recommended sites because of their size and ease of access. Leg veins should rarely, if ever, be used because of the high risk of thromboembolism. Additional sites to avoid include veins distal to a previous IV infiltration or phlebitic area; sclerosed or thrombosed veins; an arm with an arteriovenous shunt or fistula; and an arm affected by edema, infection, blood clot, deformity, severe scarring, or skin breakdown. The arm on the side of a mastectomy is avoided because of impaired lymphatic flow. - Central veins commonly used by physicians include the subclavian and internal jugular veins. It is possible to gain access to (or cannulate) these larger vessels even when peripheral sites have collapsed, and they allow for the administration of hyperosmolar solutions. However, the potential hazards are much greater and include inadvertent entry into an artery or the pleural space.

2. A 54-year-old woman who has a history of COPD presents with a productive cough for the past 3 months and shortness of breath with little exertion. Her blood pressure is 130/90 mm Hg and pulse rate 126 bpm. Arterial blood gas results are as follows: pH 7.29; PaCO2 72 mm Hg; HCO3- 34 mEq/L; PaO2 50 mm Hg. How do you interpret the patient's blood gas values? What treatment would you anticipate? Outline the nursing plan of care to address the patient's fluid and electrolyte or acid-base disorders. Give the rationale for the nursing interventions for this patient. a. How do you interpret the patient's blood gas values?

Regarding ABG result interpretation, it is crucial the arterial blood pH stay within the range of 7.35 to 7.45, because it is the optimal pH for successful physiological processes. When arterial pH falls below 7.35, it is referred to as acidosis. Respiratory acidosis occurs from an inability to exhale carbon dioxide, due to hypoventilation (slow breathing) or obstructions in the exchange of gases. Such conditions are caused by emphysema, asthma, bronchitis, pneumonia, and pulmonary edema. A diagnosis of respiratory acidosis can be made based on the pH being less than 7.35 and the partial pressure of carbon dioxide in the blood is high. In respiratory acidosis, the increased carbon dioxide is the primary cause for the other laboratory results. Increased CO2 causes the equilibrium to shift right, increasing H2CO3, H+, and HCO3-. Increased H+ ion leads to decreased pH (7.29) from normal (7.4). The HCO3- (34 mmoles) is slightly higher than normal. The elevated bicarbonate can reflect the body's attempt to compensate, reflected in the pH only being mildly to moderately decreased.

*Be able to identify Respiratory Acidosis, Respiratory Alkalosis, Metabolic Acidosis, and Metabolic Alkalosis. See Pg 271 TABLE 13-6 Acid-Base Disorders and Compensation* Disorder - Initial Event - Compensation

Respiratory acidosis: ↓ pH, ↑ or normal HCO3-, *↑ PaCO2* - *↑ Renal acid excretion* (↑ PaCO2) and ↑ serum HCO3- >26 mEq/L Respiratory alkalosis: ↑ pH, ↓ or normal HCO3-, *↓ PaCO2* - *↓ Renal acid excretion* (↓ PaCO2) and ↓ serum HCO3- <21 mEq/L Metabolic acidosis: ↓ pH, *↓ HCO3-*, ↓ or normal PaCO2 - *Hyperventilation* with resulting ↓ PaCO2 (>45 mm Hq) ↓ HCO3 Metabolic alkalosis: ↑ pH, *↑ HCO3-*, ↑ or normal PaCO2 - *Hypoventilation* with resulting ↑ PaCO2 (<35 mm Hq) ↑ HCO3

b. What criteria would you use to assess the strength of the evidence? What evidence indicates when to change the IV site?

The criteria to assess the strength of these interventions would include decreased incidence in IV complications. The 2011 Standards for Infusion Nursing recommendations for peripheral IV site rotation are based on *clinical indications rather than a specific time.*

You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as a. slight metabolic acidosis. b. slight respiratory acidosis. c. slight respiratory alkalosis.

The normal pH is 7.35 to 7.45. Normal PaCO2 levels are 35 to 45 mm Hg, and HCO3 is 22 to 26 mEq/L. Normal PaO2 is >80 mm Hg. Normal oxygen saturation is >95%. Since the patient's results all fall within these normal ranges, the nurse can conclude that the patient's blood gas results are within normal limits.

c How would your priorities, approach, and techniques differ if the patient is in *metabolic acidosis*?

The nurse will closely monitor the potassium levels and, if necessary, administer sodium bicarbonate in acute metabolic acidosis. In chronic metabolic acidosis, the nurse would address low serum calcium levels before the chronic metabolic acidosis is treated, to avoid tetany. Alkalizing agents may also be administered. Treatment modalities may also include hemodialysis or peritoneal dialysis.

4. Identify the priorities, approach, and techniques you would use to provide nursing care to a patient in respiratory alkalosis. How would your priorities, approach, and techniques differ if the patient is in respiratory acidosis? If the patient is in metabolic acidosis? If the patient is in metabolic alkalosis? a. Priorities, approach, and techniques if the patient is in *respiratory alkalosis*: Nursing care priorities for acid-base imbalances are aimed at correcting the imbalance.

The nurse would assess the patient for relevant signs and symptoms then provide the prescribed treatments. Treatment depends on the underlying cause of respiratory alkalosis. If the cause is anxiety, the nurse would instruct the patient to breathe more slowly to allow CO2 to accumulate or to breathe into a closed system (e.g., a paper bag). An antianxiety agent may be administered to relieve hyperventilation in very anxious patients. Treatment of other causes of respiratory alkalosis is directed at correcting the underlying problem.

A 38-year-old woman is admitted to the emergency department following a motor vehicle crash. She is hypotensive and her pulse rate is 110 bpm. Her laboratory test results are as follows: pH 7.32; sodium 151 mEq/L; glucose 120 mg/dL; PaCO2 28 mm Hg; potassium 5.5 mEq/L; creatinine 1.4 mg/dL; HCO3- 14 mEq/L; chloride 95 mEq/L; BUN 30 mg/dL. What assessment parameters would you use to further evaluate this patient? What actions and interventions are indicated? Which electrolyte results should be followed? What IV fluids would you anticipate being prescribed? Give the rationale for their use. a. What assessment parameters would you use to further evaluate this patient?

The nurse would utilize several assessment parameters to further evaluate this patient. Being hypotensive and tachycardic, this trauma patient presents as hemodynamically unstable. The nurse would need to routinely assess level of consciousness, respiratory status (e.g., breath sounds, pulse oximetry, respiratory rate, ABGs), and circulatory status (e.g., pulse, blood pressure, skin color) for further evaluation. The assessment would also include accurate monitoring her fluid balance via I&Os, weight, and ideally, central pressure monitoring. Additional diagnostic studies would be helpful, such as serum osmolality. Her ABG reflects metabolic acidosis (pH 7.32); the bicarbonate and PaC02 are low; she will need to repeat the patient's ABGs.

GI tract

The usual loss through the GI tract is 100-200 mL daily, even though approximately 8 L of fluid circulates through the GI system every 24 hours. - Because the bulk of fluid is normally reabsorbed in the small intestine, diarrhea and fistulas cause large losses.

pt's pH is 7.26 PCO2 is 59 HCO3 is 26 What does he have?

Uncompensated respiratory acidosis

b. What treatment would you anticipate?

When anticipating the patient's treatment, the nurse would need to consider the history of COPD with a productive cough lasting 3 months, along with shortness of breath with little exertion. The patient's ABGs show she is in respiratory acidosis retaining CO2 with hypoxemia. Her pulse is tachycardic and her blood pressure is borderline hypertensive. The patient's oxygenation status is of primary concern to address. For example, the nurse might administer pharmacologic agents, such as bronchodilators, to help reduce bronchial spasm, and antibiotics for respiratory infections. The nurse would encourage pulmonary hygiene and adequate hydration. Supplemental oxygen is administered; mechanical ventilation may be necessary. Placing the patient in a semi-Fowler's position facilitates expansion of the chest wall.

*Hypertonic Fluids* things w/ 5% dextrose, 50% dextrose, saline solutions

When normal saline solution or lactated Ringer's solution contains 5% dextrose, the total osmolality exceeds that of the ECF. - However, the dextrose is quickly metabolized, and only the isotonic solution remains. - Therefore, any effect on the intracellular compartment is temporary. - Similarly, with hypotonic multiple-electrolyte solutions containing 5% dextrose, once the dextrose is metabolized, these solutions disperse as hypotonic fluids. - Higher concentrations of dextrose, such as 50% dextrose in water, are strongly hypertonic and must be administered into central veins so that they can be diluted by rapid blood flow. - Saline solutions are also available in osmolar concentrations greater than that of the ECF. - These solutions draw water from the ICF to the ECF and cause cells to shrink. - If administered rapidly or in large quantity, they may cause an extracellular volume excess and precipitate circulatory overload and dehydration. - As a result, these solutions must be administered cautiously and usually only when the serum osmolality has decreased to dangerously low levels. - Hypertonic solutions exert an osmotic pressure greater than that of the ECF. - Quality and Safety Nursing Alert: *The nurse must know that solutions with higher concentrations of dextrose, such as 50% dextrose in water, are strongly hypertonic and must be administered into central veins so that they can be diluted by rapid blood flow.*

Correcting Hypovolemia

When possible, oral fluids are administered to help correct FVD, with consideration given to the patient's likes and dislikes. - The type of fluid the patient has lost is also considered, and fluids most likely to replace the lost electrolytes are appropriate. - If the patient is reluctant to drink because of oral discomfort, the nurse assists with frequent mouth care and provides nonirritating fluids. - The patient may be offered small volumes of oral rehydration solutions (e.g., Rehydralyte, Elete, Cytomax). - These solutions provide fluid, glucose, and electrolytes in concentrations that are easily absorbed. - If nausea is present, an antiemetic may be needed before oral fluid replacement can be tolerated. - If the deficit cannot be corrected by oral fluids, therapy may need to be initiated by an alternative route (enteral or parenteral) until adequate circulating blood volume and renal perfusion are achieved. Isotonic fluids are prescribed to increase ECF volume

*hypertonic solution!* shrink like a raisin

a solution with an osmolality HIGHER than that of serum *When hypertonic solutions are introduced into the veins water or fluid inside the Red Blood cells leave in an attempt to dilute the hypertonic solution around it!* *10% Dextrose in water* *3% Saline* *5% Dextrose in 0.45% Saline* *5% Dextrose in 0.9% Saline*

*hypotonic solution!* HIPPO - SWELL

a solution with an osmolality LOWER than that of serum *When a hypotonic solution is introduced into the veins water or fluid moves into the red blood cells in an attempt to dilute the higher concentration of solutes found in the RBC!* *The RBC can fill up with too much water and pop and die*. This is also known as *apoptosis or cell death* *0.45% Saline* *5% Dextrose in water*

*isotonic solution!*

a solution with the SAME osmolality as serum and other body fluids *when introduced into the veins, it increases the amount of fluid in the blood vessels without significantly changing the balance of the electrolytes in the body* *0.9% Saline (Normal Saline)* *Ringer's Solution* *Lactated Ringers* *5% Dextrose in 0.225% Saline* *5% Dextrose in water (has both Isotonic and Hypotonic properties)*

You receive a physician's order to change a patient's IV from D5½ NS with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which serum laboratory values on this same patient best support the rationale for this IV order change? a. Sodium 136 mEq/L, potassium 4.5 mEq/L b. Sodium 145 mEq/L, potassium 4.8 mEq/L c. Sodium 135 mEq/L, potassium 3.6 mEq/L d. Sodium 144 mEq/L, potassium 3.7 mEq/L

a. Sodium 136 mEq/L, potassium 4.5 mEq/L The normal range for serum sodium is 135 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV order decreases the amount of potassium and increases the amount of sodium. Therefore for this order to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.

You are caring for a patient admitted with diabetes mellitus, malnutrition, and massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply)? a. The potassium level may be increased if the patient has renal nephropathy. b. The patient may be excreting extra sodium and retaining potassium because of malnutrition. c. The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels. d. There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood. e. The patient has been overeating raisins, baked beans, and salt substitute that increase the potassium level.

a. The potassium level may be increased if the patient has renal nephropathy. c. The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels. d. There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood. Hyperkalemia may result from hyperglycemia, renal insufficiency, and/or cell death. Diabetes mellitus, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus it is not a contributing factor to this patient's potassium level. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. The patient with a massive GI bleed would have an NG tube and not be eating.

*alkalosis*

an acid-base imbalance characterized by a reduction in H+ concentration (increased blood pH) A high arterial pH with increased bicarbonate concentration is called *metabolic alkalosis* high arterial pH due to reduced PCO2 is called *respiratory alkalosis*

*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 called *respiratory acidosis*

Fluid volume excess (FVE) or hypervolemia

an isotonic expansion of the ECF caused by the abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ECF - may be related to simple fluid overload or diminished function of the homeostatic mechanisms responsible for regulating fluid balance - Contributing factors can include: 1. heart failure 2. renal failure 3. cirrhosis of the liver 4. consumption of excessive amounts of table or other sodium salts 5. *excessive administration of sodium-containing fluids in a patient with impaired regulatory mechanisms may predispose him or her to a serious FVE as well!* 6. fluid shifts (i.e. txt of burns) 7. prolonged corticosteroid therapy 8. severe stress 9. hyperaldosteronism

*The patient is admitted with metabolic acidosis. Which system is not functioning normally?* a. Buffer system b. Kidney system c. Hormone system d. Respiratory system

b. Kidney system When the patient has metabolic acidosis, the kidneys are not combining H+ with ammonia to form ammonium or eliminating acid with secretion of free hydrogen into the renal tubule. The buffer system neutralizes hydrochloric acid by forming a weak acid. The hormone system is not directly related to acid-base balance. The respiratory system releases CO2 that combines with water to form hydrogen ions and bicarbonate. The hydrogen is then buffered by the hemoglobin.

*You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the physician?* a. Antibiotics b. Loop diuretics c. Bronchodilators d. Antihypertensives

b. Loop diuretics Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing physician should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.

*You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. You assess this patient for which anticipated primary acid-base imbalance if the obstruction is high in the intestine?* a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

b. Metabolic alkalosis Because gastric secretions are rich in hydrochloric acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis.

*Which nursing intervention is most appropriate when caring for a patient with dehydration?* a. Auscultate lung sounds every 2 hours. b. Monitor daily weight and intake and output. c. Monitor diastolic blood pressure for increases. d. Encourage the patient to reduce sodium intake.

b. Monitor daily weight and intake and output. Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume. Recall that a 1-kg weight gain indicates a gain of approximately 1000 mL of body water.

*The nurse is caring for a 76-year-old woman admitted to the clinical unit with hypernatremia and dehydration after prolonged fever. Which beverage would be safest for the nurse to offer the patient?* a. Malted milk b. Orange juice c. Tomato juice d. Hot chocolate

b. Orange juice Orange juice has the least amount of sodium (approximately 2 mg in 8 ounces). Hot chocolate has approximately 75 mg sodium in 8 ounces. Tomato juice has approximately 650 mg sodium in 8 ounces. Malted milk has approximately 625 mg sodium in 8 ounces.

*You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results?* a. Fully compensated respiratory alkalosis b. Partially compensated respiratory acidosis c. Normal acid-base balance with hypoxemia d. Normal acid-base balance with hypercapnia

b. Partially compensated respiratory acidosis A low pH (normal 7.35-7.45) indicates acidosis. In the patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal 35-45 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for the elevated CO2.

*While performing patient teaching regarding hypercalcemia, which statements are appropriate (select all that apply)?* a. Have patient restrict fluid intake to less than 2000 mL/day. b. Renal calculi may occur as a complication of hypercalcemia. c. Weight-bearing exercises can help keep calcium in the bones. d. The patient should increase daily fluid intake to 3000 to 4000 mL. e. Treatment of heartburn can best be managed with Tums as needed.

b. Renal calculi may occur as a complication of hypercalcemia. c. Weight-bearing exercises can help keep calcium in the bones. d. The patient should increase daily fluid intake to 3000 to 4000 mL. A daily fluid intake of 3000 to 4000 mL is necessary to enhance calcium excretion and prevent the formation of renal calculi, a potential complication of hypercalcemia. Tums are a calcium-based antacid that should not be used in patients with hypercalcemia. Weight-bearing exercise does enhance bone mineralization.

*A 46-year-old woman with a subclavian triple-lumen catheter is transferred from a critical care unit after an extended stay for respiratory failure. Which action is important for the nurse to take?* a. Change the injection cap after the administration of IV medications. b. Use a 5-mL syringe to flush the catheter between medications and after use. c. During removal of the catheter, have the patient perform the Valsalva maneuver. d. If resistance is met when flushing, use the push-pause technique to dislodge the clot.

c. During removal of the catheter, have the patient perform the Valsalva maneuver. The nurse should withdraw the catheter while the patient performs the Valsalva maneuver to prevent an air embolism. Injection caps should be changed at regular intervals but not routinely after medications. Flushing should be performed with at least a 10-mL syringe to avoid excess pressure on the catheter. If resistance is encountered during flushing, force should not be applied. The push-pause method is preferred for flushing catheters but not used if resistance is encountered during flushing.

When planning the care of a patient with dehydration, what would the nurse instruct the unlicensed assistive personnel (UAP) to report? a. 60 mL urine output in 90 minutes b. 1200 mL urine output in 24 hours c. 300 mL urine output per 8-hour shift d. 20 mL urine output for 2 consecutive hours

d. 20 mL urine output for 2 consecutive hours The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for 2 consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.

*The nurse on a medical-surgical unit identifies that which patient has the highest risk for metabolic alkalosis?* a. A patient with a traumatic brain injury b. A patient with type 1 diabetes mellitus c. A patient with acute respiratory failure d. A patient with nasogastric tube suction

d. A patient with nasogastric tube suction Excessive nasogastric suctioning may cause metabolic alkalosis. Brain injury may cause hyperventilation and respiratory alkalosis. Type 1 diabetes mellitus (diabetic ketoacidosis) is associated with metabolic acidosis. Acute respiratory failure may lead to respiratory acidosis.

*When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit?* a. Fluid movement from the blood vessels into the cells b. Fluid movement from the interstitial spaces into the cells c. Fluid movement from the blood vessels into interstitial spaces d. Fluid movement from the interstitial space into the blood vessels

d. Fluid movement from the interstitial space into the blood vessels In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.

*When assessing a patient admitted with nausea and vomiting, which finding supports the nursing diagnosis of deficient fluid volume?* a. Polyuria b. Decreased pulse c. Difficulty breathing d. General restlessness

d. General restlessness Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma.

You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? a. Notify the physician and complete an incident report. b. Slow the rate to keep vein open until next bag is due at noon. c. Obtain a new bag of IV solution to maintain patency of the site. d. Listen to the patient's lung sounds and assess respiratory status.

d. Listen to the patient's lung sounds and assess respiratory status. After 4 hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for FVE, and you should assess the patient's respiratory status and lung sounds as the priority action and then notify the physician for further orders.

*You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy?* a. Sodium falling to 138 mEq/L b. Potassium rising to 4.1 mEq/L c. Magnesium rising to 2.9 mg/dL d. Phosphorus falling to 2.1 mg/dL

d. Phosphorus falling to 2.1 mg/dL *Calcium has an inverse relationship with phosphorus in the body!!!* When phosphorus levels fall, calcium rises, and vice versa. Since hypercalcemia rarely occurs as a result of calcium intake, the patient's phosphorus falling to 2.1 mg/dL (normal 2.5-4.5 mg/dL) may be a result of the phosphate-binding effect of calcium carbonate.

tonicity

fluid tension or the effect that osmotic pressure of a solution with impermeable solutes exerts on cell size because of water movement across the cell membrane - is the ability of all solutes to cause an osmotic driving force that promotes water movement from one compartment to another. The control of tonicity determines the normal state of cellular hydration and cell size - Sodium, mannitol, glucose, and sorbitol are effective osmoles (capable of affecting water movement)

dialysis R/T FVE

if renal function is so severely impaired that pharmacologic agents cannot act efficiently, other modalities are considered to remove Na and fluid from the body - *hemodialysis or peritoneal dialysis* may be used to remove nitrogenous wastes and control potassium and acid-base balance, and to remove Na and fluid - continuous renal replacement therapy may also be required - * if Cr level >2!!!*

*What are some of the local complications from IV therapy?* Local complications of IV therapy include:

infiltration extravasation phlebitis thrombophlebitis hematoma clotting/obstruction of the needle mechanical failure

Sodium Excess (Hypernatremia) *FRIED SALT*

is a serum sodium level higher than 145 mEq/L (145 mmol/L) - can be caused by a *gain of sodium in excess of water or by a loss of water in excess of sodium!!!* - can occur in patients with *normal fluid volume or in those with FVD or FVE* - w/ a water loss, the patient loses more water than sodium; as a result, the serum sodium concentration increases and the increased concentration pulls fluid out of the cell. This is both an extracellular and an intracellular FVD. In sodium excess, the patient ingests or retains more sodium than water. - Water moves out of the cell into the ECF, resulting in cellular dehydration and a more concentrated ECF - as in hyponatremia, fluid losses and gains are carefully monitored in patients who are at risk for hypernatremia. The nurse should assess for abnormal losses of water or low water intake and for large gains of sodium, as might occur with ingestion of OTC medications that have a high sodium content (e.g., Alka-Seltzer). In addition, the nurse obtains a medication history, because some prescription medications have a high sodium content. The nurse also notes the patient's thirst or elevated body temperature and evaluates it in relation to other clinical signs and symptoms. The nurse monitors for changes in behavior, such as restlessness, disorientation, and lethargy

Osmotic pressure

is the amount of hydrostatic pressure needed to stop the flow of water by osmosis. It is primarily determined by the concentration of solutes.

Osmotic diuresis

is the increase in urine output caused by the excretion of substances such as glucose, mannitol, or contrast agents in the urine

Oncotic pressure

is the osmotic pressure exerted by proteins (e.g., albumin)

*The body is equipped with remarkable homeostatic mechanisms to keep the composition and volume of body fluid within narrow limits of normal. Organs involved in homeostasis include:*

kidneys heart lungs pituitary gland adrenal glands parathyroid glands Quality and Safety Nursing Alert: *When fluid balance is critical, all routes of systemic gain and loss must be recorded and all volumes compared. Organs of fluid loss include the kidneys, skin, lungs, and GI tract.*

*homeostasis*

maintenance of a constant internal equilibrium in a biologic system that involves positive and negative feedback mechanisms

*nursing mgmt of FVE!*

nurse measures I&O at regular intervals to identify excessive fluid retention - the pt is *weighed daily, and rapid weight gain is noted. An acute weight gain of 1 kg (2.2 lb) is equivalent to a gain of approximately 1 L of fluid* - breath sounds are assessed at regular intervals in at-risk patients, particularly if parenteral fluids are being administered. - monitors the degree of edema in the most dependent parts of the body, such as the feet and ankles in ambulatory patients and the sacral region in patients confined to bed - *pitting edema* is assessed by pressing a finger into the affected part, creating a pit or indentation that is evaluated on a scale of 1+ (minimal) to 4+ (severe) - peripheral edema is monitored by measuring the circumference of the extremity with a tape marked in millimeters

FVD (hypovolemia)

occurs when loss of ECF volume exceeds the intake of fluid, causes include: 1. abnormal fluid & electrolyte losses resulting from V/D, GI suctioning, sweating, fever, burns, blood loss 2. decreased intake, as in nausea, lack of access to fluids, anorexia 3. third-space fluid shifts, or the movement of fluid from the vascular system to other body spaces (e.g., with edema formation in burns, ascites with liver dysfunction) 4. *diabetes insipidus* (a decreased ability to concentrate urine owing to a defect in the kidney tubules that interferes with water reabsorption) 5. adrenal insufficiency 6. osmotic diuresis 7. hemorrhage 8. coma - The presence and cause of FVD may be determined through the health hx and physical exam

compensated

pH - WNL PCO2 AND HCO3 - out of range

uncompensated

pH - out of range PCO2 OR HCO3 - out of range

*active transport!*

physiologic pump that moves fluid from an area of LOWER concentration to one of HIGHER concentration; active transport requires adenosine triphosphate (ATP) for energy - Na concentration is greater in ECF than in ICF so Na tends to enter cell by diffusion, this tendency is offset by the sodium-potassium pump that is maintained by the cell membrane and actively moves Na from the cell into the ECF - the high intracellular K concentration is maintained by pumping K into the cell, so this definition implies that energy must be expended for the movement to occur against a concentration gradient

Sodium Deficit (Hyponatremia)

refers to a serum sodium level that is <135 mEq/L (135 mmol/L) - primarily occurs due to an *imbalance of water* rather than sodium - the urine sodium value assists in differentiating renal from nonrenal causes of hyponatremia - Low urine sodium occurs as the kidney retains sodium to compensate for nonrenal fluid loss (i.e., vomiting, diarrhea, sweating) - High urine sodium concentration is associated with renal salt wasting (i.e., diuretic use) - In *dilutional hyponatremia*, the ECF volume is increased without any edema 1. loss of sodium R/T diuretics, loss of GI fluids, renal disease, adrenal insufficiency 2. gain of water R/T excessive admin of D5W, water supplements for pts receiving hypotonic tube feedings 3. dx states w/ SIADH like head trauma & oat-cell lung tumor 4. meds w/ water retention like oxytocin & certain tranquilizers 5. psychogenic polydipsia 6. hyperglycemia 7. heart failure

Thrombophlebitis

refers to the presence of a clot plus inflammation in the vein. It is evidenced by *localized pain, redness, warmth, and swelling around the insertion site or along the path of the vein, immobility of the extremity because of discomfort and swelling, sluggish flow rate, fever, malaise, and leukocytosis*. - Treatment includes discontinuing the IV infusion; applying a cold compress 1st to decrease the flow of blood and increase platelet aggregation, followed by a warm compress; elevating the extremity; and restarting the line in the opposite extremity. - If the patient has s/s, the IV line should NOT be flushed (although flushing may be indicated in the absence of phlebitis to ensure cannula patency and to prevent mixing of incompatible medications and solutions). - The catheter should be cultured after the skin around the catheter is cleaned with alcohol. - If purulent drainage exists, the site is cultured before the skin is cleaned. - can be prevented by avoiding trauma to the vein at the time the IV line is inserted, observing the site every hour, and checking medication additives for compatibility

*Treatment for Hyperkalemia*

serum potassium level greater than 5 mEq/L [5 mmol/L], seldom occurs in patients with normal renal function - Medications have been identified as a probable contributing factor in more than 60% of hyperkalemic episodes. Medications commonly implicated are KCl, heparin, ACE inhibitors, NSAIDs, beta-blockers, cyclosporine (Neoral), tacrolimus (Prograf), and potassium-sparing diuretics. Potassium regulation is compromised in acute and chronic renal failure, with a glomerular filtration rate less than 10% to 20% of normal. c. In acidosis, potassium moves out of the cells and into the ECF. This occurs as hydrogen ions enter the cells to buffer the pH of the ECF. An elevated ECF potassium level should be anticipated when extensive tissue trauma has occurred, as in burns, crushing injuries, or severe infections. Similarly, it can occur with lysis of malignant cells after chemotherapy (i.e., tumor lysis syndrome). - Pseudohyperkalemia (a false hyperkalemia) has several causes, including the improper collection or transport of a blood sample, a traumatic venipuncture, and use of a tight tourniquet around an exercising extremity while drawing a blood sample, producing hemolysis of the sample before analysis - Quality and Safety Nursing Alert: *Potassium supplements are extremely dangerous for patients who have impaired renal function and thus decreased ability to excrete potassium. Even more dangerous is the IV administration of potassium to such patients, because serum levels can rise very quickly. Aged (stored) blood should not be administered to patients with impaired renal function, because the serum potassium concentration of stored blood increases due to red blood cell deterioration. It is possible to exceed the renal tolerance of any patient with rapid IV potassium administration, as well as when large amounts of oral potassium supplements are ingested.* Medical Mgmt - An ECG should be obtained immediately to detect changes. Shortened repolarization and peaked T waves are seen initially. To verify results, a repeat serum potassium level should be obtained from a vein without an IV infusing a potassium-containing solution. - In nonacute situations, restriction of dietary potassium and potassium-containing medications may correct the imbalance. For example, eliminating the use of potassium-containing salt substitutes in a patient who is taking a potassium-conserving diuretic may be all that is needed to deal with mild hyperkalemia. - Administration, either orally or by retention enema, of cation exchange resins (e.g., *sodium polystyrene sulfonate [Kayexalate]*) may be necessary. Cation exchange resins cannot be used if the patient has a paralytic ileus, because intestinal perforation can occur. Kayexalate binds with other cations in the GI tract and contributes to the development of hypomagnesemia and hypocalcemia; it may also cause sodium retention and fluid overload and should be used with caution in patients with heart failure. Kayexalate is first!!!

osmolality

the number of milliosmoles (the standard unit of osmotic pressure) per kilogram of solvent expressed as milliosmoles per kilogram (mOsm/kg) The term is used more often than osmolarity to evaluate serum and urine

*osmolarity!*

the number of milliosmoles (the standard unit of osmotic pressure) per liter of solution expressed as milliosmoles per liter (mOsm/L) describes the concentration of solutes or dissolved particles

hydrostatic pressure

the pressure created by the weight of fluid against the wall that contains it. In the body, this pressure in blood vessels results from the weight of fluid itself and the force resulting from cardiac contraction.