Fluid, Electrolyte, and Acid-Base Balance
hypernatremia risk factors
-NPO (water deprivation) -heat stroke -excess hypertonic IV fluids, tube feedings, bicarbonate intake -Cushing's syndrome *** -aldosteronism -glucocorticosteroids -fluid losses- fever, diaphoresis, burns, resp. infection, diabetes insipidus, hyperglycemia, watery diarrhea
when do 'life-threatening transfusion reactions' occur? what are signs and symptoms it is occurring in a patient?
-about 5-15 minutes in -itchiness, shortness of breath
requirements of thirst
-alert state -fluids must be accessible and person must be strong enough to reach for fluids -communication barriers?
What is the standard drop factor of microdrip tubing?
60 drops/ml
A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?
An implanted central venous access device (CVAD)
A nurse monitoring an IV infusion notes the signs and symptoms of a thrombus. Which nursing interventions would the nurse perform?
-Stop the infusion immediately -apply a warm compress as ordered -restart the IV at another site
what solution is given to a patient with hypovolemia?
IV of 0.9% normal saline
what type of fluid is pitting edema?
interstitial fluid
which patients are at risk for fluid volume overload during IV therapy? (isotonic/hypotonic solution administration)
renal failure heart failure cardiac problems -this is because these conditions already have a risk for fluid retention in the body
s/s of hypokalemia
#1 cardiac dysrhythmias muscle weakness leg cramps fatigue paresthesias
at what rate are packed red blood cells administration? when are they given?
-internal bleeding/GI bleeding -1 unit over 2 to 3 hours, no longer than 4 hours
signs of phlebitis as complication of IV therapy
-local acute tenderness/pain, redness, warmth, and slight edema of the vein above the insertion site. -Phlebitis is an inflammation of a vein caused by mechanical trauma from a needle or catheter.
What is the physiologic process that drives the thirst factor?
-located within the hypothalamus, decreased blood volume and dehydration (intracellular)
How does vomiting affect fluids, electrolytes, or acid-base imbalances?
-loss of fluids, acids, and potassium -risk for ECF deficit -metabolic alkalosis
interventions for hypernatremia
-monitor LOC & safety -oral hygiene to reduce thirst (?) -monitor I&O -encourage fluids as prescribed if patient has fluid loss administer: -hypotonic or isotonic solution (non-sodium)
age-related populations at risk for fluid volume deficit
-newborns and infants because they have a larger % of fluid body weight (majority is water) -their kidneys do not concentrate well -adults coming out of surgery, have renal/heart failure, and use diuretics
what kind of patient would present with metabolic alkalosis?
-prolonged vomiting -NG suction
function of RAAS system
-regulates ECF via aldosterone -aldosterone "saves" salt in the kidneys and "water follows salt" -raising blood pressure
what are the primary extracellular fluids?
-sodium -bicarbonate (HCO3) -chloride
sodium
-sodium absorption and excretion is the driving force of osmolarity (maintaining water balance) -if elevated >145, we get dehydrated (thirst mechanism activates)-water loss=too much sodium -most abundant electrolyte in ECF -regulated by aldosterone and intake
what is the function of hypotonic solution? when is it administered?
-used to rehydrate cells -body has lost water without any electrolytes -does not need electrolyte replacement, only water -used on patients who are severely dehydration (does not have water in ICF)
what is the function of hypertonic solution? when is it administered?
-water moves out of the cells into the bloodstream, causing the cells to shrink -infused to treat severe hyponatremia (low sodium) -sometimes used to treat cerebral edema (swelling in brain)
what would you suggest to a thirsty client who is on fluid restriction?
Avoid salty or excessively sweet fluids.
The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean?
Clients with type B blood have anti-A antibodies. This means they would attack any type A blood they receive, prompting a transfusion reaction.
range of adequate hydration/day
In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of output
Which blood type is the universal donor?
O neg -because it lacks both A and B blood group markers on its cell membrane.
primary cause of transfusion-related client death in the United States?
Transfusion-related acute lung injury
what is third spacing and what are some examples?
When fluid leaves the vascular space and goes into interstitial space. The interstitial space is the space in between the cells, outside of the blood vessels.The fluid leaves the vascular space and goes into the tissues ECF volume deficit -pleural effusion -ascites (from liver failure/cirrhosis) -anything that makes the fluid go into a place it is normally not supposed to be
An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use:
a winged-infusion needle for a short period of time only
how does the body compensate during metabolic acidosis?
by increasing ventilation through the lungs, thus increasing the rate of carbonic acid excretion, resulting in a fall in PaCO2. -lungs reduce PaCO2 (fast)
vital signs with hypovolemia
decreased blood pressure increased heart rate (tachycardia) possible shock symptoms
risk factors for hyponatremia
deficient ECF volume -excess GI losses: vomiting. NG suction, diarrhea, tap water enema -diuretics, adrenal insufficiency, diaphoresis -burns, wound drainage, GI obstruction, peripheral edema, ascites -excess water intake (dilutes sodium levels) -SIADH*** -excess dextrose 5% in water
what should the nurse do if she sees an IV site red, swollen, warm to the touch, and painful?
discontinue the IV and relocate it to another site
what is the function of isotonic solution? when is it administered?
fluid volume deficit when the body has lost both water and electrolytes -used to increase blood pressure when it is low ex: -fluid resuscitation -hypovolemia (low blood volume)
what would you suspect if a patient has distended neck veins? (JVD) why does it occur?
fluid volume excess -Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended.
How does diaphoresis affect fluids, electrolytes, or acid-base imbalances?
gradual loss of fluid and electrolytes
When are ACE inhibitors used?
heart failure hypertension (decreases blood pressure) blocks angiotensin in the body to lower BP
which patients are at risk for fluid volume overload during D5 or D10 infusions?
hyperglycemia (pts with high blood sugar) -diabetic patients (DKA)
how does the body compensate during metabolic alkalosis?
hyperventilation because the lungs will try to increase PCO2 fast
what clinical manifestations suggest a patient has an incompatible blood transfusion? (hemolytic transfusion reaction)
immediate onset facial flushing, hypotension, tachycardia, and chills.
how does the body compensate during respiratory alkalosis?
kidneys reduce HCO3 -the kidneys increase the excretion of HCO3− to the urine.
how does the body compensate during respiratory acidosis?
kidneys retain HCO3 -increasing the excretion of H+ ion into the urine.
fluid output occurs through the
kidneys, skin, lungs, GI tract
What commonly used intravenous solution is hypotonic?
less concentrated than blood. less concentrated than particles (solutes) than plasma (solvent) -0.45% NaCl*** -D5W after absorption -0.33% NS
causes of hypervolemia
liver failure- ECF excess with ascites pregnancy renal failure (hyperkalemia, hypocalcemia) heart failure (left sided-crackles, right sided-pitting edema) too much IV fluid resuscitation
How does diarrhea affect fluids, electrolytes, or acid-base imbalances?
loss of fluid and bicarbonate risk for ECF deficit metabolic acidosis
how does the body compensate during metabolic alkalosis?
lungs try to increase pCO2 (fast) -kidneys retain acid and excreting HCO3−.
A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing?
metabolic alkalosis -Endocrine disorders and ingestion of large amounts of antacids cause metabolic alkalosis.
hypertonic solution
more concentrated than the blood. greater concentration of particles (solutes) than plasma (solvent) -D5NS**** -10% dextrose in water (D10W) is hypertonic. -D5 0.45 NS -3% NS -TPN -Albumin
s/s of hypovolemia
orthostatic hypotension (low BP) decreased LOC decreased urine output (<30 ml/hr) weight loss tachycardia (increased HR) weak/rapid pulse (thready?) decreased body temperature
What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells?
plasma -The infusion of plasma helps restore and replace the clotting factors that are lost with the infusion of large amounts of packed red blood cells.
s/s hypervolemia
rapid weight gain increased BP bounding pulse JVD decreased urine output pulmonary edema dyspnea crackles
nursing interventions hypovolemia
safety precautions (fall risk) IV fluids-isotonic
isotonic solutions
same equal concentration of particles as plasma (solutes and solvents). same concentration as blood allows free movement across membrane without changes the concentration. -0.9% NaCl normal saline*** -lactated ringers solution -D5W is initially isotonic but turns into a hypotonic solution after absorption -plasma (remains in intravascular compartment)
what is the function of interstitial fluid? where is it located?
surrounds the body's cells, important for the transportation of oxygen, nutrients, hormones, waste removal, etc.
manifestations of infiltration
swelling, coolness, and pallor at the catheter insertion site.
osmolarity
the concentration of dissolved particles in an amount of fluid (IV fluid) -ADH maintains osmolarity by adjusting the amount of water excreted in the urine
what electrolytes does the parathyroid regulate?
the levels of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances.
Osmolality
the proportion of dissolved particles to weight of fluid (body fluids) -increases with fluid volume deficit (too little water and higher concentrations of dissolved particles)
what is the function of intracellular fluid?
to maintain cell size
why does a nurse look for a large vein when using a needle with a large gauge
to prevent compromising circulation
A Groshong catheter
used to administer medications, fluids, or draw blood tunnel placement then subclavian vein the tip should be located in superior vena cava -used for extended therapy such as chemotherapy to prevent risk of infection
s/s hypernatremia
vitals: -hyperthermia -tachycardia -orthostatic hypotension neuro: -decreased LOC -restlessness, fatigue, disorientation, irritability -muscle twitching, muscle weakness -decreased/absent DTRS GI: -thirst -dry and sticky mucous membranes -increased motility -hyperactive bowel sounds/abdominal cramping Other: -edema -warm flushed skin -oliguria (abnormally small amounts of urine)
s/s hyponatremia
vitals: hypothermia, tachycardia, rapid/thready pulse, hypotension neuro: decreased LOC, headache, confusion, coma decreased deep tendon reflexes, muscle weakness (may compromise respiratory) GI: increased motility, hyperactive bowel sounds, abdominal cramping, anorexia, vomiting
Which client would be a candidate for total parenteral nutrition?
when there is interference with nutrient absorption from the gastrointestinal tract or when complete bowel rest is necessary for healing. -A client with bloody diarrhea and colitis requires complete bowel rest.
