Nursing - Unit 5 (Fluids)

The calcium level of the blood is regulated by which mechanism? Parathyroid hormone (PTH) Thyroid hormone (TH) Adrenal gland Androgens

Parathyroid hormone (PTH) The serum calcium level is controlled by PTH and calcitonin. The thyroid hormone, adrenal gland, or androgens do not regulate the calcium level in the blood.

define normal phosphorus levels

Phosphorus (inverse to calcium) 2.5-4.5

Define the normal potassium levels

Potassium 3.5-5.1

Define Hypernatremia

.Hypernatremia: a serum Na+ greater than 145mEq/L (normal range 135- 145mEq/L)

At what level do symptoms appear in Hypomagnesemia

1.Clinical manifestations usually appear when serum Mg++ level drops below 1 mEq/L

List treatment options for Hyponatremia

1.Focuses on restoring normal levels, preventing complications, and treating underlying problems 2.Encourage inclusion of high Na+ foods in diet a. Processed food products (highest sources of sodium in the diet) b. Lunch meats c. Ham, bacon, and pork products (high sodium levels) d. Dill pickles, corned beef, and products that are "pickled" in brine solutions e. Potato chips and other salted snack foods f. Butter, cheese, and milk g. Condiments such as ketchup, mustard, soy sauce, relishes h. Anchovies, mackerel, and other saltwater fish products

Define HyperChloremia

1.Hyperchloremia: a serum Cl- level greater than 108 mEq/L (normal range 95 - 108 mEq/L)

Define Hypermagnesemia

1.Hypermagnesemia: serum Mg++ level greater than 2.1 mEq/L (normal range 1.4 - 2.1 mEq/L)

Define HypoChloremia

1.Hypochloremia: a serum chloride (Cl-) level less than 95 mEq/L (normal range 95 - 108 mEq/L)

Define HypoKalemia

1.Hypokalemia: a serum potassium (K+) level below 3.5mEq/L (normal range 3.5- 5.1 mEq/L)

Define HypoMagnesemia

1.Hypomagnesemia: a serum magnesium (Mg++) level less than 1.4 mEq/L (normal range 1.4 - 2.1 mEq/L)

Define hyponatremia

1.Hyponatremia: a serum sodium (Na+) level below 135mEq/L (normal range 135- 145mEq/L) Usually associated with hypervolemia (increased fluid volume), which can then be referred to as dilutional hyponatremia or water intoxication (excess fluid that dilutes serum Na+); can also occur in euvolemia (normal volume) and hypovolemia (low volume states)

Client teaching HypoCalcemia (See answer)

1.Predisposing factors 2.Paresthesias, tingling and numbness in extremities are early warning signs of tetany 3.Report onset of signs of tetany or seizures immediately to health care provider 4.Take oral replacements as prescribed 5.Avoid overuse of antacids and/or laxatives containing phosphorus 6.Increase intake of foods rich in Ca++ (dairy products) and protein 7.Vitamin D and protein are important to keep Ca++ within normal limits 8.Use appropriate substitutes for milk and dairy products if lactose intolerant 9.Avoid foods high in phosphorus 10. Limit foods that decrease absorption of Ca++ in diet

HypoPhosphatemia Overview

2.May be associated with increased Ca++ levels (hypercalcemia) 3.Predisposing factors a. A complication of refeeding after severe malnourishment (has high mortality rate) or administering total parenteral nutrition with adequate phosphorus b. Poor dietary intake or decreased absorption from vitamin D deficiency, malabsorption disorders, and starvation c. Prolonged use of aluminum- and Mg++- based antacids (bind to phosphorus) d. Severe vomiting and diarrhea; prolonged gastric suction e. Increased renal excretion from hyperparathyroidism, hypomagnesemia, hypokalemia, thiazide diuretic therapy, the diuretic phase of acute tubular necrosis, renal tubular disorders, polyuria and glycosuria from uncontrolled diabetic ketoacidosis f. Respiratory alkalosis (may stimulate glycolysis, which enhances movement of phosphorus into cells)

Predisposing conditions of Hypochloremia

2.Predisposing clinical conditions a. Hyponatremia, metabolic alkalosis, hypokalemia, prolonged D5W IV therapy b. Chronic respiratory acidosis c. Chronic lung disease accompanied by high PaCO2 and HCO3- levels that result in decreased serum Cl- d. Diabetic ketoacidosis because of increased anion gap e. Acute infections, although how they lower serum Cl- is unclear f. Vomiting (loss of HCl), GI suctioning, perspiration, diarrhea, and fistulas g. Metabolic stress conditions, such as severe burns, fever, heat and exhaustion states h. Disease states such as Addison's disease, anorexia, salt-wasting, renal nephropathy, SIADH, and hypervolemic states such as congestive heart failure (CHF) and cirrhosis i. Medications that promote electrolyte loss, are diuretics, or promote alkalosis

Predisposing conditions of Hyperchloremia

2.Predisposing clinical conditions a. Fluid and electrolyte imbalances such as hypernatremia and metabolic acidosis b. Drugs that promote CL- retention, such as IV saline, certain diuretics, salicylate intoxication, corticosteroids, guanethidine, and phenylbutazone c. Dehydration d. Endocrine disturbances that result in diabetes insipidus and certain cases of hyperparathyroidism (seen in association with hypercalcemia) e. Hyperaldosteronism (increased sodium and chloride reabsorption) f. Renal changes that manifest as renal tubular acidosis or acute renal failure

Predisposing Clinical conditions of Hypercalcemia

2.Predisposing clinical conditions a. Hyperparathyroidism b. Metastatic cancer c. Use of thiazide diuretics d. Sarcoidosis e. Immobility f. Hypophosphatemia g. Hyperthyroidism (thyrotoxicosis) h. Renal tubular acidosis i. Milk-alkali syndrome j. Familial hypocalciuric hypercalcemia k. Lithium therapy l. Vitamin D intoxication 3.Other risk factors a. Excessive dietary intake of Ca++ rich foods b. Excessive intake of antacids for gastric distress

List predisposing factors of Hypermagnesemia

2.Predisposing factors a. Decreased renal excretion of Mg++, such as with decreased urine output or renal failure b. Increased Mg++ intake, such as with overuse of Mg++-containing antacids, cathartics, or enemas; total parenteral nutrition; or hemodialysis using hard water dialysate

HyperPhosphatemia Predisposing factors

2.Predisposing factors a. Acute and chronic renal failure b. Hypocalcemia from antacids, diuretic agents, steroids c. Chemotherapy for malignant tumors d. Hypoparathyroidism (primary or secondary), which causes a decreases in Ca++ and increased renal absorption of phosphorus e. Excessive intake of phosphorus or its supplements f. Vitamin D excess or increased GI absorption g. Massive transfusions (phosphorus can leak from cells during blood storage) h. Hyperthyroidism, hyperparathyroidism i. Large milk intake j. Overzealous administration of oral or IV phosphorus supplements k. Rhabdomyolysis (breakdown of striated muscle), which releases cellular phosphorus

List Calcium excretion promoting treatments

2.Promote calcium excretion a. Use loop diuretics, such as furosemide or bumetanide to promote increased urine output so that more Ca++ will be excreted b. Maintain hydration of 3000 to 4000mL (3-4 L) of fluid/day; oral fluids should be high in acid ash, such as cranberry or prune juice c. Give 0.9% NaCl IV at 300 to 500mL/hr up to 6 liters as ordered until volume status restored, then 0.45% NaCl may be used; watch for fluid overload as a complication, especially with preexisting cardiac or respiratory disease d. Corticosteroids to decrease GI absorption of Ca++: prednisone 20 to 50 mg po BID is usual dose or 40 to 100 mg daily in four divided doses; may take 5 to 10 days for Ca++ levels to fall e. Chronic management of hypercalcemia is effective only with parathroidectomy for primary hyperparathyroidism

HypoMagnesemia Overview (See answer)

2.Usually occurs with nutritional or metabolic abnormalities, decreased absorption, increased renal loss, or redistribution of body magnesium 3.Predisposing clinical conditions a. Chronic alcoholism is most common cause b. Decreased dietary intake or prolonged IV therapy without Mg++ supplementation; in parenteral nutrition therapy, Mg++ moves into cells from bloodstream, leading to low serum Mg++ levels c. Decreased absorption: inflammatory bowel disease, small bowel resection (less surface available to absorb), GI cancer, chronic pancreatitis, or medications such as gentamicin (an aminoglycoside antibiotic) or cisplatin (an antineoplastic agent) d. Increased intestinal (lower GI) losses: prolonged diarrhea, draining intestinal fistulas, and ileostomy e. Increased renal excretion: loop diuretics, hyperaldosteronism that leads to volume expansion, diabetes that leads to osmotic diuresis f. Losses can also occur because of burns and debridement therapy

Predisposing Clinical conditions of Hypermagnesemia (See answer)

3.Predisposing clinical conditions a. Untreated diabetic ketoacidosis (glucose carries cations across cell membranes) b. Adrenal insufficiency (Addison's disease): causes fluid and electrolyte shifts c. Mg++ treatment in preeclampsia of pregnancy d. Lithium ingestion e. Volume depletion

Predisposing factors of Hypokalemia

3.Predisposing factors a. Increased secretion of aldosterone leading to excretion of K+ from renal tubules (adrenal adenomas, cirrhosis, nephrosis, heart failure and hypertensive crisis, Cushing's syndrome, diabetes insipidus) b. Excessive loss of K+ by loop diuretics, thiazide diuretics, corticosteroids, cardiac glycosides, penicillins, amphotericin B, gentamicin, theophylline, cisplatin, and tocolytic agents c. GI loss by vomiting, diarrhea, prolonged nasogastric suctioning, newly created ileostomy, villous adenoma on intestinal tract, laxative abuse, or enema administration d. Heat induced diaphoresis e. Renal disease affecting reabsorption of K+ seen in diuretic phase of renal failure f. Hemodialysis and peritoneal dialysis g. Reduced intake (K+ restricted diets), NPO status without sufficient IV replacement therapy, starvation, malnutrition, alcoholism, anorexia, high glucose levels (leading to diuresis), large ingestion of black licorice (causes aldosterone effects)

Normal partial pressures of carbon dioxide? (PaCO2)

35 to 45 mmHg

How to treat a HyperCalcemia Crisis

4.Treatment of hypercalcemic crisis a. 0.9% NaCL at 300 to 500mL/hr initially and up to 6 liters until intravascular volume restored or calcium level is 8 to 9 mg/dL b. Bisphosphonates, such as pamidronate IV to inhibit bone resorption; returns Ca++ to normal within 24 to 48 hours with effects lasting for weeks in most clients c. Salmon calcitonin may temporarily lower Ca++ level by 1 to 3 mg/dL in clients with severe hypercalcemia d. Phosphorus IV to decrease Ca++ because of inverse relationship in emergency situations only

Normal partial pressure of O2 in arterial blood? (Pa02)

80 to 100 mmHg

A client with a feeding tube has been experiencing severe watery diarrhea. The client is lethargic with decreased skin turgor, a pulse rate of 110bpm, and hyperactive reflexes. The nurse would include which of the following interventions on the client's plan of care? Select all that apply. A. Monitor and record intake, output, and daily weights B. Administer salt tablets C. Withhold tube feedings until diarrhea subsides D. Avoid adding additional water before and after tube feedings E. Initiate seizure precautions

A, E: The client is exhibiting signs of hypernatremia and dehydration. Appropriate nursing interventions are to measure and record I&O (intake and output) and daily weight. The client is at risk to develop seizures secondary to an elevated sodium level. Administering salt tablets would further contribute to the client's hypernatremic state. Restricting fluid intake and holding feedings could worsen the hypernatremia and fluid volume deficit (hypertonic dehydration) as the client already has extensive fluid loss due to diarrhea, elevated pulse rate, and decreased skin turgor. Avoiding adding additional water would worsen the hypertonic dehydration.

The nurse should include dietary teaching regarding addition of potassium rich foods if the client is receiving which diuretic? Select all that apply. A. Hydrochlorothiazide B. Spironolactone C. Triamterene with hydrochlorothiazide D. Amiloride E. Furosemide

A,E: Hydrochlorothiazide (HCTZ) and furosemide are diuretics that increase the excretion of potassium, so clients should be taught to increase the intake of potassium in their diet. All of the other medications are considered potassium-sparing or combination diuretics and, as such, dietary supplementation would not be indicated.

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate? A: Metabolic acidosis B: Metabolic alkalosis C: Respiratory acidosis D: Respiratory alkalosis

A: Respiratory alkalosis A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

What two things should you avoid with HyperKalemia?

Avoid foods that are high in K+ Avoid salt substitutes

A 78-year-old client is admitted with dehydration and urinary tract infection. After IV infusion of 750mL normal saline, the client begins to cough and asks for the head of the bed to be raised to ease breathing. The nurse assesses jugular vein distention (JVD) and increased respiratory rate. How should the nurse interpret this data? A. The fluid volume deficit is worsening. B. Hypervolemia is developing. C. Hypotonic water intoxication is beginning. D. Ascites is causing respiratory compromise.

B. Hypervolemia is developing. Dyspnea and increased respiration are most likely caused by fluid accumulation in the lungs, both signs of fluid volume excess. The jugular vein distention is also a sign of fluid accumulation related to hypervolemia. The client is exhibiting signs of fluid volume excess, not fluid volume deficit. The client is receiving an isotonic solution, not a hypotonic solution. The client does not show evidence of accumulation in the abdomen related to ascites, but rather in the lungs and jugular veins.

Client teaching for Hypophosphatemia

D. Client teaching 1.Predisposing factors and signs and symptoms of hypophosphatemia 2.Avoiding phosphorus-binding antacids 3.Increase intake of foods high in phosphorus

HypoCalcemia Nursing Assessment (See answer)

B. Nursing assessment 1.Cardiovascular - decreased blood pressure; ECG changes include prolonged QT interval and lengthened ST segment; cardiac arrest 2.Neuromuscular - paresthesias in hands and feet; muscle cramps, positive Chvostek sign (twitching of cheek) and Trousseau sign (spasm of arm when BP cuff inflated); increased deep tendon reflexes (DTRs), increased irritability and apprehension; mental status changes ranging from depression, memory impairment, delusions and hallucinations to seizures 3.Renal - decreased serum Ca++ are associated with renal failure, along with other electrolyte disturbances 4.Gastrointestinal (GI) - possible hyperactive bowel sounds and diarrhea, intestinal cramps 5.Musculoskeletal - possible bone fractures from bone demineralization; bone pain; chronic hypocalcemia may retard growth and cause rickets in children; can lead to osteomalacia and osteoporosis in adults

Hypomagnesemia Nursing Asssessment (See answer)

B. Nursing assessment 1.Clinical manifestations usually appear when serum Mg++ level drops below 1 mEq/L 2.Respiratory: laryngeal stridor 3.Cardiovascular: supraventricular tachycardia, premature ventricular contractions and ventricular fibrillation, and increased susceptibility to digitalis toxicity (possibly enhanced by concurrent hypokalemia) 4.ECG changes: diminished voltage of P wave; broad, flat, or inverted T waves; depressed ST segments; prolonged QT interval; possible prominent U wave 5.Neuromuscular: mood changes, such as apathy, depression, and confusion; muscle twitching, tremors, hyperreactive reflexes 6.GI: nausea and vomiting, diarrhea, and anorexia (from concurrent hypokalemia 7.Growth failure in children can occur 8.Severe deficiency can lead to convulsions, hallucinations, or tetany 9.Signs and symptoms are similar to hypokalemia or hypocalcemia (all are cations and may occur together); positive Chvostek's sign (twitching of cheek when stimulated) can occur

HypoPhosphatemia Nursing assessment

B. Nursing assessment 1.Hematologic effects (anemia from increased RBC fragility from low ATP levels), impaired granulocyte functioning (immunosuppression), bruising and bleeding from platelet dysfunction and destruction 2.Neuromuscular: slurred speech, confusion, apprehension, seizures, coma 3.Cardiac: chest pain, dysrhythmias related to decreased oxygenation, heart failure and shock from decreased myocardial contractility 4.Respiratory: alkalosis from an increased rate/depth of breathing in response to hypoxemia: respiratory muscle fatigue leading to respiratory failure 5.GI: hypoactive bowel sounds, anorexia, dysphagia, vomiting, gastric atony and ileus related to reduced gastric motility

HyperPhosphatemia Nursing assessment

B. Nursing assessment 1.Most signs relate to development of hypocalcemia or soft tissue calcification (calcium phosphate deposits in nonosseous sites such as kidney and heart) 2.Metastatic calcification includes oliguria, corneal haziness, conjunctivitis, irregular heart rate 3.Paresthesias (especially lips and fingertips), muscle spasms, and tetany (positive Chvostek and Trousseau signs) from decreased Ca++ that accompanies increased phosphorus 4.Anorexia, nausea, vomiting

Nursing assessment of Hypermagnesemia (See answer)

B. Nursing assessment 1.Neuromuscular symptoms (most common): decreased DTRs and depressed neuromuscular activity; symptoms are similar to those seen in hyperkalemia 2.Cardiovascular: hypotension, bradycardia, bradyarrhythmias, flushing and sensation of warmth, possible cardiac arrest 3.ECG may show prolonged PR interval, widened QRS complex, and elevated T wave

Nursing assessment Hypochloremia

B. Nursing assessment 1.Neuromuscular: tremors and twitching 2.Respiratory: slow and shallow breathing 3.Cardiac: hypotension if severe Cl- and ECF losses 4.Seldom a primary problem; usually associated with hyponatremia, hypokalemia, metabolic alkalosis or hypokalemic alkalosis

Nursing Assessment of Hyperchloremia

B. Nursing assessment 1.Neuromuscular: weakness and lethargy; can progress to significant CNS damage 2.Respiratory: deep, rapid, vigorous breathing that can lead to unconsciousness (results from attempt to compensate for acidotic state due to loss of bicarbonate) 3.Cardiac: dysrhythmias due to retained Cl- and result acid-base imbalance 4.Increased aldosterone leads to greater reabsorption of both Na+ and Cl- 5.Fluid volume disturbances: dehydration, retention of salt and water due to drug administration, and a greater Na+ loss than Cl- loss 6.Increased Cl- sweat levels are seen in diabetes insipidus, hypothyroidism, malnutrition, acute renal failure, and certain genetic disorders such as cystic fibrosis and glucose-6-phosphate-dehydrogenase (G6PD) deficiency 7.Associated electrolyte imbalances that usually occur with elevated Cl- levels and elevated K+ and Na+ levels and decreased HCO3-

Nursing Assessment HyperCalcemia (See answer)

B. Nursing assessment 1.Cardiovascular - hypertension, shorten ST segments and QT interval on ECG, cardiac dysrhythmias such as heart block; cardiac arrest 2.Neuromuscular - headache and confusion, subtle changes in personality to acute psychosis, fatigue, decreased deep tendon reflexes (DTRs); impaired memory and bizarre behavior, lethargy, or coma (seizures are rare) 3.Renal - polyuria and polydipsia due to altered renal function; decreased ability of kidneys to concentrate urine; renal colic from development of kidney stones due to high Ca++ levels; renal failure may occur 4.Gastrointestinal (GI) - anorexia, nausea and vomiting; abdominal pain; constipation, hypoactive bowel sounds 5.Musculoskeletal - pathologic bone fractures; bone thinning, deep bone pain

Nursing Assessment (HyperKalemia) See answer

B. Nursing assessment 1.Cardiovascular - irregular, slow heart rate, decreased blood pressure, ECG changes (narrow, peaked T waves, widened QRS complexes, prolonged PR intervals, flattened P waves, frequent ectopy, ventricular fibrillation and standstill) 2.Respiratory - unaffected until level is very high, leading to muscle weakness and paralysis and causing respiratory failure 3.Neuromuscular - muscle twitching (early) and cramps, irritability, anxiety; a late sign is ascending flaccid paralysis involving arms and legs 4.Gastrointestinal (GI) - hyperactive bowel sounds, diarrhea, nausea 5.Other - not applicable

Nursing assessment of Hypokalemia

B. Nursing assessment 1.Cardiovascular - weak, thread pulse with variable rate; pedal pulses difficult to palpate; ECG changes (ST segment depression, flattened T wave, onset of U wave, ventricular dysrhythmias, heart block); digitalis toxicity is potentiated 2.Respiratory - decreased breath sounds; weak, shallow respirations; dyspnea 3.Neuromuscular - anxiety, lethargy, depression, confusion, paresthesias, weakness, leg cramps 4.Gastrointestinal (GI) - nausea, diarrhea or constipation (from decreased peristalsis), polydipsia 5.Other - renal: polyuria and nocturia, decreased urine specific gravity

Define Normal BUN levels

BUN 10 to 20 mg/dL

Which serum electrolyte imbalances would the nurse assess for in a child admitted with a high fever and severe dehydration? Select all that apply. A. Hypercalcemia B. Hypokalemia C. Hypernatremia D. Hyperchloremia E. Hypophosphatemia

C, D: The combination of high fever and severe dehydration leads to insensible water loss. This indicates a loss of pure water and does not contain electrolytes. Therefore, excessive amounts of insensible water loss result in a hypertonic dehydration that leads to a state of hypernatremia and hyperchloremia. Calcium levels usually decrease in the presence of dehydration and fever. Phosphate levels usually increase in the presence of dehydration and fever. Potassium levels can usually remain normal in the serum and are increased in the urine. Sodium and chloride usually go hand-in-hand.

Therapeutic management of Hypochloremia

C. Therapeutic management 1.Administer oral salt tablets 2.Provide IV infusion of Cl- (as NaCl or KCl) if levels are critical or client is unable to tolerate oral dose 3.Monitor I&O because excess water administration can cause dilutional hypochloremia and hyponatremia 4.Monitor BP (a drop can occur if hypochloremia is caused by ECF volume loss) 5.Monitor ABG results if clinical presentation or underlying medial history suggests accompanying acid-base imbalance 6.Maintain safety precautions: keep bed rails up and assist with ambulation if client has muscle tremors and/or decreased BP 7.Dietary therapy: foods high in Cl-, such as salt, processed foods, canned vegetables, dates, bananas, cheese, spinach, milk, eggs, celery, crabs, fish, olives, and rye

HypoPhosphatemia Therapeutic management

C. Therapeutic management 1.Administer phosphorus via oral supplements; dissolve dose in a full glass of water and give after meals to minimize gastric irritation and laxative effect 2.Provide IV replacement and monitor infusion site for infiltration, which may lead to tissue necrosis or sloughing 3.Avoid use of phosphorus-binding antacids 4.Assess clients for difficulty speaking; note weakening respiratory efforts; have appropriate size airway available 5.Assess serial hand grasps for increasing weakness 6.Investigate episodes of bleeding and/or bruising 7.Monitor for other associated fluid and electrolyte imbalances, especially in clients with nausea, vomiting, and/or diarrhea 8.Assess orientation and neurologic status with each set of vital signs; incorporate seizure precautions into care 9.Carefully monitor fluid I&O 10. Increase intake of foods high in phosphorus, such as red and organ (brain, liver, kidneys) meats, fish, poultry, eggs, milk and milk products, legumes, whole grains, and nuts 11. Reduce dietary sources of oxalates (spinach and rhubarb) and phytates (bran and whole grains), which bind phosphates in GI tract and reduce absorption

Therapeutic management of Hyperchloremia

C. Therapeutic management 1.Decrease Cl- intake: stop all chloride-containing agents used as treatment measures 2.Promote Cl- excretion by administering diuretics 3.Continue monitoring client, including acid-base, respiratory, and cardiac status 4.Monitor vital signs and I&O parameters 5.Promote client safety 6.Hypotonic IV solutions such as 0.45% NaCL and D5W to correct dehydration or IV diuretics to promote Cl- loss

Therapeutic Management (HyperKalemia)

C. Therapeutic management 1.Decrease K+ intake: implement prescribed K+ restrictions; do not administer K+ supplements; refer client to dietitian to evaluate hidden dietary intake of K+ 2.Promote K+ excretion: increase urinary output and monitor adequate renal function 3.Continues monitoring of client: serum K+ levels; report abnormals; assess cardiac status, and signs and symptoms of hyperkalemia and metabolic acidosis 4.Whenever possible, determine and treat underlying cause to restore balance 5.Dialysis may be performed for intractable conditions to prevent development of potentially lethal problems 6.Monitor for response to therapeutic treatment 7.Sodium polystyrene sulfonate, to reduce K+ levels, can be given either orally or as an enema with an osmotic agent (sorbitol) to decrease possible constipation 8.Intravenous medications a. Calcium gluconate b. Regular insulin and dextrose (usually 50%) solution (shifts K+ from ECF to ICF) c. Sodium bicarbonate 9.K+ wasting diuretics (loop diuretics and thiazide and thiazide-like diuretics)

Therapeutic Management of Hypermagnesemia (See answer)

C. Therapeutic management 1.Decrease Mg++ intake; withhold Mg++-containing drugs (antacids) and enemas 2.Promote Mg++ excretion using diuretics (in stable renal function) 3.Provide rehydration to promote increased urine output and Mg++ excretion 4.Emergency treatment includes IV calcium gluconate to antagonize effect of Mg++ and counteract cardiac and respiratory symptoms 5.Dialysis: in clients with renal failure, dialysis may be necessary for Mg++ removal; if hemodialysis is not feasible, peritoneal dialysis is an option 6.Monitor I&O 7.Identify risk factors such as antacid use, laxative use, diabetic instability, and renal failure 8.Promote client safety

Therapeutic management of HypoKalemia

C. Therapeutic management 1.Focuses on restoring normal levels, preventing complications, and treating underlying problems 2.If client also has hypocalcemia and/or hypomagnesemia, all electrolyte levels must be corrected together 3.Check for signs of metabolic alkalosis (including irritability and paresthesias) because hypokalemia is present in alkalotic states 4.Monitor pertinent client assessment data for potential effects related to hypokalemia and for response to therapeutic treatment a. Vital signs, especially BP (hypokalemia can lead to orthostatic hypotension) and respiratory rate, depth, and pattern b. Serum electrolyte levels c. ECG changes and heart rate and rhythm pattern d. I&O and possible daily weight 5.Monitor therapeutic serum drug levels for clients taking cardiac glycosides (digoxin) and serum K+ levels for clients taking loop and thiazide diuretics 6.Protect client from injury and maintain a safe environment because client may experience weakness due to hypokalemia 7.Dietary intervention to promote normal K+ levels a. Encourage high-fiber diet and increased fluid intake, if not on fluid restriction, to prevent constipation b. Provide adequate dietary sources of K+ i. Vegetables such as spinach, broccoli, carrots, green beans, tomato juice, acorn squash, and potatoes ii. Fruits such as bananas, cantaloupe, apricots, oranges, and raisins iii. Milk, milk products, yogurt, and meat iv. Legumes, nuts, and seeds v. Whole grains c. Avoid foods such as black licorice that, when eaten in large quantities, can cause hypokalemia 8.Oral replacement therapy (note: K+ supplements should never be given unless client has a urine output of at least 0.5mL/kg/hour) a. Usual dose is 20 mEq; higher doses (up to 100 mEq in divided doses) may be given depending on client's baseline b. Medication can be given in either liquid or pill form 9.Administer parenteral K+ carefully a. Verify additive K+ in solution prior to hanging infusion b. Always use an infusion pump, paying attention to rate, intake and output c. Do not exceed an infusion rate of 5 to 10 mEq/hr unless there is moderate hypokalemia d. Dilute K+ in a solution that provides no more than 1 mEq/10mL e. If more than 20 mEq/hr is given, use continuous ECG monitoring and check serum level every 4 to 6 hours until normal f. Monitor IV site closely because potassium chloride (KCl) is irritating to blood vessels and can lead to infiltration, phlebitis, and tissue necrosis; this could cause sloughs that may require skin grafts g. Never administer K+ by IV push or intramuscular routes because these methods can lead to fatal dysrhythmias

Therapeutic Management of Hypomagnesemia

C. Therapeutic management 1.Identify risk factors: malabsorption and/or GI dysfunction, renal disease, diabetes, alcohol intake, and medications such as diuretics 2.Monitor client with continuous IV fluid therapy without Mg++ replacement 3.Monitor client with hyperaldosteronism because volume expansion may result in decreased Mg++ 4.Monitor client taking a diuretic for increased renal excretion of Mg++ 5.Institute ECG monitoring and seizure precautions 6.Monitor for stridor and/or difficulty swallowing 7.Keep bed rails raised if client is confused; take other safety precautions as needed 8.Maintain accurate intake and output records 9.Monitor DTRs in clients receiving IV solutions containing Mg++; depressed DTRs indicate a rebound elevated Mg++ level 10. Medication therapy Oral replacement therapy: Mg++-containing antacids; magnesium oxide; use caution because they may cause diarrhea, leading to decreased absorption Parenteral magnesium sulfate or magnesium chloride Ensure urine output of at least 30mL/hr or 120mL every 4 hours during therapy to avoid rebound Hypermagnesemia if renal insufficiency is present Monitor DRTs (such as patellar reflex) before each dose of parenteral Mg++; if reflex is present, Hypermagnesemia from previous doses has not occurred Dietary therapy: for mild hypomagnesemia, encourage foods high in Mg++, such as legumes, whole grain cereals, nuts, dark green vegetables, seafood, bananas, oranges, and chocolate

HyperPhosphatemia Therapeutic management

C. Therapeutic management 1.Restrict dietary phosphorus: avoid medications or enemas with phosphorus 2.Administer phosphate binding agents 3.Perform renal dialysis in clients with renal failure 4.Treat concurrent hypocalcemia 5.Monitor renal function carefully, particularly urine output, BUN, creatinine 6.Monitor I&O; keep clients well hydrated; pay particular attention to types of fluids being ingested (avoid carbonated beverages, which are high in phosphates)

Therapeutic management of HypoCalcemia (See answer)

C. Therapeutic management 1.Treatment focuses on restoring normal levels, preventing complications, and treating underlying problems 2.Replacement therapies a. Calcium gluconate (more common) or calcium chloride (less common; irritating to vein) by slow IV push in an emergency; may give slow IV infusion of calcium gluconate until tetany has been controlled or until calcium reaches 8 to 9 mg/dL b. Daily oral doses of elemental Ca++, usually 1.0 to 3.0 grams/day c. Calcitrol, vitamin D supplements, or phosphorus-binding antacids based on need d. Thiazide diuretics may be used to decrease urinary excretion of calcium 3.Continue monitoring client (laboratory values and clinical condition) for treatment effectiveness a. Continuous ECG monitoring, especially during calcium gluconate or calcium chloride administration b. Continually reassess neurologic, respiratory, and cardiac status c. Monitor clients receiving Ca++ replacement who are also on digitalis for enhanced digitalis effect - check pulse

Define the normal Calcium Levels

Calcium (Inverse to phosphorus) 8.5-10.5

List the two electrolytes that have a inverse relationship

Calcium and Phosphorus

Which of the following is considered an isotonic solution? Dextran in NS 0.45% normal saline 0.9% normal saline 3% NaCl

Correct response: 0.9% normal saline Explanation: An isotonic solution is 0.9% normal saline (NaCl). Dextran in NS is a colloid solution, 0.45% normal saline is a hypotonic solution, and 3% NaCl is a hypertonic solution.

A 54-year-old male patient is admitted to the hospital with a case of severe dehydration. The nurse reviews the patient's laboratory results. Which of the following results are consistent with the diagnosis? Select all that apply. Blood urea nitrogen (BUN) of 23 mg/dL Serum osmolality of 310 mOsm/kg Serum sodium of 148 mEq/L Serum glucose of 90 mg/dL Urine specific gravity of 1.03 Hematocrit level of 48%

Correct response: Blood urea nitrogen (BUN) of 23 mg/dL Serum osmolality of 310 mOsm/kg Serum sodium of 148 mEq/L Urine specific gravity of 1.03 Explanation: Severe dehydration is associated with an increased BUN (N = 10 to 20 mg/dL), serum osmolality (N = 275 to 300 mOsm/kg), serum sodium (N = 135 to 145 mEq/L) and urine specific gravity (N = 1.01 to 1.025). Glucose and hematocrit levels would also be elevated but are within normal range for this question.

Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism? Chest pain Hypertension Slow pulse Jaundice

Correct response: Chest pain Explanation: Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain. Jaundice is not associated with air embolism.

The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration? Cool and pale skin Crackles in the lung fields Distended jugular veins Dark, concentrated urine

Correct response: Dark, concentrated urine Explanation: Dehydration indicates a fluid volume deficit. Dark, concentrated urine indicates a lack of fluid volume. Adding more fluid would dilute the urine. The other options indicate fluid excess.

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level? No effect Increases arterial pH Decreases arterial pH Provides long-term pH regulation

Correct response: Increases arterial pH Explanation: Respiratory alkalosis is always caused by hyperventilation, which is a decrease in plasma carbonic acid concentration. The pH is elevated above normal as a result of a low PaCO2.

The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which? Lung function Summer allergies Insensible fluid loss Cardiovascular compromise

Correct response: Insensible fluid loss Explanation: Due to the high heat and humidity, geriatric clients are at a high risk for insensible fluid loss through perspiration and vapor in the exhaled air. These losses are noted as unnoticeable and unmeasurable. Those with respiratory deficits and allergies may be only able to be outside for a limited period. Those with cardiovascular compromise may need to alternate outdoor activities with indoor rest.

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? Administer an ordered decongestant. Instruct the client to breathe into a paper bag. Offer the client fluids frequently. Administer ordered supplemental oxygen.

Correct response: Instruct the client to breathe into a paper bag. Explanation: The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn't raise the lowered PaCO2 level.

The nurse is analyzing the electrocardiographic (ECG) rhythm tracing of a patient experiencing hypercalcemia. Which of the following ECG changes is typically associated with this electrolyte imbalance? Prolonged PR intervals Prolonged QT intervals Peaked T waves Elevated ST segments

Correct response: Prolonged PR intervals Explanation: Cardiovascular changes associated with hypercalcemia may include a variety of dysrhythmias (e.g., heart blocks) and shortening of the QT interval and the ST segment. The PR interval is sometimes prolonged. The other changes are not associated with an elevated serum calcium level.

A patient is diagnosed with hypocalcemia. The nurse advises the patient and his family to immediately report the most characteristic manifestation. What is the most characteristic manifestation? Confusion and depression Tingling or twitching sensation in the fingers Dyspnea and laryngospasm Hyperactive bowel sounds.

Correct response: Tingling or twitching sensation in the fingers Explanation: All the choices are signs and symptoms of hypocalcemia, but tetany is the most characteristic manifestation that occurs when the calcium level is less than 4.4 mg/dL.

HyperPhosphatemia Client teaching

D. Client teaching 1.Purpose of phosphate bingers; take them with or after meals to maximize effectiveness 2.Avoid OTC phosphorus in laxatives, enemas, and vitamin-mineral supplements 3.Use bulk-binding supplements or stool softeners to combat constipating effects of some phosphate-binders, especially those with an aluminum base 4.Avoid or limit foods high in phosphorus, as previously described, and avoid carbonated beverages, which have low nutrient value and are also high in phosphates

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? pH, 7.5; PaCO2 30 mm Hg pH, 7.40; PaCO2 35 mm Hg pH, 7.35; PaCO2 40 mm Hg pH, 7.25; PaCO2 50 mm Hg

Correct response: pH, 7.25; PaCO2 50 mm Hg Explanation: In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. A ph value of 7.40 with a PaCO2 value of 35 mm Hg and a pH value of 7.35 with a PaCO2 value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs.

The nurse is analyzing the arterial blood gas (AGB) results of a patient diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis? pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L pH: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /L

Correct response: pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Explanation: Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3-: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3-: 22 mEq/L indicate a normal result/no imbalance.

Define Normal Creatinine Levels

Creatinine 0.7 to 1.4 mg/dL

Client teaching (HypoKalemia)

D. Client teaching 1.Report signs and symptoms of hypokalemia to physician 2.Take K+ supplements with at least 4 ounces fluid or with food 3.Never crush or break K+ tablets or capsules 4.Dissolve powder form of K+ in at least 4 ounces of water or other fluids (no carbonated beverages) 5.Take K+ after meals to prevent GI upset 6.Do not use salt substitutes when taking K+ supplements 7.Know and report signs and symptoms of hyperkalemia to health care provider 8.Get regular serum K+ levels drawn per health care provider's recommendation

Client teaching Hypochloremia

D. Client teaching 1.Predisposing factors 2.Include in diet Na+ and processed foods that are also high in Cl- 3.Electrolyte replacement as well as fluid replacement is important if activity level is increased and client perspires excessively

A client was admitted to your unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and his family? Select all that apply. Drink at least eight glasses of fluid each day. Drink caffeinated beverages to retain fluid. Drink carbonated beverages to help balance fluid volume. Drink water as an inexpensive way to meet fluid needs. Respond to thirst

Drink at least eight glasses of fluid each day. Drink water as an inexpensive way to meet fluid needs. Respond to thirst Explanation: In addition, the nurse teaches clients who have a potential for hypovolemia and their families to respond to thirst because it is an early indication of reduced fluid volume; consume at least 8 to 10 (8 ounce) glasses of fluid each day and more during hot, humid weather; drink water as an inexpensive means to meet fluid requirements; and avoid beverages with alcohol and caffeine because they increase urination and contribute to fluid deficits.

Define Hypervolemia

Excess Fluid Volume

Define HyperCalcemia

HYPERCALCEMIA A. Overview 1.Hypercalcemia: a serum Ca++ level greater than 10.5mg/dL (normal range 8.5- 10.5mg/dL); symptoms may not appear until serum Ca++ level is higher than 12mg/dL

Hypochloremia overview (See answer)

HYPOCHLOREMIA A. Overview 1.Hypochloremia: a serum chloride (Cl-) level less than 95 mEq/L (normal range 95 - 108 mEq/L) a. Decreases in Cl- usually are accompanied by decreases in Na+ and K+ b. A reduction in hydrochloric acid decreases Cl- c. Chloride is excreted with cations during massive diuresis when HCO3- is elevated

Consequences of HypoKalemia?

Has widespread effects on body, and if severe or not corrected quickly, death can result from cardiac and respiratory arrest

Define normal percentage of Hematocrit in males and females

Hematocrit 42%-52% (males), 35%-47% (females)

Define HyperKalemia

Hyperkalemia: a serum K+ level greater than 5.1 mEq/L (normal range 3.5-5.1 mEq/L)

Define Hypervolemic state

Hypervolemic state - greater gain of sodium in relation to fluids, leading to elevated serum sodium.

Define HypoCalcemia

Hypocalcemia: a serum calcium (Ca++) level less than 8.5 mg/dL (normal range 8.5 - 10.5 mg/dL) or decreased availability of ionized Ca++

HypoCalcemia risk factors (See answer)

Hypoparathyroidism or post-thyroidectomy Hypomagnesemia Alkalotic states Multiple blood transfusions Hypoalbuminemia Acute pancreatitis Hyperphosphatemia Vitamin D deficiency Malabsorptive states Renal disease Alcoholism Neonatal hypocalcemia Gram-negative sepsis Medullary thyroid carcinoma Burns 3.Other risk factors a. Postmenopausal women not taking estrogen b. Family history of hereditary hypoparathyroidism c. History of Crohn's disease or small bowel dysfunction d. Increased incidence of fractures; osteoporosis and/or osteopenia e. Immobility f. Dietary patterns that lack adequate Ca++ and vitamin D sources g. Excessive use of dietary phosphorus supplements h. Eating disorders with laxative use as part of dietary pattern i. Lactose-intolerance unless alternative products are used j. Dietary factors that limit absorption of Ca++ (oxalates such as spinach and rhubarb, phytates such as bran and whole grains, and tannins as in tea) k. Medications (loop diuretics, antiepileptics, citrate-buffered blood products, phosphates, antineoplastic agents, radiographic contrast media, corticosteroids, bisphosphonates, antacids, and heparin)

List the two fluid compartments of the body and the ratio of fluid stored in each

Intracellular (2/3rds) Extracelluar (1/3) • Intravascular (vessels) • Interstitial (surrounds cells) • Transcellular (helps cells move)

Define the normal magnesium levels

Magnesium 1.8. - 2.7

What creates Osmotic Pressure (pulling power for water?)

Osmolality and osmolarity refer to concentration of a solution, which creates its osmotic pressure (pulling power of a solution for water)

Define Osmolality

Osmolality is concentration of solute (particles) measured per kilogram of water

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality? Sodium Potassium Calcium Magnesium

Sodium Sodium is the primary determinant of ECF osmolality. Sodium plays a major role in controlling water distribution throughout the body because it does not easily cross the intracellular wall membrane and because of its abundance and high concentration in the body. Potassium, calcium, and magnesium are not primary determinants of ECF osmolality.

Define the Normal Serum Sodium levels

Sodium 135-145

List treatment of Hypervolemic state

Treatment - remove sodium source, administer diuretics, and replace water.

HyperKalemia Overview (See answer)

VII. HYPERKALEMIA A. Overview 1.Hyperkalemia: a serum K+ level greater than 5.1 mEq/L (normal range 3.5-5.1 mEq/L) 2.Actual hyperkalemia (K+ level in the extracellular fluid is elevated) a. Excessive K+ intake from K+ rich food or medications, use of salt substitutes, or rapid infusion of K+ containing IV solutions b. Decreased K+ excretion due to adrenal insufficiency (Addison's disease), renal failure, K+ sparing diuretics, or use of ACE inhibitors 3.Relative hyperkalemia (movement of K+ from intracellular fluid to extracellular fluid leading to elevated serum K+ levels without a true body increase of K+) a. Excessive cellular release: massive cell damage, burns, hyperuricemia in tumor lysis syndrome, major surgeries, and hypercatabolism b. Pseudohyperkalemia: hemolysis of blood sample c. Excessive transcellular shifting: metabolic acidosis, insulin deficiency, rapid increase in blood osmolality d. Medication therapy: digoxin use, overdose of replacement therapy, administration of stored blood (hemolysis of RBCs in solution increases serum K+), use of K+ sparing diuretics e. Addison's disease is associated with decreased aldosterone that leads to Na+ depletion and K+ retention

Osmosis

a process by which molecules of a solvent tend to pass through a semipermeable membrane from a less concentrated solution into a more concentrated one, thus equalizing the concentrations on each side of the membrane.

List common signs related to shift of water into cells

a. Cardiovascular - bounding pulse, tachycardia, hypotension (in decreased extra cellular volume), hypertension (in increased extra cellular volume) b. Integumentary - pale, dry skin and mucous membranes (in decreased extra cellular volume), edema and weight gain (in increased extra cellular volume) c. Renal - increased urine output with low specific gravity (<1.010) d. Neuromuscular - lethargy, agitation, dizziness, weakness, headache, confusion, seizures e. Gastrointestinal (GI) - anorexia, vomiting, diarrhea, hyperactive bowel sounds, abdominal cramping 2.Decreased BUN and Hct 3.Dietary: prolonged NPO status; excess infusion of non-electrolyte solutions, causing free water accumulation

What kind of water should patients suffering from Hypomagnesemia drink?

hard water or mineral water, which are high in Mg++

List treatments of Hypervolemic state

ii. Treatment - water restriction, treat existing disease states, loop diuretics such as furosemide, and restrict dietary salt intake.

Define Hypovolemic state

is a state of decreased blood volume; more specifically, decrease in volume of blood plasma

Define respiratory acidosis,

occurs when the lungs can't remove enough of the carbon dioxide (CO2) produced by the body. Excess CO2 causes the pH of blood and other bodily fluids to decrease, making them too acidic.

Define Metabolic Alkalosis

pH of tissue is elevated beyond the normal range (7.35-7.45). This is the result of decreased hydrogen ion concentration, leading to increased bicarbonate, or alternatively a direct result of increased bicarbonate concentrations.

Define "Biguanides"

prevent the production of glucose in the liver. The term biguanide refers to a group of oral type 2 diabetes drugs that work by preventing the production of glucose in the liver, improving the body's sensitivity towards insulin and reducing the amount of sugar absorbed by the intestines.

Define HyperPhosphatemia

serum phosphorus level of greater than 4.5 mg/dl (normal range 2.5 - 4.5 mg/dl)

Define HypoPhosphatemia

serum phosphorus level of less than 2.5mg/dl (normal range 2.5 - 4.5 mg/dl)

What emergencies may arise from HypoCalcemia?

tetany, seizures, laryngospasm, and respiratory and cardiac arrest

Define metabolic acidosis

the body produces excessive quantities of acid or when the kidneys are not removing enough acid from the body.