chapter 4 fluid and electrolyte

what are hormones that maintain homeostasis?

1. ADH vasopressin (antidiuretic hormone: retaining fluid. helping keeping your volume up) 2. aldosterone (help keep the volume of solutes and water maintain in the body) 3. BNP natriuretic peptide indicator of heart failure just a measure of fluid balanced in body

Diagnostic factors for hypervolemia

1. BNP (high) 2. CBC 3. Urine sample: Hct/Hgb low, Na+ low, serum osmolality low, urine Na+ low, urine specific gravity low, BUN low 4. blood samples 5. urine samples; CXR, ECHO 6. xray will be greyish white if you have fluid in lungs 7. echo to see fluid in heart 8. sodium levels will be high

diagnostics labs for fluid volume deficit?

1. CMP (complete metabolic panel liver) 2. CBC (complete blood count) 3. BMP (basal metabolic panel no liver enzyme) 4. Urine sample; Hct (fluid volume of blood high), BUN (kidney) , Cr, Na+ elevated 5. elevated serum osmolality (concentrated) 6. (dark urine, concentrated, high specific gravity) 7. blood samples 8. urine sample 9. BMP

hypermagnesemia risk factor

1. ESRD 2. untreated DKA 3. excess treatment for preeclampsia in pregnant patients 4. addison disease 5. hypothermia 6. increased used of antacids or laxatives

risk factors of hypochloremia

1. GI tube drainage 2. severe V/D 3. laxative 4. ileostomies 5. fistulas

Hypercalcemia risk factors

1. HCTZ therapy 2. hyperparathyroidism 3. ESRD 4. cancerous tumors increase Ca+

hypophosphatemia interventions

1. IV supplementation 2. monitor Ca+ levels 3. prevent infection 4. encourage PO phos intake (milk/milk products, organ meats, nuts, fish, poultry)

infiltration

1. IVF leaks out of vein into surrounding tissue 2. swollen, cold, painful 3. take IV out 4. stop fluid 5. warm compress

risk factors for hypomagnesemia

1. NG suctioning 2. diarrhea 3. intestinal fistulas 4. alcoholism 5. diuretic therapy 6. certain medications (aminoglycosides and amphotericin and cyclosporine) antibiotics 7. digoxin therapy

hypernatremia risk factors?

1. NPO 2. hypertonic enteral 3. diabetes insipidus 4. burns 5. cushing syndrome 6. increased intake of Na+

manifestations of hypochloremia

1. S/SX associated with hyponatremia, hypokalemia, and metabolic alkalosis

air embolism

1. always prime before flushing

Complications of hypervolemia

1. big trouble 2. pulmonary edema 3. fluid shifts to lungs

ECF

1. calcium 2. sodium 3. bicarbonate 4. chloride

pathophysiology hypokalemia

1. can result from transcellular shifts (from EC to IC spaces) or when K+ losses are increased 2. can be renal or non renal causes

pathophysiology of hyperkalemia

1. caused by increased intake, a shift of K+ from cells to ECF, decreased renal excretion of drugs that decreased K+ excretion

interventions for hypochloremia

1. correct the underlying cause 2. ensure adequate PO Cl- intake (tomato juice, bananas, dates, eggs, cheese, canned vegetables, processed meats) 3. monitor I&O 4. monitor ABGs 5. monitor LOC, muscle strength movement

interventions hyperglycemia

1. correct underlying cause 2. hypotonic IVF therapy 3. diuretics 4. restrict Na+, fluids, and Cl- 5. monitor I&O, ABGs, VS

osmolality/osmolarity

1. decrease is osmolality = increase in volume 2. increase in osmolality = decrease in volume 3. 1KG of a solvent 4. 1L of solution

*What are changes in our elderly patients?

1. decreased kidney perfusion 2. decreased skin turgor 3. decrease thirst 4. decreased nutrients 5. takes a lot of medications for different disease processes 6. comorbidity

pathophysiology of hypernatremia

1. develops when serum Na+ concentrations climb above 145 or when loss of H20 2. ICF down ECF up 3. hyperosmolarity is a common result; water is pulled out of cell into ECF cells shrinks!

pathophysiology of hyponatremia?

1. develops when serum Na+ concentrations fall under 136. 2. from inadequate intake of Na+ 3. from dilution of Na+ by water axcess 4. Na+ depletion cuasing hypoosmality with movement of water into cells = cells to swell! 5. ECF down ICF up

contributing factors to any loss of fluid?

1. diarrhea 2. vomiting 3. ostomy output 4. diuretic therapy 5. diabetes insipidus 6. CKD (chronic kidney disease) 7. NPO status 8. ETOH alcohol 9. burn victims (evaporation)

interventions for hypomagnesemia

1. dietary changes to increase PO Mg+ (nuts, seeds, seafood ) 2. magnesium salts 3. IV Mg replacement (slow- to fast can lead to heart block or asystole) 4. monitor UOP if supplementing 5. swallow eval to ensure safety 6. monitor DTR

hypokalemia manifestations

1. dysrhythmias 2. low BP 3. weak *4. flat T wave 5. S-T depression 6. shallow breathing 7. paresthesia (assess deep tendon reflex)

hyperkalemia manifestations

1. dysrhythmias 2. slow, irregular pulse 3. paresthesia 4. PVCs, V Fib, elevated T waves 5. widened QRS 6. increased bowel sounds, diarrhea

pathophysiology of hypercalcemia

1. excess caused by increased intake, a shift of Ca+ from cells to ECF, decreased renal excretion, or drugs that decrease renal Ca+ excretion

ECF

1. extra cellur fluid 2. outside of cells

What is tonicity (IVF)?

1. fluid replacement 2. example: shock

what interventions to do for hypervolemia?

1. give diuretics (lasix, HCTZ Etc.) 2. decrease IVF 3. limit Na+ intake 4. fluid restriction 5. daily weights 6. I&O 7. monitor VS 8. breath sounds 9. Head of bed elevated (fluid in the lungs makes it hard to breath)

Contributing factors to hypervolemia?

1. heart failure 2. kidneys failure 3. hormonal changes 4. increase in IVF 5. increase PO intake 6. liver failure (albumin) 7. high salt diet (retains water) 8. steroids

manifestations of hypomagnesemia

1. hyperexcitability 2. muscle weakness 3, tremors 4. athetoid movements (slow involuntary rising movements) 5. tetany 6. seizures 7. apathy, depression, apprehension and agitation

risk factors for hyperchloremia

1. hyperparathyroidism 2. hyperaldosteronism 3. kidney failure

fluid volume deficit

1. hypovolemia 2. low volume

risk factors of hyperphosphatemia

1. increased phos intake 2. decreased output 3. chemotherapy 4. hypoparathyroidism 5. metabolic/respiratory acidosis 6. profound muscle necrosis

Risk factors for hyponatremia

1. increased swelling 2. diuretics 3. wound drainage 4. decreased Na intake 5. increased IVF 6. hyperglycemia 7. SSRI therapy 8. SIADH

thrombophlebitis

1. inflammation due to clotting in the vein

phlebitis

1. inflammation of the vein 2. red, warm, painful

ICF

1. intracellular fluid 2. inside

risk factors of hypophosphatemia

1. irritability 2. fatigue 3. weakness 4. dysphagia 5. tissue anoxia 6. hyperglycemia r/t insulin resistance 7. bruising 8. bleeding 9. antacid with calcium and magnesium 10. rhabdomyolysis

All involved in fluid shifting back in fourth

1. kidneys 2. lungs 3. heart 4. adrenal gland 5. parathyroid glands 6. pituitary glands

hyperkalemia interventions

1. lab draws to confirm 2. EKG 3. ABG 4. loop diuretics 5. SPS therapy (causes bowel movement) 6. consult neurology, cardiology

interventions for hyporkalemia

1. lab draws to confirm 2. EKG 3. monitor K+ levels 4. monitor I&Os, VS, rhythm, LOC, bowel sounds, DTRs 5. encourage K+ rich foods (bananas, avocados, broccoli, meloris, citrus fruits, dark leafy greens) 6. K+ supplements (liquid, IVPB, pill form)

hypokalemia interventions

1. labs to confirm (CMP) 2. EKG 3. Ca+ supplement (PO and IV) 4. vitamin D supplements 5. PO Ca+ sources (dairy products, canned salmon, fresh oysters, dark leafy green vegetables) 6. consult endocrinology cardiology 7. all calcium need to be slow you can put patient in cardiac arrest if fast

hypocalcemia risk factors

1. lactose imbalance 2. crohn's disease 3. ESRD 4. thyroidectomy 5. hypoparathyroidism 6. low PO Ca+ intake

interventions for hypermagnesemia

1. loop diuretic therapy 2. IVF therapy 3. EKG 4. monitor VS 5. monitor kidney function

hypokalemia risk factors

1. loop diuretic therapy 2. digoxin therapy 3. steroid therapy 4. V/D 5. tap water enemas *6. prolonged NG suctioning 7. CKD

manifestations of hypermagnesemia

1. low bp 2. N/V 3. weakness 4. soft tissue calcifications 5. facial flushing 6. DTRs are lost 7. respiratory depression 8. heart block

pathophysiology of hypomagnesemia

1. magnesium is an activator for many IC enzyme system and plays a role in both carbohydrates and protein metabolism 2. often results for alcoholism or GI losses

pathophysiology of hypermagnesemia

1. magnesium is an activator for many IC enzyme systems and plays a role in both carbohydrate and protein metabolism 2. rare; usually caused by renal failure

pathophysiology of hypochloremia

1. major anion in the ECF 2. rarely occurs in the absence of other abnormalities

Pathophysiology of hyperchloremia

1. major anion in the ECF 2. related to bicarbonate loss, metabolic acidosis, and hypernatremia

interventions of hypernatremia

1. monitor VS 2. monitor labs, I&Os, LOC 3. provide oral hygiene 4. encourage H20 intake 5. loop diuretics 6. DDAVP therapy 7. salt substitutes (Mrs Dash)

What to monitor and inventions of fluid volume deficit

1. monitor VS 2. track UOP 3. admin IVF 4. encourage PO intake if possible 5. monitor weight 6. fall precaution (dizziness and confusion, orthostatic HXTN) 7. re position slowly 8. monitor LOC (where are you) vital will improve 1. heart come down 2. bp go up 3. temp decrease 4. respirations rate go down

manifestations of hyperphosphatemia

1. most are due to calcium fluctuations 2. tetany 3. anorexia 4. N/V 5. bone and joint pain 6. hyperreflexia

hypotonic solution

1. net water gain 2. lower particles high water 3. 0.5 normal saline 4. decreased ECF 5. decreased salt 6. swells 7. sugar free water down juice 8. Increase in ICF

hypertonic

1. net water loss 2. increase in ECF 3. increased salt 4. cell shrinks 5. d50 and d20 6. decrease in ICF

pathophysiology of hypocalcemia

1. not enough Ca+ in the ECF 2. caused from insufficient PO Ca+ intake 3. inadequate PTH and vitamin D levels 4. low calcium high phosphorus vis versus

isotonic solution

1. not net loss or gain 2. cell remains the same fluid and salt are the same inside and out 3. 0.9% sodium chloride

complications of fluid volume deficit

1. organ instability 2. hypovolemic shock (organ failure, low o2 3. low intravascular space

pathophysiology of hypophosphatemia

1. phosphorus is necessary for multiple physiological processes 2. can results from use of nutritional supplements (enteral or parenteral feeding)

hyperphosphatemia pathophysiology

1. phosphorus is necessary for multiple physiological processes 2. usually results from renal failure 3. often asymptomatic (mostly see low calcium signs)

ICF

1. potassium 2. magnesium 3. phosphorus 4. proteins

what electrolytes hang out in the ICF?

1. potassium 2. magnesium 3. phosphorus 4. proteins

Skin infections

1. red, tender, warm, exudate, hard on palpation 2. SCRUB the skin before sticking

Interventions for hyponatremia?

1. restrict H20 intake 2. seizure precaution 3. tolvaptan therapy 4. foods high in sodium (beef broth, tomato soup, cheeses, processed foods/meats 5. hypertonic solution

hyperkalemia risk factors

1. salt substitutes (Mrs Dash) 2. K+ sparing diuretics 3. ACEI 4. DKA 5. post MI

manifestations of hyperchloremia

1. same as S/Sx for metabolic acidosis, hypervolemia and hypernatremia 2. if untreated can lead to decreased cardiac output, arrhythmias and coma

hypercalcemia manifestations

1. slower clotting time 2. shortened QT interval 3. muscle weakness *4. constipation *5. kidney stones

What electrolytes hang out in the ECF?

1. sodium 2. calcium 3. bicarbonate 4. chloride

hematoma

1. solid swelling of clotted blood within the tissue 2. monitor size-large hematomas can require surgery r/t infection risk

Manifestations of hyponatremia?

1. tachycardia 2. rapid, thready pulse 3. hypotension 4. hypothermia 5. lethargy 6. muscle weakness 7. cramps 8. seizures brain swells

Manifestation of hypervolemia

1. tachycardia (trying to work out to pump the extra fluid) 2. hypertension (too much volume) 3. tachypnea 4. weakness (body is working very hard) 5. bounding pulse 6. headache (intracranial pressure) 7. decreased LOC 8. ascites (big collection of fluid in abdomen) 9. crackles in lungs (fluid in lungs) 10. cough (get fluid out of lungs) 11. SOB (fluid taking up space where air should be) RR increase 12. pitting edema (third space or intestinal space) 13. weight gain 14. JVD

manifestations of hypovolemia

1. tachycardic (body compensating because decrease volume) 2. hyperthermic (hot) 3. weak/thready pulse 4. low BP 5. orthostasis (bp drops when you stand up) 6. dry mouth 7. dizzy 8. hypoxia (no blood to get o2 to tissue) 9. confusion (decreased perfusion to brain) 10. cool clammy skin (not enough perfusion to skin) 11. flat neck veins

Hypocalcemia manifestations

1. tetany (muscle spasms) 2. chvostek's sign (tap on check and face contracts) 3. trousseau's sign (bp cuff on upper arm and thumbs contracts) 4. seizures 5. paresthesia (fingers, lips) 6. increased clotting time 7. prolonged QT interval 8. muscle cramps (charlie horse)

hypernatremia manifestations?

1. thirst 2. dry mouth 3. tachycardia 4. decreased DTRs 5. N/V/D

what is hypervolemia?

1. too much fluid 2. isotonic (normal fluid) expansion of ECF 3. abnormal retention of H2O + Na+ 4. where sodium goes water follows

interventions for hyperphosphatemia

1. treat underlying cause 2. calcitriol therapy 3. Ca+ binding antacid therapy 4. monitor diet to ensure low phos intake

hypercalcemia interventions

1. treat underlying cause (stop HCTZ, partial parathyroidectomy, etc) 2. NS, IVF 3. calcitonin therapy 4. steroids 5. IV phosphorus (because phosphorus is low)

extravasation

1. vesicant fluid leaks from vein into surrounding tissue; ulcerations, necrosis 2. dopamine; Ca+ solutions, chemo, NaHCO3, 10% dextrose solutions

Calloids

1. whole blood products 2. plasma

Magnesium (Mg)

1.3-2.1 muscle

interstitial

1.between, but not within, the parts of a tissue

Sodium (Na)

136-145 heart and muscles

Bicarbonate

21-28

Phosphorus

3-4.5 bone and muscle

Potassium (K)

3.5-5 heart and muscles

The safe IV rate for potassium is

5 meq/hr

How much body composition is fluid in an grown adult?

50-60% (ECF, ICF, Interstitial) This is regulated by many different processes 1. osmosis 2. sodium potassium pump 3. diffusion 4. renal filtration 5. tonicity (IVF)

Average urine Ph is

6

Calcium (Ca)

9-10.5 bone and muscle

Chloride (Cl)

98-106

The nurse suspects that a patient who is receiving NG suction has hypokalemia. What manifestations would the nurse expect this patient to exhibit?

ECG changes

Must electrolyte enter body how?

GI

What is homeostasis?

Maintaining a stable internal environment

what is sodium potassium movement?

Na in K out

what is the creatinine level?

Normal: male: 0.6-1.2 Female: 0.5-1.1 Main lab for kidney function; protein/muscle breakdown

What is diffusion?

The movement of PARTICLES from an area of high concentration to an area of low concentration using no energy

What is osmosis?

WATER movement across a membrane

hypernatremia

above 145

fluid volume excess

hypervolemia

The nurse is caring for a patient who is in renal failure. During shift assessment, the patient complains of tingling in her lips and fingers when ever anyone takes her BP. She claims she gets a spasm in her wrist and hand and that it is very painful. What would the nurse suspect?

hypocalcemia

what is renal filtration?

kidneys filter out waste and extra fluid

what is fluid volume deficit?

loss of ECF

urine specific gravity

normal 1.005-1.030

what is the normal Blood urea nitrogen BUN

normal 10 -20 Breakdown of protein in liver; urea nitrogen excreted by kidneys

what is the normal hematocrit value?

normal 37%-52% ratio of volume of RBCs to total volume

An ICU nurse has orders to infuse a hypertonic solution. This solution will increase the number of dissolved particles in the patient's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. What term is described by this process?

osmosis

hypercalcemia

over 10.5

hyperchloremia

over 106

hypermagnesemia

over 2.3

hyperphosphatemia

over 4.5

hyperkalemia

over 5

A patient who is experiencing hypovolemia is likely to have a weak, rapid pulse and hypotension.

true

hypomagnesemia

under 1.3

hypoantremia

under 136

hypophosphatemia

under 3

hypokalemia

under 3.5

hypocalcemia

under 9

hypochloremia

under 98

The most accurate measure of fluid movement for a patient

weight -same amount of clothing blankets, time