Exam 5- NUR 110
A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?
Remove the IV.
How much insensible water loss from skin and lungs per day?
Skin: 400 ml; lungs: 300-400ml
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
Start an IV of normal saline as prescribed.
During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first?
Stop the transfusion immediately.
Overhydration findings
Tachy (increased HR), hypertension, tachypnea, confusion/weakness, crackles, edema, JVD, weight gain
The nurse has inserted a peripheral intravenous catheter. When applying a transparent dressing, what is the nurse's best action?
The nurse has inserted a peripheral intravenous catheter. When applying a transparent dressing, what is the nurse's best action?
A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy?
The nurse is responsible for deciding the location and size of the IV catheter, as well as for administering the solution. The primary care provider is responsible for prescribing the kind and amount of solution.
The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action?
Tighten the roller clamp to stop the infusion. ex. The priority nursing action is to tighten the roller clamp on the tubing as this action prevents forward movement of air. All other options are appropriate to remove the air once the tubing has been clamped.
What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution?
To assure the IV solution is appropriate for this administration
IV calculation formula
Total volume/Total minutes x gtt factor= gtt/min
Which statement most accurately describes the process of osmosis?
Water moves from an area of lower solute concentration to an area of higher solute concentration.
Renin-Angiotensin System
When extracellular fluid volume is decreased, receptors in the glomeruli respond to the decreased perfusion of the kidneys by releasing renin. Renin is an enzume responsible for the chain of reactions that converts antiotensinogen to angiotensin 11. Agiotensin 11 acts on the nephrons to retain sodium and water and directs the adrenal cortex to release aldosterone. Aldosterone stimulates the distal tubules of the kidneys to reabsorb sodium and excrete potassium. Sodium reabsorption results in passive reabsorption of water, thereby increasing plasma volume and improving kidney perfusion.
•Post op abdominal surgery client is ordered a clear liquids diet. Mid AM the client begins to vomit, NPO status is enacted and an NG tube is placed to Low wall suction. Calculate the fluid balance for this client for a 24 hour period: IV NS at 80 ml/hr, 600 ml urine, 30 ml drainage from Jackson Pratt drain, 8 ounces of tea, 300 mL vomit, 4 ounces of coke, 8 ounces of apple juice, 1000 ml from NG tube.
+590
Hyperphosphatemia causes
-Acute or chronic renal failure -Hypoparathyroidism -Chemotherapy -Excessive ingestion of milk or phosphate containing laxatives -Large intakes of vitamin D •Level: > 4.5
Hypermagnesium interventions
-Cardiac monitoring -Preparation for drug administration -Monitor vital signs -Monitor lab values -Intake and output -Identify hi-risk patients -Dietary restrictions -Assess DTR's
Hypovolemia nursing Dx
-Deficient fluid volume -Decreased cardiac output -Potential complication: hypovolemic shock
RAAs
-ECF decreased, receptors release renin in kidneys -Angiotensin II acts on nephrons to retain Na+ and H2O -Aldosterone causes tubules to absorb Na+ and excrete K
Sodiums role
-ECF volume and concentration •Maintains H20 balance throughout the body; Na loss or gain happens with H2O loss or gain •Affects serum olmolality -Participates in muscle contraction and generation and transmission of nerve impulses -Acid-base balance -Accounts for 90% of ECF cations
Hypoproteinemia clinical manifestations
-Edema -Slow healing -Anorexia -Fatigue -Anemia -Muscle loss -Ascites
Electrolyte replacement IV fluid
-Electrolyte •Na, K, Cl, Mg, Ca, PO4, HCO3
Hypervolemia Nursing Dx
-Excess fluid volume -Ineffective airway clearance -Risk for impaired skin integrity -Disturbed body image -Potential complications: pulmonary edema
Interstitial fluid to plasma (vessels)- fluid shift
-Fluid drawn into plasma space whenever there is increase in plasma osmotic or oncotic pressure -Wearing of compression stockings or hose is a therapeutic action on this effect
Hyponatremia management includes:
-Fluid restriction if caused by excess water -If severe symptoms (seizures) occur, small amount of intravenous hypertonic saline solution (3% NaCl) is given -If associated by fluid loss need to replace with appropriate fluids -Correct it slowly!
Hypermagnesium manifestations
-Flushing and warmth -hypotension -Lethargy -Drowsiness -N/V -Reflexes hypoactive -Respiratory and cardiac arrest can occur
Management of hyproteinemia
-High-carbohydrate, high-protein diet -Dietary protein supplements -Enteral nutrition or total parenteral nutrition
Hypertonic IV fluids
-Higher osmotic pressure than blood -i.e. D5W in 0.45% NaCL
Hyperphosphatemia management
-Identifying and treating underlying cause -Restricting foods and fluids containing phosphorus -Adequate hydration and correction of hypocalcemic conditions -Sevelamer (Renagel) •Phosphate binder -Remember: phosphorus has an Inverse relationship with calcium
Serum electrolytes, Bun and Creatinine labs
-Increased BUN and Cr seen with impaired renal function (also heart failure, shock, dehydration)
complete blood count (CBC)
-Increased hematocrit; found in severe FVD -Decreased hematocrit; found with massive blood loss -Increased hemoglobin; found in hemoconcentration -Decreased hemoglobin; found with anemia, hemorrhage
Hypokalemia causes
-Increased loss •Aldosterone •Loop diuretics (Lasix) •GI losses: diarrhea, vomiting or gastric function •Polyuria •Movement into cells -Intake is low -Certain antibiotics (aminoglycosides) •Level: < 3.5
Hyperkalemia causes
-Increased retention •Renal failure (can't excrete K) •Potassium sparing diuretics: Aldactone; ace inhibitors -Increased intake -Mobilization from ICF: (Shift of K out of cells) •Tissue destruction •Acidosis Level > 5.0
Hypotonic IV fluids
-Lower than blood. i.e. 0.45% NaCL
Hypophosphatemia causes
-Malnourishment/malabsorption -Alcohol withdrawal/alchoholism -Use of phosphate-binding antacids - -Diabetic Ketoacidosis -Vitamin D deficiency -Starvation states - -Level: < 2.5
Hypercalcemia manifestations
-Muscular weakness -confusion -disorientation -Fatigue/lethargy -Depressed DTR -N/V -Constipation -Renal stones
Hypophosphatemia management
-Oral supplementation -Ingestion of foods high in phosphorus -May require IV administration of sodium or potassium phosphate -Decrease calcium level
Hypomagnesemia management
-Oral supplements -Increase dietary intake -If severe, parenteral IV or IM magnesium
What is calcium controlled by?
-Parathyroid hormone -Calcitonin -Vitamin D
Hypomagnesemia interventions
-Prevention: assess patient's risk -Assess for neuro changes -Assess for chvostek's and trousseau's signs -Vital sign monitoring -Cardiac monitoring -Monitor airway -Maintain IV access -Seizure precautions
Hypermagnesemia management
-Prevention; decrease intake -IV CaCl or calcium gluconate -Fluids & diuretic
•Urine pH and Specific Gravity
-Range for pH: 4.6-8.2 -SG: 1.005-1.030
Hypermagnesemia causes
-Renal Failure - -Laxative use containing Mg - Level:> 2.3
Isotonic IV fluids
-Same as blood i.e. D5W; 0.9% NaCL
transcellular fluid
-Small but important fluid compartment -Approx. 1 Liter -Includes: CSF, GI Tract, Pleural space, Synovial spaces, Peritoneal space
Hypocalcemia Management
-Treat cause -Oral or IV calcium supplements -Vitamin D supplements -Adjust diet -Educate regarding etoh and nicotine use
intravascular fluid (IVF) (extracellular)
-Within vascular space -measures w/ blood tests -1/3 of ECF
Body water content
-average adult male- 60% of body weight is water (approx. 2/3) -older become, less water content= skeletal mass decline -infant= 70-80% water
Older adults and electrolyte imbalances
-decreased sense of thirst -increased medial conditions (HF, HTN) requiring diuretics -decreased renal blood flow -decreased cardiac output and functioning/volume intolerance
interstitial fluid (extracellular)
-fluid spaces between cells & the plasma space -most prev. cation= Na+ -most prev anion= Cl- -expands & contracts -2/3 of ECF
What are the 3 fluid compartments?
-intracellular (ICF)-WITHIN the cells (70% of body water) -extracellular (ECF)- intravascular or within blood vessels and interstitial in between cells (30% body water) -transcellular EX. Cars: cells (ICF) Lanes: Blood vessels (ECF) Space between cars and lanes: interstitial fluid
Hypercalcemia management
-loop diuretic -hydration with isotonic saline infusion -synthetic calcitonin -Increase activity Bisphosphonates
ADH (antidiuretic hormone)
-stimulated by hypothalimus detecting osmolality (increased conc. of solutes in blood)
Calcium functions
-transmission of nerve impulses -myocardial contractions -blood clotting -formation of teeth and bone -muscle contractions and relaxation
How much is 1kg (2.2lbs) of weight in fluid?
1 liter
A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?
1 unit over 2 to 3 hours, no longer than 4 hours
Which actions would a nurse perform after selecting a site and palpating accessible veins in order to start an IV infusion?
1. Advance the needle or catheter into the vein. A sensation of "give" can be felt when the needle enters the vein. 2. When blood returns through the lumen of the needle or the flashback chamber of the catheter, advance device into the vein until the hub is at the venipuncture site. 3. Release the tourniquet, quickly remove the protective cap from the IV tubing, and attach the tubing to the catheter or needle.
Magnesium range
1.3-2.3
Sodium range
135-145
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?
2,500 mL/day
Phosphate range
2.5-4.5
Potassium range
3.5-5
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate?
50 gtt/min
•The physician ordered 1300 ml of 5%D/W to run 24 hrs. How many ml/hr?
54 ml/hour
The physician ordered 2100 ml of LR to infuse in 12 hrs. The gtt factor is 20. How many gtt/min?
58 gtt
A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?
60 drops/mL -Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL).
Calcium range
8.6-10.2
The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate?
83 mL/hr
Chloride range
97-107
ANF
A cardiac hormone. ANF: stored in the cells of the atria, and it kicks in when blood volume and BP increases. Atria stretch and the ANF is released.
A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving?
A hypotonic solution
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)
When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication?
Apply a warm compress.
The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client?
Apply pressure to insertion site for at least 3 minutes.
A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?
Avoid salty or excessively sweet fluids.
Classic Signs & Symptoms of Potassium Imbalance Include:
Cardiac Dysrhythmias
The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?
Cardiac dysrhythmias
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
Decreased potassium levels ex. Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.
A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation?
Discontinue the IV and relocate it to another site.
A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation?
Discontinue the IV and relocate it to another spot.
What is the nurse's best action for the individual whose serum sodium level is 138 mEq/L?
Document the findings because 138 is normal. The general normal for sodium is 135-145
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?
Ensure that the prescribed solution is clear and transparent.
A client is prescribed 0.9% sodium chloride (normal saline). What is the primary goal of this intravenous therapy?
Expand the volume of fluid in the vascular system
A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action?
Flush the IV with 3 mL of normal saline.
Dehydration causes
GI loss (diarrhea), renal loss, burns, hemorrhage, low intake
Overhydration tests
HCT, BI Osmolarity, Blood Na+, BUN, Urine Spec. Gravity, electrolytes= ALL LOW ABG- Resp. Alkylosis
Dehydration tests
HCT, Hem, Urine spec. gravity, blood sodium, BUN = ALL INCREASED
A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?
Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein.
What does albumin attract?
It is a water magnet
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
A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?
Metabolic alkalosis ex. Metabolic alkalosis is associated with an excess of HCO3, a decrease in H+ ions, or both, in the extracellular fluid (ECF). This may be the result of excessive acid losses or increased base ingestion or retention. Loss of stomach acid may result in this condition. Metabolic acidosis is a proportionate deficit of bicarbonate in ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate such as in diarrhea. Respiratory acidosis is when the carbon dioxide level is high and the ph is low. Respiratory alkalosis is when the carbon dioxide level is low and the ph is high.
Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert?
Muscle weakness, fatigue, and dysrhythmias
Which assessment finding obtained while taking the history of an older individual should alert the nurse to the possibility of fluid and electrolyte imbalance? A) I am often cold and need to wear a sweater, even when others are warm. B) I seem to urinate more when I drink coffee. C) In the summer, I feel thirsty more often. D) My rings are tighter this month.
My rings are tighter this month.
WHat are manifestations of hypercalcemia?
Nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.
When a client's serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system?
Neurological
A client is receiving IV fluids. The solution has an osmolarity of 300 mOsm/L. The nurse would expect which event to occur with the body's fluids?
No shifting of fluids occurs.
How much of body fluid is extracellular?
Only 1/3 -Too much fluid in interstitium= Edema
The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?
Phlebitis
The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document?
Rate of the IV solution Location of the IV catheter access Client's reaction to the procedure Type of IV solution Gauge and length of the IV catheter
Ascites- transcellular fluid
abnormal accumulation of fluid in the abdomen -Fluid is literally Trapped in a third compartment and is unavailable for fluid exchange
pleural effusion
abnormal accumulation of fluid in the pleural space
How is control over the extracellular concentration of potassium within the human body is exerted?
aldosterone
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? Infant, adult, adolescent?
an infant age 4 months ex. An infant has considerably more total body fluid and extracellular fluid (ECF) than does an adult. Because ECF is more easily lost from the body than intracellular fluid, infants are more prone to fluid volume deficits. An adolescent at 17 years is considered to have an adultlike body system similar to the 45-and 50-year-old.
In reviewing the results of the individual's blood work, the nurse recognizes which value that should be reported to the physician?
calcium
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?
calcium and phosphorus
transcellular fluid
cerebrospinal, pleural, pericardial, pancreatic, & synovial fluids
Which is a common anion?
chloride
What is the single best indicator of fluid status in the nurse's assessment?
daily weight
Pre-albumin
determines protein depletion in acute conditions. Ex: trauma or inflammation.
Edema happens when there is which fluid volume imbalance?
extracellular fluid volume excess
Body fluid versus body water
fluid-water and lytes water- water alone
What does ADH result in?
hyponatremia, decreased urine output, decreased seat, BV constrict (increased BP)
ECF (extracellular fluid)
intravascular fluid (plasma), fluid between dells (interstitial) , and transcellular fluids
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?
isotonic
Overhydration causes
kidney failure, excessive sodium intake, ICF-ECF fluid shift
Hypovalemia
lack of fluid & electrolytes
Dehydration
lack of fluid in body -hypovalemia -increased thirst, ADH released, aldosterone release
ICF (intracellular fluid)
lies WITHIN body cells, makes up 2/3 of body fluids
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's:
low calcium.
Albumin
measures prolonged protein depletion; or chronic malnutrition.
The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice?
ordering type of solution, additive, amount of infusion, and duration
What is ADH released by?
pituitary gland
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?
placing the tourniquet on the upper arm for 2 minutes
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?
platelets
A decrease in arterial blood pressure will result in the release of:
renin ex. Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.
Anasarca
severe generalized edema
dehydration findings
tachy (increased HR), hypotension, tachypnea (increases resp), dizziness/confusion, increased thirst, decreased urine output, decreased cap refill, dry mucus membranes, flat neck veins, decreased turgor
Overhydration
too much fluid in the body -hypervolemia -increased excreation, of water and Na+, decreased aldosterone -risk of pulmonary edema & heart failure
When does metabolic alkalosis occur?
when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as contraction alkalosis). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. Hyperventilation, commonly caused by anxiety or pain, would lead to respiratory alkalosis. Fever, which increases carbon dioxide excretion, would also be associated with respiratory alkalosis. Severe diarrhea is associated with metabolic acidosis.
intracellular fluid
within cells -70% of body fluids (40% of body weight) -Most prev. cation= K+ -Most prev. anion= PO4-
Magnesium
•50-60% contained in bone •Vital for neuromuscular functioning •Important for the metabolism of protein and carbohydrates •Factors that regulate calcium balance appear to influence magnesium balance •Important for normal cardiac function: produces vasodilation
Adrenal Cortical Regulation
•Adrenal cortex releases hormones to regulate both water and electrolyte 1. Glucocorticoids 2.Mineralcorticoids -1 & 2 are borth steroids Aldosterone is a mineralocorticoid with potent sodium-retaining and potassium excreting capability
Osmotic pressure
•Amount of pressure required to stop osmotic flow of water •Water will move from less concentrated to more concentrated side •Determined by concentration of solutes in solution -occurs at capillary level
Nursing Interventions for Hypocalcemia
•Assess your pt for risk of hypocalcemia •Cardiac monitoring •Assess for chvostek's or trousseau's sign •Maintain IV access •Administer Calcium replacement •Monitor lab results •Seizure precautions •Osteoporosis check •Dietary counseling •Remember: Calcium has an inverse relationship with phosphorus
Cardiac Regulation
•Atrial natriuretic factor (ANF) sometimes called ANP: Peptide, is released by the cardiac atria in response to increased atrial pressure (Excess blood volume). • •ANF causes vasodilation and increased urinary excretion of sodium and water (causes Na wasting and it acts like a potent diuretic.
Hypophosphatemia manifestation
•CNS depression •Acute respiratory failure •Confusion; Seizures •Muscle weakness; joint stiffness and pain (decreased DTR) •Irritability/fatigue •Arrhythmias
Nursing Management Interventions for Hypercalcemia
•Cardiac monitoring •Vital sign monitoring •Assess neuromuscular functioning •Monitor intake and output •Maintain IV access: IV fluids •Administer drugs as ordered: diuretics; calcitonin •Strain urine for calculi •Safety precautions •Increase mobilization when feasible •Monitor labs
Mechanisms Controlling Fluid and Electrolyte Movement
•Diffusion •Active transport •Osmosis •Hydrostatic pressure •Oncotic pressure
Fluid Spacing
•First spacing -Normal distribution of fluid in ICF and ECF •Second spacing -Abnormal accumulation of interstitial fluid (edema) •Third spacing: Fluid accumulation in part of the body where it is not easily exchanged with ECF
Hyponatremia Interventions
•Fluid restrictions ( if hypervolemic) •Monitor loc; behavior changes •Safety measures for seizures •0.9% Na Cl per MD order •Hypertonic saline for acute •Vital signs •Intake and output •Monitor electrolytes •Weight, assess skin turgor, •Maintain IV access •Administer oral sodium supplements
Hydrostatic Pressure
•Force within a fluid compartment •Major force that pushes water out of vascular system at capillary level -heart contraction- BP -pressure twice as great at arterial end than venous end
GI Regulation
•Gastrointestinal tract accounts for most of the water intake •Small amounts of water are eliminated by GI tract in feces •Thirst
Hypercalcemia
•High serum calcium levels •Level > 10.2 •Causes include -Hyperparathyroidism -Malignancy -Vitamin D overdose -Prolonged immobilization
hypomagnesium manifestations
•Hyperactive deep tendon reflexes •Tetany, cramps •Tremors •Seizures •Cardiac arrhythmias •Confusion; mental changes; altered LOC.
Hyperphosphatemia manifestation
•Hypocalcemia (inverse relationship) •Muscle problems (tetany) •Deposition of calcium-phosphate precipitates in skin, soft tissue, cornea, viscera, and blood vessels
How does body regulate fluid?
•Hypothalamic regulation •Pituitary regulation •Adrenal cortical regulation •Renal regulation •Cardiac regulation •Gastrointestinal regulation •Insensible water loss
Signs and Symptoms of Hypervolemia
•Increased cardiac output •Pulse rapid and bounding •Initially BP increased •As heart fails: BP drops •Distended neck veins; JVD •Edema •Crackles and wheezes •S3 • Increased weight
Insensible Water Loss (immeasurable)
•Invisible vaporization from lungs and skin •Immeasurable •Approximately 900 ml per day is lost •No electrolytes are lost with insensible water loss Excessive sweating, not insensible loss, leads to loss of water and
Renal Regulation
•Kidneys are primary organs for regulating fluid and electrolyte balance •Selective reabsorption of water and electrolytes •Excretion of electrolytes occurs •Renal tubules are sites of action of ADH and aldosterone LABS: Bun, Cr., K, Sodium, and Phos.
Hypoproteinemia
•Low Protein (much more common imbalance) Caused by: -Anorexia -Malnutrition -Starvation -Fad dieting -Poorly balanced vegetarian diets -Poor absorption can occur in certain GI malabsorptive diseases -Protein can shift out of intravascular space with inflammation
Hypocalcemia
•Low serum calcium levels -< 8.6 •Causes include: -Decreased intake of Ca. -Hypoparathyroidism -Lack of vitamin D in diet -Impaired absorption of Ca -Diuretics -Renal failure
Hypernatremia
•Management includes -Treat underlying cause -Monitor for changes in behavior, neuro status -If oral fluids cannot be ingested, IV fluids (isotonic to restore volume) •Serum sodium levels must be reduced gradually to avoid cerebral edema
Interventions for Hypernatremia
•Monitor VS •Administer IV fluids as ordered •Intake and output •Daily weight •Monitor electrolytes •Oral hygiene •Provide safe environment •Monitor neuro status
Diffusion
•Movemen from an area of HIGH conc. to an area of LOW conc. •Occurs: in liquids, solids and gases •Membrane separating two areas must be PERMEABLE to substance for diffusion to occur -Solutes move -Continual movement Ex. O2 diffusion
Osmosis
•Movement of water between two compartments by a membrane permeable to water but not to a solute •Water moves from area of LOW solute concentration to an area of HIGH solute concentration •Requires NO ENEGRGY
Calcium
•Obtained from ingested foods: need vitamin D •More than 99% combined with phosphorus and concentrated in skeletal system •Inverse relationship with phosphorus •Bones readily available store of calcium •Role in blood coagulation
Hypothalamic Regulation
•Osmoreceptors in hypothalamus sense fluid deficit or increase in plasma osmolality (increase in solutes) •Stimulates thirst and antidiuretic hormone (ADH) release •Result in increased free water
Oncotic Pressure/colloid osmotic pressure (pulling force)
•Osmotic pressure exerted by colloids in solution •Protein is major colloid in vascular system Colloid ex.=abumin is a protein
Phosphate
•Phosphorus is primary anion in ICF •Essential to function of muscle, red blood cells, and nervous system •Deposited with calcium for bone and tooth structure •Helps maintain Acid-base balance. •Maintenance requires adequate renal functioning •Promotes energy storage •Critical element to all tissues
Protein Imbalances
•Plasma proteins, particularly albumin, are significant determinants of plasma volume •Hyperproteinemia is rare, but occurs with dehydration-induced hemoconcentration
Fluid shifts- Why?
•Plasma to interstitial fluid shift= edema -Elevation of hydrostatic pressure -Decrease in plasma oncotic pressure -Elevation of interstitial oncotic pressure -increased pressure on vessel walls -more colloids
Potassium
•Potassium major ICF cation •(98% of K is in the cells) •Potassium is necessary for -Intracellular osmolality -Role in transmission of electrical impulses, nerve, heart, skeletal, intestinal and lung tissue -Maintenance of normal cardiac rhythms -Skeletal muscle contraction -Acid-base balance -Regulator of cell enzyme activity
hypokalemia manifestations
•Potentially lethal ventricular arrhythmias •Changes on ECG •Increased digoxin toxicity in those taking the drug •Skeletal muscle weakness and leg cramps •Fatigue •Decreased GI motility
Active transport
•Process in which molecules move AGAINST concentration gradient •ATP is energy source •Example: Sodium-potassium pump
Hypokalemia Nursing Management Interventions:
•Replacement: PO or IV •Never give IV push •Never give with anuric renal failure •Teach prevention methods •Vital signs •Monitor electrolytes •Monitor digoxin level: why •Encourage K intake; dietary counseling.
Hyponatremia
•Results from loss of sodium-containing fluids or from water excess; deficit of sodium in the ECF. • •Clinical manifestations include confusion, nausea, vomiting, seizures, and coma, muscle cramps and twitching, headache, lethargy, changes in LOC. • •Level < 135
Hyperkalemia manifestations
•Skeletal muscles weak or paralyzed • •Cardiac arrhythmias; cardiac arrest • •Paresthesias of face, tongue, feet, and hands • Abdominal cramping or diarrhea
Signs and Symptoms of Hypovolemia
•Tachycardia •Orthostatic hypotension •Restlessness •Oliguria •Delayed capillary refill •Flat jugular veins •Decreased blood pressure •Thirst •Weakness, fatigue •Poor skin turgor
Pituitary Regulation
•Under control of hypothalamus, posterior pituitary releases ADH •Stress, nausea, nicotine, and morphine also stimulate ADH release
Nurse management interventions for hyperkalemia
•Vital sign assessment •Eliminate oral and parenteral K intake •Increase elimination of K (Loop diuretics, dialysis, Kayexalate, calcium gluconate) •Force K from ECF to ICF by IV insulin or sodium bicarbonate •Caution about foods with increased K •Monitor ECG •Monitor electrolytes •Caution with salt substitute.
Hypernatremia
•dry mucous membranes, lethargy, disorientation, muscle irritablility, seizures, coma; elevated body temp. •Cells of the CNS are sensitive to sodium levels. •Can occur with water deprivation or loss or sodium gain Level > 145
Hypomagnesemia causes
•levels < 1.3 -Prolonged fasting or starvation -Chronic alcoholism -Fluid loss; •Diarrhea •NG suction -Drugs •Diuretics
Hypocalcemia manifestations
•positive Trousseau's sign and Chvostek's sign •Others include laryngeal stridor, dysphagia, numbness, and tingling around the mouth or in the extremities •Neuromuscular S/S -Anxiety, confusion, irritability -Muscle cramping -Hyperactive DTR's -Tetany and seizures •Cardiac dysrhythmias
Sources of Potassium
•vegetables (bananas and oranges) •Salt substitutes •Potassium medications (PO, IV) •Stored blood
