Fluid, Electrolyte, and acid-base balance

Nursing care for intake

-Fluids/foods - liquid at room temperature -Sips need to be recorded -IV's, GI feedings and flushes -IV flush

Nursing care for output

-Urine, diarrhea, vomitus, fistulas, wounds and ulcers -Use calibrated devices in toilets

nursing care for hypoatremia

1. Assess for anorexia, nausea and vomiting, lethargy. Confusion, hypotension, muscle cramps, weakness 2. Assess for seizures (caused by cerebral edema) 3. Care includes restriction of fluids 4. Hypertonic saline 7.5% (very dangerous can lead to fluid excess)

nursing care for hyperkalemia

1. Assess for muscle weakness, leg cramps, fatigue, parasthesias, and cardiac irregularities 2. Perform ECG as needed

nursing care for hypokalemia

1. Assess for muscle weakness, leg cramps, fatigue, parathesias, dysrhythmias 2. Use caution with ambulation (due to muscle weakness) 3. Administer IV potassium replacement very carefully (high alert)

nursing care for hypocalcemia

1. Assess for numbness and tingling of fingers, mouth, or feet; tetany, muscle cramps and seizures 2. Perform Chvostek's sign Tap on cheek - look for twitch 3. Perform Trousseau's sign Pump cuff to 200 mm Hg Look for hand flexion

nursing care for hypernatremia

1. Assess for signs of neurological impairment, restlessness, weakness, disorientation, delusion and hallucinations) Permanent brain damage, especially in children, can occur 2. Restrict sodium foods 3. Increase water intake

Excess Fluid Volume Nursing care

1. Assess: note decreased sodium, hematocrit, and BUN 2. Implement: Position patient in high fowlers 3. Implement: fluid restriction; administer loop diuretics, intake and output, daily weights 4. Strict intake and output; sodium restricted diet

Deficient Fluid Volume Nursing care

1. Assessment recap: Note elevated sodium, hematocrit, and blood urea nitrogen (BUN) 2. Implement pt. safety (patient may be lightheaded) 3. Strict intake and output 4. Oral hydration: water 5. Isotonic IV fluids normal saline or lactated Ringer's 6. Evaluate: urine output (should improve), daily weights

Fluid overload

1. Condition of too large a volume of fluid infuses into the circulatory system too rapidly 2. Engorged neck veins, increased blood pressure, and difficulty in breathing (dyspnea)

Phlebitis Nursing care:

1. Discontinue the infusion immediately 2. Apply warm. Moist compresses to the affected site 3. Avoid further use of the vein 4. Restart the infusion in another vein

fluid overload nursing care:

1. Notify the primary care provider immediately 2. Monitor vital signs 3. Carefully monitor the rate of fluid flow 4. Check rate for accuracy

Excess Fluid Volume clinical manifestation

1. Peripheral edema, increased bounding pulse, elevated BP, distended neck veins, dyspnea, crackles 2. Altered level of consciousness, confusion, aphasia

Magnesium

1.3 - 2.3 mEq/L

Phosphate

1.8 mg/dL - 2.5 mg/dL

Sodium

135 - 145 mEq/L

Potassium

3.5 - 5 mEq/L

Calcium

8.6 - 10.2 mg/dL

causes of hypermagnesemia

Acute or chronic renal failure Medications: magnesium based antacids, magnesium infusion for pre-eclampsia

While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority? Apply a tourniquet to the client's upper arm. Apply pressure to the site with sterile gauze until hemostasis is achieved. Have the client perform the Valsalva maneuver. Measure the catheter and compare it with the length listed in the chart.

Apply a tourniquet to the client's upper arm.

Hypotonic Fluids: 0.45% saline (1/2 NSS) Nursing care:

Assess for dehydration if patient is on for a while

Hypertonic: D5% 0.9%saline (D5NSS), D10% Nursing care:

Assess for fluid volume overload: jugular vein distention, increased BP, crackles, respiratory distress. Assess for hyperglycemia (increase urine output)

nursing care for hypophosphatemia

Assess for irritability, fatigue, weakness, paresthesias, confusion, seizures, and coma.

nursing care of hypermagnesemia

Assess for magnesium toxicity (nausea, muscle weakness) Loss of deep tendon reflexes

nursing care for hypomagnesemia

Assess for muscle weakness, tremors, tetany, seizures, heart block, change in mental status, hyperactive deep tendon reflexes Perform deep tendon reflexes

nursing care for hypercalcemia

Assess for nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy and slurred speech

nursing care for hyperphosphatemia

Assess for tetany, anorexia, nausea, muscle weakness, and tachycardia.

causes of calcium

Bone strength and stability. Membrane potentials Contraction of all muscle types. Clotting.

Hypocalcemia

Ca < 8.6 mg/dL)

Hypercalcemia

Ca > 10.2 mg/dL

causes of hypercalcemia

Cancer Hyperparathyroidism

Step 2 in Arterial Blood Gas Analysis

Check for the cause of the change in pH. Is it respiratory (PaCO2) or metabolic (HCO3) In respiratory disorders: the pH and PaC02 are inverse In metabolic disorders: the pH and HC03 value are both high or both low

causes of hyperphosphatemia

Common causes are impaired kidney excretion and hypoparathyroidism

causes of Hypophosphatemia

Decreased absorption: NGT suctioning, diarrhea Alcohol Tube feedings

causes of hypomagnesemia

Decreased absorption: NGT suctioning, diarrhea Alcohol Tube feedings

Step 3 in Arterial Blood Gas Analysis

Determine whether the body is compensating for the pH change. If the problem is respiratory, the renal system assists by in compensation by increasing or decreasing HCO3 If the problem is metabolic, the respiratory system assists in compensation by regulating CO2 levels. When compensation occurs the PaCO2 and HCO3 always point in the same direction

Step 1 in Arterial Blood Gas Analysis

Determine whether the pH is alkalotic or acidotic Normal value is 7.35 to 7.45. Regulated by Chemical buffer systems Lungs: eliminate CO2 Kidneys: eliminate H+, reabsorb/generate HCO3−

The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome? Bowel motility will be restored within 24 hours after beginning supplemental K+. ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+. Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet.

ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.

Causes of Metabolic Acidosis

Excess metabolic acids Excessive production of metabolic acids Impaired elimination of metabolic acids Excessive bicarbonate loss Loss of intestinal secretions Increased renal losses Increased chloride levels

Causes of Respiratory Alkalosis

Excessive ventilation Anxiety and psychogenic hyperventilation Hypoxia and reflex stimulation of ventilation Lung disease that reflexively stimulates ventilation Stimulation of respiratory center Mechanical ventilation

causes of hypernatremia

Fluid deprivation Lack of fluid Diarrhea Excess insensible fluid loss (burns, (hyperventilation)

Infusion Regulation and Monitoring Nursing care:

Health care provider orders the amount of solution and rate If order is unclear it is the nurses responsibility to clarify before starting Frequency of administration set tubing changing varies by facility

Hyperkalemia

K+ > 5 mEq/L

Hypokalemia

K+< 3.5 mEq/L

Thrombus:

Local acute tenderness, redness, warmth, and slight edema of the vein above insertion site

Phlebitis

Local acute tenderness, redness, warmth, and slight edema of the vein above insertion site Palpable venous cord

potassium causes

Maintains intracellular osmolarity Controls cell resting potential Needed for Na+/K+ pump Exchanged for H+ to buffer changes in blood pH

Functions of sodium

Maintains intracellular osmolarity. Controls cell resting potential. Needed for Na+/K+ pump. Exchanged for H+ to buffer changes in blood pH.

magnesium causes

Metabolism and carbohydrates and proteins Role in neuromuscular function Acts on cardiac system - causes dilation

Hypomagnesemia

Mg <1.3 mEq/L

Hypermagnesemia

Mg >2.1 mEq/L

sources of calcium

Milk, milk products, cheese, dried beans, fortified orange juice, green leafy vegetables, dried peas

Isotonic Fluids: 0.9% (NSS), Lactated Ringer's Nursing care:

Monitor electrolytes LR monitor potassium NSS monitor sodium Monitor for signs of fluid overload: neck vein distention, increased blood pressure, lung sounds and respiratory distress.

Causes of Metabolic Alkalosis

Most common reasons Excessive loss of hydrogen ions. Volume depletion (particularly when involving loss of gastric acid and chloride [Cl] due to recurrent vomiting or nasogastric suction) Diuretic use Others: Excessive gain of bicarbonate or alkali: Excessive NaHC03 administration Increased bicarbonate retention

IV fluids:

Must be prescribed by physician or provider Nurse must verify rates throughout shift

Hyponatremia

Na < 135 mEq/L

Hypernatremia

Na > 145 mEq/L

Complications of IV Infusions

Nursing care: Discontinue the infusion immediately. Apply warm, moist compresses to the affected site. Avoid further use of the vein. Restart the infusion in another vein.

Causes of Respiratory Acidosis

Occurs in acute or chronic conditions that impair effective alveolar ventilation and cause an accumulation of PCO2 Impaired function of the respiratory center in the medulla; opiate (heroin, morphine, oxycodone) Lung disease Weakness of the respiratory muscles Airway obstruction Chest injury

Hypophosphatemia

Ph <1.8 mg/dL

Hyperphosphatemia

Ph >4.5 mg/dL

Respiratory Alkalosis

Primary disturbance Decrease in PCO2 Respiratory compensation None Renal compensation Decreased H+ excretion and decreased HCO3- reabsorption

Respiratory Acidosis

Primary disturbance Increase in PCO2 Respiratory compensation None Renal compensation Increased H+ excretion and increased HCO3- reabsorption

Metabolic Alkalosis

Primary disturbance Increase in bicarbonate Respiratory compensation Hyperventilate to increase PCO2 Renal compensation If no renal disease, decreased H+ excretion and decreased HCO3- reabsorption

causes of hyperkalemia

Renal failure Hypoaldosteronism Medications: potassium chloride, heparin, nonsteroidal)

potassium regulation

Sources: fruits, vegetables, dried peas and bens, whole grains, milk, and meats 1. Assess for numbness and tingling of fingers, mouth, or feet; tetany, muscle cramps and seizures

magnesium sources

Sources: green leafy vegetables, nuts, seafood, whole grains, dried peas and beans, cocoa 1. Assess deep tendon reflexes

phosphate regulation

Sources: green leafy vegetables, nuts, seafood, whole grains, dried peas and beans, cocoa 1. Assess deep tendon reflexes

regulation of sodium

Sources: primarily diet Losses: GI tract, and kidneys

Nursing care for thrombus

Stop the infusion immediately. Apply warm compresses as ordered by the primary care provider. Restart the IV at another site. Do not rub or massage the affected area.

causes of hypoatremia

Vomiting Diarrhea Fistulas Sweating Medications (diuretics)

causes of hypokalemia

Vomiting Gastric suction Diarrhea Alkalosis Medications

Deficient Fluid Volume clinical manifestations

Weight loss, poor skin turgor, Oliguria, dry and sticky mucous membranes, weak pulse, tachycardia

27s A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation? a. Discontinue the IV and relocate it to another spot. b. Call the physician and ask if anti-inflammatory drugs should be administered. c. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV. d. Cleanse the site with alcohol and apply transparent polyurethane dressing over the entry site.

a. Discontinue the IV and relocate it to another spot.

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? a. Muscle weakness, fatigue, and dysrhythmias b. Nausea, vomiting, and constipation c. Diminished cognitive ability and hypertension d. Muscle weakness, fatigue, and constipation

a. Muscle weakness, fatigue, and dysrhythmias

A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate? a. Offer the client sugar-free candy to help combat thirst. b. Give the client a fluid containing additional sodium to enhance the feeling of fullness. c. Have the client use an alcohol-based mouthwash every 2 hours to reduce the thirst sensation. d. Apply a petroleum-based gel to the client's lips to prevent cracking.

a. Offer the client sugar-free candy to help combat thirst.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? a. cardiac irregularities b. muscle weakness c. increased intracranial pressure (ICP) d. metabolic acidosis

a. cardiac irregularities

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of: a. phlebitis. b. an infiltration. c. a systemic blood infection. d. rapid fluid administration.

a. phlebitis.

phosphate causes

administration of calories to malnourished patients, alcohol withdrawal, diabetic ketoacidosis, hyperventilation, insulin release, absorption problems, and diuretic use

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation? a. Notify the primary care provider immediately because these are signs of speed shock. b. Notify the primary care provider immediately for possible fluid overload. c. Check all clamps on the tubing and check tubing for any kinking. d. Place the client in the Trendelenburg position to keep the client's airway open.

b. Notify the primary care provider immediately for possible fluid overload.

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? a. Slow the rate of IV fluids. b. Remove the IV. c. Apply a warm compress. d. Elevate the arm.

b. Remove the IV.

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? a. preparing solution for administration b. ordering type of solution, additive, amount of infusion, and duration c. performing venipuncture d. regulating the rate of administration

b. ordering type of solution, additive, amount of infusion, and duration

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? a. "Fluid inside cells." b. "Fluid outside cells." c. "Fluid in the tissue space between and around cells." d. "Watery plasma, or serum, portion of blood."

c. "Fluid in the tissue space between and around cells."

What is the lab test commonly used in the assessment and treatment of acid-base balance? a. Complete blood count b. Basic metabolic panel c. Arterial blood gas d. Urinalysis

c. Arterial blood gas

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? a. Fluid volume excess b. Pulmonary embolus c. Cardiac dysrhythmias d. Tetany

c. Cardiac dysrhythmias

Potassium is needed for neural, muscle, and: a. optic function. b. auditory function. c. cardiac function. d. skeletal function.

c. cardiac function.

A decrease in arterial blood pressure will result in the release of: a. protein. b. thrombus. c. renin. d. insulin.

c. renin.

The primary extracellular electrolytes are: a. potassium, phosphate, and sulfate. b. magnesium, sulfate, and carbon. c. sodium, chloride, and bicarbonate. d. phosphorous, calcium, and phosphate.

c. sodium, chloride, and bicarbonate.

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? a. Sodium b. Chloride c. Phosphorous d. Potassium

d. Potassium

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status? daily weights daily BUN and serum creatinine monitoring output measurements daily electrolyte monitoring

daily weights

x The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing? isotonic hypotonic hypertonic plasma

hypertonic

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? hypervolemia hypovolemia edema circulatory overload

hypovolemia

causes of hypocalcemia

inadequate calcium intake

Metabolic Acidosis

low pH (increased hydrogen ion concentration) Primary disturbance: low plasma bicarbonate concentration due to a gain of hydrogen or loss of bicarbonate. Respiratory compensation: lungs attempt to increase carbon dioxide excretion by increasing the rate and depth of respirations, which occurs within a short time Renal compensation: kidneys attempt to compensate by retaining bicarbonate and by excreting more hydrogen