Hurst Review Core Content: Fluid/Electrolyte Lecture
What are the signs and symptoms of hypomagnesemia and hypocalcemia (they are the same)? 9
(think muscles first) Rigid and tight muscle tone, possible seizure, stridor/laryngospasm (airway is a smooth muscle), positive Chvostek's sign (tap cheek and it twitches; shows hyperirritability), positive Trousseau's sign (pump up BP cuff and the hand tremours), arrhythmias, increased DTRs (deep tendon reflexes) mind changes, problems swallowing (because the esophagus is a smooth muscle so worry about aspirations)
Normal saline is 0.009, 0.9, or 0.09?
0.9
Normal magnesium levels
1.3-2.1 (mEq/L)
What are normal sodium levels?
135-145 (mEqL)
When you think craniotomy, head injury, sinus surgery, transsphenoidal hypophysectomy, or any condition that can lead to an increased ICP what problems can they lead to?
ADH problems
Main disease that causes too little aldosterone and therefore a decrease in sodium and water is
Addison's disease
What hormones regulate fluid volume in the body?
Aldosterone and Anti-diuretic hormone (ADH)
Diseases that cause too much production of aldosterone include
Cushings (too much of all steroids) and hyperaldosteronism (Conn's syndrome)
What are some examples of hypotonic solutions?
D2.5W, 1/2 normal saline, 0.33% NS
What are some examples of hypertonic solutions? 5
D5LR, D5 1/2 NS, D5NS, TPN, Albumin
A way to remember solutions: Hypertonic solutions
Enter the vessel
What is the major problem with oral potassium?
GI upset (always give with food)
Treatment and considerations for hypomagnesemia? 4
Give Mg, check kidney function, seizure precautions, eat magnesium
What causes hypervolemia/fluid volume excess?
Heart failure, renal failure, high sodium
What are some causes of hypercalcemia?
Hyperparathyroidism (too much PTH), Thiazides (retain calcium), immobilization (you have to bear weight to keep Ca in the bones)
If a client has severe fluid volume deficit how do you give fluids?
IV (but monitor for overload with IV fluid replacement)
What is another term for TPN
PN (parenteral nutrition) or TNA (total nutrient admixture)
If a client has mild fluid volume deficit how do you give fluids?
PO (by mouth)
Treatment for hypocalcemia?
PO calcium, vitamin D (helps utilize calcium), phosphate binders (sevelamer hydrochloride, calcium acetate)
SIADH stands for
Syndrome of inappropriate ADH secretion
What is hypervolemia (fluid volume excess)?
Too much fluid in the vascular space
What type of medication decreases serum Ca?
biphosphates such as etidronate and calcitonin (help with bone loss)
When your serum calcium gets low, PTH kicks in and pulls Ca from the __________ and puts it in the ________; therefore, the serum calcium goes ________
bone; blood; up
What are some signs and symptoms of hypercalcemia?
brittle bones, kidney stones (because calcium is increased and kidney stones are mostly made up of calcium), low DTRs (deep tendon reflexes; Mg and Ca act like sedatives), muscle tone weakness, arrhythmias, low LOC (level of consciousness), low pulse, low respirations
Patient will complain of _______ during the infusion of potassium
burning sensation
Thiazides retain
calcium
Testing strategies: If there is nothing that you can do as a nurse the answer is
call the provider (or someone that can help)
When taking hypotonic solutions watch for ______________ because this fluid is moving out to the cells, which could lead to fluid volume ___________ and decreased blood pressure.
cellular edema; deficit
Hypotonic solutions replace what in the body?
cellular fluid
When you have too much ADH your urine is concentrated/dilute
concentrated
With not enough ADH blood is ___________________
concentrated
If you don't have enough PTH the serum calcium will _______________
decrease
With fluid volume deficit does weight increase or decrease?
decrease
When you have hypermagnesemia and hypercalcemia your DTR (deep tendon reflexes) will ____________ , your muscle tone will be ____________, you will/will not have arrhythmias, your level of consciousness will ______________, your pulse will ______________, and your respirations will ______________
decrease, weak and flaccid, will, decrease, decrease, decrease
What happens to urine output with fluid volume deficit?
decreases
What happens to blood pressure with FVD?
decreases (low volume low pressure)
What happens to skin turgor with fluid volume deficit?
decreases (no rapid recall)
Not enough ADH causes fluid volume _________
deficit
Hypernatremia =
dehydration
What are the risks of diuretic hydrochlorothiazide?
dehydration and electrolyte problems and loosing potassium
When you don't have enough ADH this is associated with what disease?
diabetes insipidus
Treatment of hyperkalemia?
dialysis (kidneys aren't working), calcium gluconate (decreases arrhythmias), glucose and insulin (insulin carries glucose and potassium into the cells), sodium polystyrene sulfonate (only given to people who are already hyperkalemic), push fluids (increases sodium and Na and K have inverse relationship)
What are the causes of hypomagnesemia?
diarrhea (because you have a lot of magnesium in your intestines), alcoholism (alcohol suppresses ADH and a decrease in ADH means the client will diurese more. And magnesium is excreted through the kidneys)
When you have too much ADH your blood is concentrated/dilute
dilute
With not enough ADH your urine is dilute or concentrated?
dilute (urine output increases)
Hyponatremia = dilution/dehydration
dilution
What are the causes of hyponatremia?
drinking too much water, psychogenic polydipsia (loves to drink too much water; psych issue), D5W (sugar and water), SIADH (retaining water)
What are the signs and symptoms of hypernatremia?
dry mouth, thirsty, swollen tongue, neuro changes
What happens to the mucous membranes with fluid volume deficit
dry mucous membranes
What medications have a lot a sodium in them and can cause fluid volume excess?
effervescent soluble medications
What three things have a lot of sodium and make us retain water and can cause hypervolemia?
effervescent soluble medications, canned/processed foods, IVF with sodium
Too much ADH causes fluid volume excess/deficit
excess
With hypertonic solutions watch for fluid volume __________. Monitor in an ICU setting with frequent monitoring of ___________, ____________, and ____________ especially if receiving a solution with high sodium such as 3% NS or 5% NS
excess; blood pressure, pulse, CVP (central venous pressure)
Testing strategies: Always pick the answer that
fixes the problem
What are isotonic solutions used for?
fluid loss through nausea, vomiting, burns, sweating, and trauma
In addition to the sedation signs and symptoms, what are some signs and symptoms of hypermagnesemia?
flushing and warmth, vasodilation
Where do you get he majority of magnesium that is inside your body?
from what we eat
When you palpate an ARTERY to check for fluid volume excess how does it feel?
full and bounding
What are some examples of loop diuretics?
furosemide, bumetanide (only give bumetanide if furosemide doesn't work)
Treatment for hypokalemia? 2
give potassium, spironolactone (makes client retain potassium)
A way to remember solutions: HypOtonic solutions
go Out of the vessel
What happens to the pulse with fluid volume excess?
goes up
Foods that are high in magnesium include
green vegetables and seeds (spinach, mustard greens, summer squash, broccoli, turnip, halibut, pumpkin seeds, peppermint, cucumber, green beans, celery, kale, sunflower seeds, sesame seeds, and flax seeds)
Signs and symptoms of hyponatremia?
headache, seizure, coma (think brain issues)
What is a safety precaution that you should consider when caring for a FVD client?
higher risk for falls (poor circulation)
The sodium level in your blood is totally dependent on?
how much water you have in the blood
With spironolactone what should you watch for?
hyperkalemia
Hypotonic solutions rehydrate but do not cause ________________ why?
hypertension because they don't stay in the vascular space
Do not use isotonic solutions in clients with:
hypertension, cardiac disease, or renal failure (these solutions can cause FVE, hypertension, or hypernatremia)
What causes hypernatremia?
hyperventilation (every time you exhale you lose water), heat stroke (you've lost a lot of fluid), diabetes insipitus, vomiting and diarrhea
Peripheral edema occurs with hypervolemia/hypovolemia
hypervolemia
What are phosphate binders used for and what are some examples?
hypocalcemia; sevelamer hydrochloride (Renagel) and calcium acetate (PhosLo)
Causes of hypocalcemia?
hypoparathyroidism, radical neck, thyroidectomy (they can accidentally take out your parathyroids) (basically not enough PTH which causes serum calcium to decrease)
Burns and third spacing are the cause of hypervolemia/hypovolemia
hypovolemia (fluid goes out of the vascular space because of burn damage and leaks into the tissues)
Ascites causes hypervolemia/hypovolemia
hypovolemia (fluid is in the peritoneal area instead of the vascular space)
Where is aldosterone found
in the adrenal glands
What happens to respirations with fluid volume deficit?
increase
Treatment for hyponatremia?
increase sodium, decrease water
What happens to blood pressure with fluid volume excess?
increases
What happens to pulse with FVD?
increases (but weak and thready)
What happens to urine specific gravity with FVD?
increases (urine is very concentrated)
What are the top 5 high alert medications?
insulin, opiates and narcotics, injectable potassium chloride or phosphate concentrate, intravenous anticoagulants (heparin), and sodium chloride solutions above 0.9 percent
Where does a 0.33% NS solution go when administered into the body?
into the vascular space and then out into the cells to replace cellular fluid
Where does hypotonic solution go when administered?
into the vascular space and then shifts out into the cells to replace cellular fluid
Calcium and phosphorus have a(n) _______________ relationship
inverse
_________________ solutions go where you put it and stays there!
isotonic
What are the causes of hyperkalemia?
kidney trouble (if kidneys aren't working you cannot properly excrete potassium and it builds up in the blood), spironolactone (makes you retain potassium)
If someone has hypermagnesemia what organ should you worry about?
kidneys
Potassium is excreted by the ________.
kidneys
The primary way to get rid of magnesium is through the __________________
kidneys
Why is urine output decreased with FVD?
kidneys are either not being perfused or they are trying to hold on the fluid
Magnesium is excreted by the ___________ but it can be lost in other ways such as the __________
kidneys; GI tract
When you don't have enough ADH are you retaining water or losing water?
losing water
What are some causes of hypovolemia (fluid volume deficit)
loss of fluid from anywhere (thoracentesis, paracentesis, diarrhea, hemorrhage), third spacing (burns, ascites), and diseases with polyuria
What are treatments for fluid volume excess?
low sodium diet, restrict fluids, check I&Os, diuretics, bed rest (induces diuresis), and IVFs slowly for the very young and elderly
_____________ and _______________ act like sedatives
magnesium and calcium
When you have respirations less than 12 think _______
magnesium toxicity
When a client has fluid volume deficit caused by ascites what should you do daily?
measure abdominal girth and worry about hypotension
What are some treatments for hypercalcemia?
move!, fluids (prevent kidney stones), add phosphorus to your diet (phosphorus has an inverse relationship with calcium), steroids, biphosphates (etidronate calcitonin)
Signs and symptoms of hypokalemia?
muscle cramps, muscle weakness, and life-threatening arrhythmias
Signs and symptoms of hyperkalemia? in order:
muscle twitching, muscle weakness, flaccid paralysis (and life threatening arrhythmias can occur)
If you want to get magnesium and calcium questions right think ____________ first
muscles
When dealing with sodium level issues think ____________
neuro changes
_______________ Is the basic solution when administering blood.
normal saline
What are some examples of isotonic solutions?
normal saline, lactated ringers, D5W, and D5 1/4 NS
Hypertonic solutions are packed with _____________
particles
ADH is found in the ________
pituitary
What happens to the kidneys with fluid volume excess?
polyuria; kidneys are trying to help you diurese to decrease excess fluid
If sodium goes up ______________ goes down
potassium (they have an inverse relationship)
What are some treatments for FVD?
prevent further loss, replace volume, and safety precautions
Anything with __________ has phosphorus. Therefore adding more __________ to a hypercalcemic client's diet is considered treatment
protein
Hypermagnesemia is caused by
renal failure (If the kidneys aren't working then you can't get rid of magnesium) and antacids (have a lot of magnesium)
How do you treat hypernatremia?
restrict sodium, dilute client with fluids (daily weights, I&O, lab work)
ADH causes you to retain/diurese water
retain
Hypomagnesemia = not enough ____________
sedative
What should you worry about with diabetes insipidus?
shock
A big-time deficit of any kind = ____________ and is a concern for people with fluid volume deficit/ fluid volume excess
shock; fluid volume deficit
Hyponatremia: Too much water not enough ___________
sodium
You should always check ____________ levels when your client is on a feeding tube because the client tends to become dehydrated
sodium
When aldosterone secretions increase what happens to sodium and water and blood volume?
sodium and water are retained and blood volume goes up
Kayexalate (sodium polystyrene sulfonate) exchanges ___________ for _____________ in the GI tract
sodium for potassium
Hypernatremia: Too much __________ = not enough __________
sodium; water
Foods that are high in potassium include?
spinach, fennel, kale, mustard greens, brussels sprouts, bananas, avocado, cabbage, bell peppers, ginger root, strawberries, tuna, oranges, potatoes
What is the potassium sparing medication used for FVE?
spironolactone
A way to remember solutions: Isotonic solutions
stay where "I" put it
Why do you get bone loss with hypercalcemia?
the calcium is in the blood and not in the bones
What are hypotonic solutions such as 1/2 normal saline and D2.5W used for?
the client who has hypertension, renal, or cardiac disease who need fluid replacement or for dilution (when a client has hypernatremia and cellular dehydration)
What are hypertonic solutions used for?
the client with hyponatremia or a client who has shifted large amounts of vascular volume to a 3rd space or has severe edema, burns, or ascites
If the kidneys are not working well, the serum potassium will go ______________
up
Before/during IV potassium always assess ________
urine output (if urine output drops this means potassium is being retained and this can lead to death)
What lab work is effected with concentrated or dilute ADH?
urine specific gravity, sodium, and hematocrit
In hypertonic solutions are volume expanders that will draw fluid into the _______________ from the _________
vascular space; cells
What happens to peripheral veins with FVD?
vasoconstriction which causes extremities to become cool
Another name for anti-diuretic hormone (ADH) is
vasopressin (Pitressin)
The drug ________ or __________ __________ may be utilized as an ADH replacement in diabetes insipidus
vasopressin; desmopressin acetate
What are some treatments for hypermagnesemia?
ventilator, dialysis, calcium gluconate (an antidote for magnesium toxicity)
Hypokalemia causes:
vomiting, NG tube suction (because we have lots of potassium in our stomach), diuretics, not eating
When you think SIADH think too many letters too much ________
water
In fluid volume excess the heart is __________, cardiac output ______, Kidney perfusion ________, and urinary output ________.
weak, lowers, lowers, lowers
What do the lungs sound like with fluid volume excess?
wet
When administering isotonic solutions when should you be concerned with hypernatremia?
when the solution contains sodium
Can hypovolemia lead to shock?
yes
Can fluid volume excess cause heart failure? Why/why not?
yes; too much fluid can cause fluid to go backwards into the heart and into the lungs