Nurs 100 Week 6: FLUID, ELECTROLYTE, & ACID-BASE
Osmolarity imbalances
disturbances of the concentration of body fluids hypernatremia and hyponatremia (alot of salt)
Isotonic
equal concentration
Rehydration Tubing changed _____
every 96 hours for continuous and 24 hours for intermittent
Extracellular fluid (ECF)
fluid outside cells 30% of total body water
Intracellular fluid (ICF)
fluid within cells *only can change this!!!* 70% of total body water
Hyperkalemia treatments
get the body to excrete it -*Diuretics, hemodialysis, resin medications (Kayexalate)*
Hypercalcemia S/S
greater than 10.5 -Decreased neuromuscular excitability -Lethargy and confusion, coma Anorexia, Constipation, abdominal pain Arrhythmias, thirst, polyuria if i forget to take chill pill im hyper (hyper): less than 9 ; Decreased neuromuscular excitability
Hypermagnesemia
greater than 2.1 -Decreases neuromuscular excitability (wouldnt move) -Excessive magnesium intake (antacids and laxatives) -Decreased deep tendon reflex (DTR) -Lethargy, blurred vision, headache, respiratory depression, bradycardia, arrhythmias, seizures, coma, cardiac arrest
Hyperkalemia
greater than 5.0 Decreased K+ output
Hypervolemia causes
heart failure, kidney failure, cirrhosis, pregnancy, too much IV fluid, H2O retention Bounding pulse, pitting edema, crackles in lungs (fluid), weight gain
fluid intake is affection
homeostasis
How to treat hypokalemia
how to treat it give potassium-rich food (bananas, avocados)
phlebitis
inflammation of a vein
Hypomagnesemia
less than 1.3 -Increases neuromuscular excitability (they would kick dramatic) -Nausea, vomiting, fatigue, arrhythmias -Muscle weakness, tremors, tetany, heart block, numbness, tingling *Hyperactive deep tendon reflex (DTR)*
blood transfusion reactions
low back pain, hypotension, tachycardia, fever, chills, chest pain, tachypnea, hemoglobinuria,
blood transfusion allergic reactions
mild: hives, pruritus, facial flushing severe: shortness of breath , bronchospasm, anxiety
autologous transfusion
occurs when a patient donates one's own blood for a transfusion
if you suspect cellulitis:
Stop, draw cultures, send tips for culture (we do this before to see specific what it is to treat it), antibiotics, antipyretics Asepsis and hand hygiene Replace catheter every 72-96 hours or per policy
Cellitus s/s
redness, warmth, swelling, pain, fever, chills, purulent discharge, edema, red streak
Hypocalcemia symptoms
-less than 9) -Increases neuromuscular excitability -Numbness and tinging around lips, fingers and toes -Muscle cramping, spasms, arrhythmias Confusion, personality changes, seizures if i take too much i'm chilled(hypo): greater than 10 ; Chvostek's (CHEEK) & Trousseau (TURN IN SPAMS) sign Hypocalcemia
Electrolyte imbalance
seriously disturbs vital body functions May occur separately or in combination: dehydration, over hydration
Discontinuing peripheral IV access importance
the patient's fluid volume has returned to baseline; the patient is being discharged from the facility; the IV catheter needs to be replaced; or the IV site has become unfavorable due to infection, infiltration, extravasation, or phlebitis.
Serum Osmolality
the ratio of water to solutes
dehyrdation example
think of McDonald with no water
Hypervolemia
too much fluids in my body the specific gravity would be lower than value (clear urine)
Total body water refers to the
total amount of water
The nurse is caring for a client with severe dehydration and a sodium level of 154 (high) mEq/L. Which of the following IV solutions should the nurse anticipate administering? Dextrose 5% in 0.45% normal saline Lactated ringers 0.45% normal saline Dextrose 5% in water
0.45% normal saline
The nurse is caring for a client with a sodium level of 122 (low) mEq/L. After assessing the client's neurologic status, which of the following IV solutions should the nurse anticipate administering? Dextrose 10% in Water Lactated ringers 0.45% normal saline Dextrose 5% in water
Dextrose 10% in Water
A client who had recent surgery has been vomiting and becomes dizzy when standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the heart rate is 140. The nurse hangs which of the following IV fluids to correct this condition? D5 ½ NS at 50 mL/hr. 0.9% NS at an open rate D5W at 125 mL/hr. 0.45% NS at an open rate
0.9% NS at an open rate
Hypokalemia causes
Diarrhea, vomiting, furosemide (pee it out) Consider potassium-sparing diuretics (helps spare potassium)
Sodium levels
135-145
how long do you stay with paitent eith blood tranfusion?
15 mins
Transfusing blood procedure requires ________ checks
2 RN check
Every _____ pounds a person loses equates to 1 liter of fluid los
2.2
Initiating IV Therapy complications
Fluid overload Infiltration and extravasation Phlebitis Local infection Bleeding at IV insertion site
blood transfusion is given to
Hemoglobin 7-8 or below usually requires transfusion
Potassium normal range
3.5-5.0 mEq/L
normal range of calcium
9-10.5
Hypokalemia
-less than 3.5 Increased K+ output
A senior nurse delegates the task of intake and output to a new nursing assistant. The student will verify that the nursing assistant understands the task of I&O when the nursing assistant states: "I will record the amount of all voided urine" "I will not count liquid stools as output" "I will not record a café mocha as intake" I will notate perspiration and record it as a small or large amount"
"I will record the amount of all voided urine"
Isotonic IV FLUIDS
*Normal Saline (0.9% NaCl)* only give when changing the fluid the state hypoplovemic
Colliods
*plasma or volume expanders* Contain *larger* insoluble molecule Albumin, Hetastarch, Dextran 40
A patient is receiving an intravenous infusion of 0.9% normal saline. Which of the following assessment findings indicates that the patient has developed hypervolemia? (Select all that apply) Hypotension (expected) Crackles upon auscultation Jugular vein distention 3+ pitting edema in lower extremities Urine specific gravity of 1.036 (expected to be less)
-Crackles upon auscultation -Jugular vein distention -3+ pitting edema in lower extremities
blood transfusion 3 primary reasons to transfuse
-Increase blood volume -Increase the number of RBC's (hemoglobin levels) -Cellular component replacement (clotting factors, albumin, platelets, plasma, WBC)
A client who had recent surgery has been vomiting and becomes dizzy when standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the heart rate is 140. The nurse hangs which of the following IV fluids to correct this condition? D5 ½ NS at 50 mL/hr.( hypertonic) 0.9% NS at an open rate D5W at 125 mL/hr. (too low dangerous) 0.45% NS at an open rate (hypotonic
0.9% NS at an open rate hypovolemia (only volume issues) (isotonic solution)
Magnesium normal range
1.3-2.1 mEq/L
Hypernatremia
Hypertonic Water deficit Cell shrinkage if I have water deficit my cell is shrinking
Air embolism S/S
Abrupt dyspnea, coughing, wheezing, hypotension, tachycardia, chest and shoulder pain.
A client is receiving an intravenous magnesium infusion to correct a serum level of 1.0 mEq/L. Which of the following assessment findings would alert the nurse to immediately stop the infusion? Absent patellar reflex Diarrhea Premature ventricular contractions Increase in blood pressure
Absent patellar reflex
Fluid Intake and Output
Assess 24-hr I&O (every fluid need to be reported)
Dehydration
Not enough water, increases salt concentration
blood transfusion can only be given with
Can only be given with *Normal Saline*
Initiating IV Therapy
Changing IV fluid containers, tubing, and dressings Assisting patient with ADLs
hypertonic
Concentrated (mom feels having nothing to live for anymore)
Osmolarity
Concentration or "pulling power"
VESCICANT FLUIDS EXTRAVASATION (if it happens) 3 C's
Cut off the infusion = STOP IT! Counteract = give an antidote(provider) (if available) Contain = elevate and apply a cool compress
overhyderation state
Hypervolemic, hyponatremic
Hyponatremia
Hypotonic Water intoxication Cell swelling too much water and cell swells
Dehydration state
Hypovolemic, hypernatremic state
Cellitus
Infection of skin cells
fluid overload s/s
JVD Elevated BP, HR, RR Crackles in the lungs Shortness of breath Edema Enlarged spleen or liver
Infiltration
Leakage of IV fluid or medication into the extravascular tissue
Infiltration s/s & interventions
Leakage of IV fluid or medication into the extravascular tissue Edema, pallor, cool temperature, pain, fluid leak Difficult to flush or infuse interventions: Elevate extremity D/C IV Apply warm compress, take iv out
VESCICANT FLUIDS prevention:
Monitor every 15 minutes during infusion
Hypertonic IV fluids
More solutes than in the cells Causes a shift of fluid into the cells *3% Sodium Chloride, D51/2 NS, D5NS, D5LR, D10W* Used to treat hyponatremia and cerebral edema fluid is coming out (hypo state uses hypernatuic state)
Hyperkalemia Clinical manifestations
Muscle weakness Peaked T wave
Hypokalemia Clinical manifestations
Muscle weakness (shallow respirations, fatigue) -Dysrhythmias - Prominent U waves
Intake
Oral, intravenous
A client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented? Encourage fluids orally Administer 10% NS IV piggyback Administer antidiuretic hormone intranasally Place on seizure precautions
Place on seizure precautions
The nurse is caring for a client who is on diuretic therapy. The client begins to complain of leg cramping and fatigue. Which lab value is consistent with this finding? Calcium 8.0 mg/dL Potassium 3.1 mEq/L Magnesium 1.9 mEq/L Sodium 139 mEq/L
Potassium 3.1 mEq/L
ADPIE: PLANNING & IMPLEMENTATION
Prevent or correct fluid, electrolyte and acid-base imbalances
Water and body fluids functions
Primary body fluid Transports nutrients and waste Transports hormones, enzymes, blood products Facilitate cellular metabolism Acts as a solvent Maintains body temperature Digestion and elimination
phlebitis S&S and intervention
Redness, Heat, Pain, Swelling D/C (discontinue) IV interventions: Apply a moist warm compress, take it out and start again
Hyperkalemia causes
Renal failure, dehydration, diabetes, getting or eating too much potassium,
fluid overload preventions:
Review the history for cardiac and renal problems Use a pump Assess frequently Accurate I & O Daily weights
if fluid overload happens:
STOP the infusion Assess the ABC's, take vitals Elevate HOB Plan for diuretics and modify fluid intake
The nurse is evaluating lab values on four clients. Which lab value is a priority for the nurse to report to the provider? Calcium 10.0 mg/dL Magnesium 1.8 mEq/L Potassium 3.8 mEq/L Sodium 149 mEq/L
Sodium 149 mEq/L
Crystalloids
Solutions of salts, water, and variable electrolyte composition
Air embolism treatment
Stop the infusion, clamp the line, place on side with with head down *Trendelenburg*, call a code or Rapid Response, provide O2 if needed Prime the line, burp the bag, monitor patient
The nurse reviews the electrolyte results of a client and notes that the potassium is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value? ST depression Inverted T wave Prominent U wave Tall peaked T waves
Tall peaked T waves *greater than 5*
air embolism
The presence of air in the veins, which can lead to cardiac arrest if it enters the heart.
Output
Urine, feces, vomitus, gastric secretions, wound drainage
fluid overload
a condition in which the body cannot eliminate the fluid consumed
CATHETER EMBOLISM
a small portion of the catheter breaks off and enters vascular system considered medical emergency
Osmosis
diffusion of water across a selectively permeable membrane
if hanging magnesium you need _________
another nurse
Hypotonic
dilute everyone around the mom and she exposes (too much water not enough solutes)
Hypovolemia causes
blood loss, GI loss, severe burns, third spacing, excessive sweating and urination Weak pulse, hypotension, poor skin turgor, flat neck veins tachycardia, weight loss
Hypolemia
body is working harder to get the fluid, does not have enough water urine color: dark would be above urine specific gravity
Volume imbalances
disturbances of the amount of fluid in the extracellular compartment hypovolemia, hypervolemia
Hypotonic IV FLUIDS
cause a shifting fluid in the cell (hypernatremic state to hypotonic solution) (anything less than *0.9* is hypotonic *Sodium Chloride .45%, .33% or .225% (1/2 NS, 1/3 NS, ¼ NS)* Treats hypernatremia and diabetic ketoacidosis
overhyderation & Hyponatremia
cerebral edema: lethargy, confusion, HA, restlessness, irritability, seizures, coma
dehydration and hypernatremia
confusion, lethargy, irritability, muscle twitching, *seizures*
t/f We need Vitamin D for absorption of Calcium
true (besties need to be together)
t/f We do not push Potassium
true , hang it and give pills (2-4 hours)
catheter embolism interventions
utlrasound and need to fix immediately
Laboratory Studies
we need to make sure we ask because it can get lower. so assess
physical assessment Consistent conditions:
weight them in same clothes,, voiding, before eating , same time daily (Consistent conditions)
blood transfusion
whole blood or cells are taken from a donor and infused into a patient
Overhydration example
whole bunch of water not enough fries but whole drink