Fluid and Electrolyte

Which age groups are at risk for severe fluid imbalances?

Very old and very young patients

Why are older adults at risk for fluid imbalances?

decreased kidney function

How is dehydration treated?

PO fluid (4 oz Q 1 hour)

IVF

What Vital sign changes should the nurse anticipate in fluid volume deficit?

Elevated temp greater than 100.6 F (late sign in older pt)

tachycardia but weak thready pulse

Tachypnea

Postural hypotension

Postural hypotension (orthostatic hypotension) puts the client at risk for?

Falls

What should the nurse assess to determine fluid volume deficit?

Mental status: dizziness, confusion, headache, thirst

Skin turgor: pinch forehead or sternum will be decreased

GI: constipation, assess for dry mucous membranes

CV: Flat neck veins, orthostatic hypotension

I and Os

Daily weight

Should the nurse assess skin turgor in an older adult?

No-it is not an accurate sign

What is the Best early indicator of deficient fluid volume in an older adult?

Constipation

Confusion

Thirst and low grade fever are late signs

What is the normal range for specific gravity?

1.010-1.030

What does a high specific gravity indicate?

concentrated urine (dehydration)

The higher the dryer!

Fluid volume deficit: lab values

Hematocrit increased in hypovolemia

Bun greater than 25mg/dL due to hemoconcentration

Urine specific gravity greater than 1.030

Serum sodium greater than 145 mEq/L

Serum osmolarity greater than 295 mOms/kg

The higher the dryer!

These labs will return to normal as treatment with IVF is administered

What is the nursing care for fluid volume deficit?

Monitor I and O

Daily weights

Weight Q 8 hours when fluid replacement is in progress

Monitor vital signs- orthostatic change

Monitor for changes in mentation

Determine gait balance

Initiate fall precautions

Encourage the client to change positions slowly

What are the signs and symptoms of excess fluid volume (hypervolemia)?

Vital signs: tachycardia, bounding pulse, hypertension, tachypnea

Neuromuscular: weakness, headache, alter loc

CV: jvd, edema

Respiratory: crackles, cough, increased RR, dyspnea

GI: ascites

Skin: periorbital edema

Renal: increased u/o

What is edema?

Abnormal accumulation of fluid in interstitial spaces of tissues.

What is Dependent Edema?

Gravity caused edema

What should the nurse assess to determine if a client has dependent edema?

Feet, ankles, and lower legs

Sacral region (patients on bedrest)

What are nursing interventions for edema?

I and O

fluid restriction as ordered

daily weights

Elastic stockings or SCDs

Low Na diet

diuretics

bedrest

elevate lower extremities

Why are patients placed on bedrest to treat edema?

the supine position facilitates kidney function

When should the HCP be notified about weight?

1 to 2 lb weight gain in 24 hours

or 3 lbs in a week

What is the normal range of NA?

135-145 mEq/L

How is Hyponatremia described?

Na less than 135mEq/L

What causes hyponatremia?

Na loss

sweating (diaphoresis)

Inadequate intake of dietary sodium

Excess of water (without NA retention)

Diarrhea

NGT drainage

Tap water enemas

How is hyponatremia treated?

Water restriction (fluid restriction)

Liberalize NA diet

Closely monitor

Replace water loss with fluids containing sodium

What are the signs and symptoms of hyponatremia? (SALT LOSS )

Stupor (confusion, irritability, headache, seizures, and coma)

Anorexia ( N or V)

Lethargy

Tendon Reflexes decreased

Limp Muscles

Orthostatic hypotension

Seizures/headache

Stomach cramping

What is the definition of Hypernatremia?

Na above 145 mEq/l

What are the Risk factors of hypernatremia?

high salt diet

excessive IV fluids w NA

What are the signs and symptoms of Hypernatremia ? Fried Salt

Flushed skin and Fever (low grade)

Restlessness, irritable, anxious, confused

Increased blood pressure and fluid retention

Edema: peripheral and pitting, red swollen tongue

Decreased urine output and dry mouth

Skin flushed

agitation

low-grade fever

thirst

How do patients with Hypernatremia look?

Big and bloated

What are the signs and symptoms shared by hypo and hypernatremia?

restlessness

fatigue

abd cramping

What is the Treatment of hypernatremia?

Encourage increased fluid intake

Measure I and O

Give water between tube feedings

Restrict NA

Monitor temperature

Which foods high in sodium should the patient avoid?

Dried fruits

canned food

tomato juice

cheese

ketchup

fast food

processed and pickled food

What is the normal range of K in the body?

3.5-5.0 meq/l

What is the definition of Hypokalemia?

K less than 3.5 mEq/l

What are the causes of Hypokalemia?

Inadequate intake of K rich foods

Loss of K through urine

Loss of K through GI tract as a result of diarrhea, vomiting, fistulas, overuse of gastric suction

Improper use of diuretics

What are the signs and symptoms of Hypokalemia? A SIC WALT

Alkalosis

Shallow respirations

dysrhythmias

Confusion, drowsiness, lethargy

Weakness and fatigue

Arrhythmias-tachycardia and irregular heart beat

Lethargy

Thready pulse

Intestinal Motility decreased (abd distension, ileus, N and V)

What are the GI symptoms of hypokalemia?

Abdominal pain

distention

paralytic ileus

How is hypokalemia treated?

Instruct about foods high in potassium

Observe those taking digitalis for toxicity

Monitor for abdominal distention

Teach patients to monitor for s/s of hypokalemia

Admin KCL as ordered

Monitor I & O and cardiac rhythm

What does the nurse need to assess before administering KCL?

Urinary output needs to be at least 30ml/hour

Nursing Implications for giving IV KCL?

Never give IV push

Monitor ECG

DO not give in dextrose

Use an IV pump

Check urine output

Teach foods high in K

Which foods are high in potassium? (POTASSIUM and ABCD)

P-plantains(banana), potato w skin, pistachio nuts

O-oranges

T-tomato

A-apricot, avocado

S-strawberry

S-Spinach

I Iceberg lettuce-green leafy vegetables spinach, swiss chard

U-ugli fruit

M-mango

A-avocado, apricots.

B-beans, white; beets, bell peppers, broccoli

C-citrus, chard swiss. cantaloupe, chocolate

D-dried fruits (dates, prunes, raisins, figs), dew honey melon,

What are the signs and symptoms of Hyperkalemia?

K above 5.0 mEq/l

What are the causes of Hyperkalemia ? Machine

MACHINE

Medications- ace inhibitors, NSAIDS, K sparing diuretics

Acidosis- metabolic and respiratory

Cellular destruction- burns, traumatic injury

Hypoaldosteronism/hemolysis

Intake- excessive intake from foods, insulin deficit, overuse salt substitutes

Nephrons, renal failure

Excretion impaired

What is important to note about High and Low K?

both result in dysrhythmias (pt needs ECG monitoring)

Which diuretic is contraindicated in a patient with hyperkalemia?

Spironolactone

What are the signs and symptoms of hyperkalemia? MURDER

M-Muscle weakness and fatigue

U-Urine- oliguria, anuria

R-Respiratory distress

D-Decreased cardiac contractility

E-ECG changes: bradycardia and hypotension, irregular heartbeat

R-Reflexes- hyperreflexia, or areflexia (flaccid)

What is the Treatment of hyperkalemia?

Decrease intake of foods high in potassium.

Increase fluid intake to enhance urinary excretion of potassium

Insulin and dextrose moves K inside cell

No salt substitutes containing potassium

Medication : A potassium exchange resin polystyrene (Kayexalate)

What are the S/S common to both hypo and hyperkalemia?

confusion

weakness

resp failure

Irregular heart rhythm

What is the normal Calcium range?

9.0-10.5 mg/dL

What does calcium do for the body?

Involved in the formation of bones and teeth

needed for blood coagulation

essential for nerve conduction

What is the definition of Hypocalcemia?

Calcium below 9.0 mEq

What are the S/S of hypocalcemia? CATS

C convulsions

A arrhythmias,

T tetany (Chvostek's and Trousseau's signs, stridor laryngospasm, convulsions, increased DTRs

S stridor spasms, perioral tingling

What are Chvostek's and Trousseau's signs?

What is the Treatment of Hypocalcemia?

Encourage patients to consume foods high in calcium;

Which foods are high in Calcium?

salmon

greens

oranges

dairy

What is the definition of Hypercalcemia?

Calcium above 10.5 mEq/L

What causes Hypercalcemia?

Immobilization causes calcium to be immobilized from bone

Excess of calcium(antacids) or Vitamin D

Bone tumors

Multiple fractures

What are the S/S of hypercalcemia? BACKME

Bone Pain and pathological fractures

Arrhythmia

cardiac arrest, confusion, constipation, calculi

kidney stones

muscle weakness and weak DTRs

excessive urination

What is the Treatment of hypercalcemia?

Diuretics as ordered

Monitor I and O

Encourage high fluid intake 3000-4000mL/day

What is the definition of Hypomagnesemia?

Mg less than 1.3 mEq/l

What Causes low Mg?

Chronic malnutrition

Chronic ETOH abuse

What are the S/S of hypomagnesemia?

seizures

Increased DTR

hyperactive bowel sounds, diarrhea

What is the definition of high Mg?

Mg greater than 2.1 mEq/l

Which Foods are High in Mg?

spinach, yogurt, almonds, green leafy veg

What does a High Mg level do to the body?

makes body calm

What are the S/S of Hypermagnesemia?

Muscle weakness

Hypotension

Bradycardia

Resp shallow and distress

hypoactive bs, and N and V

Loss of DTRs

Which medication should the nurse anticipate administering in a client who receives Mg and has low RR?

Calcium gluconate

Which 3 ABG values determine acid-base balance?

pH

PaCO2

HCO3