fundamentals - electrolytes, vitamins, nutritions

nursing care of patients with altered electrolyte balance

sodium

• major cation of extracellular fluid

  • NaCl, cholride follows Na

• water distribution

• neuromuscular activity

  • muscle contraction

  • nerve impulses

• most come from diet

• normal range: 135-145mEq/L

kidneys

• primary regulator of odium balance in the body

• decreased blood volume leads to Na and water retention

• increased blood volume leads to elimination of Na and water by the kidneys

hyponatremia: Na < 135mEq/L: Pathophysiology

• GI loss: prolonged vomiting, NG suction, diarrhea, or laxative abuse

• skin loss: burns or large amount of wound drainage, excessive diaphoresis

• older adults have decrease locoorsse

• adrenal insufficiency

• prolonged use of diuretics

• critical value <120mEq/L or >160mEq:L

hyponatremia: pathophysiology

• excessive water intake - dilutes serum sodium

• heart failure, renal failure, lover cirrhosis

• decreae domdium)

• SIADH (retaining water)

hyponatremia: manifestations

• muscle cramps, weakness, and fatigue

• anorexia, n/v, diarrhea

• gi upeset n/v

• headache, confusion, irritability, lethargy, tremors, seizures, coma

hyponatremia: treatment

• fluid restriction

• eat a “normal” diet, it will have enough sodium in it

• sometimes oral rehydration with electrolyte solution

• lactated ringers are given with hyponatremia

hyponatremia: nursing interventions

• clients with neurologic symptoms are at risk for injury, safety is important

• elevating the HOB may help control headaches

• daily wts to monitor fluid status

• monitor electrolytes

• assess muscle strength and tone

hypernatremia: >Na 145mEq/L: pathophysiology

• regulatory mechanism: the body is protected from hyponatremia when excess Na stimulates the release of ADH and the kidneys retain water

• thirst mechanism is stimulated in response to high Na levels (increase water intake)

• insensible water loss (high fever, burns, increase environmental temp) results in water loss

• increased water intake could refer to 3% NS IV’s, saltwater near drowning, high sodium meds, while decrease water intake could occur if have limited access to water concentrated tube feedings

hypernatremia manifestations

• thirst

• neuro: lethargy, weakness, irritability

• seizures, coma, death (if severe)

hypernatremia: treatment

• diuretics (increase excretion of sodium)

• low sodium

• low sodium diet might include whole wheat bread, steamed carrots, chicken legs

• would NOT include ham, cheese, cottage cheese

• read the labels to determine sodium content

hypernatremia nursing interventions

• client safety

• daily weight

• monitor neuro status

potassium

• major cation of intracellular fluid

• generated action potential and transmits nerve impulses

• normal range-3.5-5mEw/L

control of potassium

• enters the body by the food we eat

• kidneys play a primary role in excretion, but some is lot via GI and skin

• regulated by changes in plasma K+ and aldosterone levels

• where Na+ goes, K+ doesnt

hypokalemia: K < 3.5mEq/L: pathophysiology

• diuretics such as furosemide and HCTZ are a common cause of hypokalemia

• increased aldosterone secretion and stress are other reasons a person may have excessive renal K+ excretion

• diarrhea, vomiting, ileostomy drainage can result in K+ loss

hypokalemia: manifestations

• client are prone to dysrhythmias and cardiac arrest

• hypokalemia increases the sensitivity of excitable membranes to digoxin

  • toxic effects may occur with normal doses

hypokalemia: manifestations

• muscle weakness usually doesnt start until K+ is less than 2.5mEq/L

• muscle weakness can lead to respiratory failure

• leg cramps, fatigue, paresthesias

• confusion that develops may be the result of hypokalemia

hypokalemia: treatment

• oral potassium

  • should not be given on an empty stomach

• when given in a liquid form, K+ should be diluted in at least 4oz fluid

• K+ is absorbed well from the GI tract

IV potassium replacement

• IV potassium is NEVER given IVP

• administer slowly

• do not administer undiluted

• not given faster than 10-20mEq/hr

• monitor for manifestations of hyperkalemia

• monitor I/O

• A > 30 ml/hr urine output is recommended

• people with normal K levels do not need cardiac monitoring

  • ex). keep in mind that all clients receiving KCl in their IV’s have cardiac monitoring

nursing diagnoses

• risk for injury r/t muscle weakness

• activity intolerance/impaired physical mobility

• self care deficit

• decreased cardiac output r/t dysrhythmias

• clients are at risk for falls due to their muscle weakness

hypokalemia: nursing interventions

• encourage intake of foods high in potassium such as milk, dried fruit, bananas, apricots, oranges, cantaloupes, baked potato with skin, meats, avocado, raw carrots, raw tomatoes

• teach s/s of hypokalemia

• if a diuretic is needed a potassium sparing diuretic such as spironolactone (Aldactone) should be given

hyperkalemia: K> 5mEq/L: pathophysiology

• potassium irritates

• more K+ means more irritability

• increased excitability of nerves and muscles r/t increased resting potential

hyperkalemia: etiologies

• watch for hyperkalemia in clients with renal failure (most common cause)

• aldactone (spirnolactone) is a potassium-sparing diuretic

• giving too much oral or IV potassium can result in hyperkalemia

• be careful!

hyperkalemia: manifestations

• more depolarization

• initially increases cells excitability (more irritable), but eventually produces weakness because of persistent neuromuscular depolarization

hyperkalemia: manifestations

• the heart is very sensitive to potassium imbalances

• dysrhythmias

• muscle twitching and muscle cramps

• seizures

• nausea/ abdominal cramping/diarrhea

• muscle weakness, leading to paralysis

  • weakness first noticed in the legs

hyperkalemia: treatment

• monitor heart rhythm and rate (telemetry)

  • bradycardia

• monitor pulse strength, BP (hypotension)

• restrict potassium intake

  • avoid salt subsitutes

• dialysis if indicated

hyperkalemia: medication

• kayexalate (sodium polystyrene)

• classification: K+ ion exchange resin

• action: it exchanges sodium ions for potassium ions in the intestine

  • excess k+ is removed

• side effects: hypokalemia, hypocalcemia, hypernatremia, constipation, fecal impaction, N&V, anorexia

calcium

• contraction of smooth, cardiac, and skeletal muscles

• blood coagulations

• bones and teeth

• nerve impulse transmission

• normal range: 8.6-10.2 (8.9-10.1) mg/dL

control of calcium

• about 30% comes from ingested food

  • absorbs in intestines

• more than 99% of the calcium in the body is combined with phosphorus and is concentrated in the bone

  • this makes a readily available source

• balance of calcium depends on Vitamin D, parathyroid hormone and calcitonin

hypocalcemia: Ca < 8.9mg/dL pathophysiology

• calcium ions play an important role in cardiac contractility

  • hypocalcemia has a depressive effect on cardiac contractility

  • this leads to decreased cardiac output

• if calcium is not available for clotting, bleeding problems occur

• if calcium is not available for bone, the bones become weak

  • bone demineralization places a client at risk for injury

• parathyroid glands can affect calcium and phosphorus

hypocalcemia: manifestations

• tetany (leg/arm spasms, twitching)

• numbness and tingling

• carpal-pedal spasms

• seizures

• decreased BP

physical exam

• how do you assess for Trousseau’s sign

  • inflate a BP cuff above systolic blood pressure level for 3 minutes

  • if positive, carpal spasms develop

• how do you assess for chvostek’s sign

  • tap lightly over the facial nerve (in front of the ear)

  • this causes contraction of the facial muscles

hypocalcemia: treatment

• can be an emergency if laryngeal spasms and respiratory arrest are imminent

• monitor closely after thyroid and neck surgery

  • damage to the parathyroid gland may occur

• IV calcium via a drip is preferred but can be given IVP (calcium chloride and calcium gluconate)

• monitor calcium closely in client with parathyroid function

hypocalcemia: nursing interventions

• 1000-1500mg/day depending on age

• foods high in C++ include milk and other dairy products, shellfish, and dark green leaft vegetables

• ensure adequate vitamin D

hypocalcemia meds: calcium supplements

• give supplements 1hr before or 1-2hrs after a meal

• encourage fluids to avoid calcium-based urinary stones

• foods high in Vitamin D include egg yolks, fortified milk, fish liver oils, whole grain cereals, wheat germ, liver, vegetable oils

hypercalcemia: Ca > 10.2mg/dL: pathophyiology

• causes: hyperparathyroidism, malignancies (solid tumors and hematological malignancies), excess vitamin D, and aluminum intoxication

hypercalcemia: symptoms

• things slow down

• muscle weakness, fatigue, anorexia, nausea, vomiting, constipation, thirst

• decreased strength, decreased deep tendon reflexes

• confusion, lethargy

• cardiac arrest (severe Ca > or = 17)

hypercalcemia: manifestations

• renal calculi (kidney stone)

• polyuria (increase urination)

• impaired higher cerebral functioning, such as confusion, personality changes, emotional instability

• lethargy, slurred speech

magnesium

• present in intracellular fluid

• needed for intracellular activites such as protein synthesis, carbohydrate metabolism, and muscle contractions

• normal range is 1.3-2.3mEq/L

hypomagnesemia

• causes: insufficient Mg intake, NG suction, vomiting, diarrhea, malabsorption, chronic alcoholism

  • assessment: tachycardia, HTN, seizures, tremors, change in mental statues (neuro)

• interventions: discontinue diuretic therapy and administer IV magnesium sulfate, seizure precautions

  • eat Mg-rich foods, milk, green leafy veggies, pork, beefy, chicken

hypermagnesemia

• overview- due to increased Mg intake or decreased excretion (renal failure)

• assessment: bradycardia, hypotension, weakness, nausea, vomiting, lethargy

• interventions: give diuretics to increase renal excretion of Mg

  • restrict dietary intake of Mg-rich food, avoid laxatives and antacids with magnesium

phosphate (PO4)

• major anion in intracellular fluid

• needed to activate B-complex vitamins

• assists with cell division and carbohydrate, protein and fate metabolism

• a decrease in serum phosphorus level is accompanied by an increase in serum calcium level

• normal value is 2.5-4.5mg/dL

hypophosphatemia: <2.5mg/dL

• overview- more likely in clients with chronic alcoholic pancreatitis due to insufficient intake; malnutrition; may also be due to impaired kidney excretion from renal failure, malignancy

• assessment- irritability, fatigue, weakness, paresthesias, confusion, seizures, coma

• interventions- administer oral vitamin D and phosphorus supplements

  • decrease intake of Ca foods and increase PO4 foods (fish, whole grains, meats, nuts)

• CNS effects may include irritability, confusion, seizures

• if client being treated suddenly has a positive Trousseaus sign, the phosphorus replacement is causing hypocalcemia

• interventions also include assess systems noted under assessment

hyperphosphatemia: >4.5mg/dL

• overview: problems that occur center on the hypocalcemia that results with increase in serum phosphorus

• assessment: refer to assessment of hypocalcemia

• interventions: instruct to avoid laxatives, decrease phosphorus intake

  • laxatives and enemas contain phosphates

nutrition

body mass index

• determines whether a person wt is appropriate for height

• may provide a useful estimate of malnutrition

• ideal body weight (IBW) requires a balance between expenditure of energy and intake of nutrients

weight in pounds divided (ht in inches x ht inches) x 703

guide for BMI evalution

• <18.5 underweight

• 18.5-24.9 normal

• 25-29.9 overweight

• 30-39.9 obesity, Class I and II

• 40 or >40 extreme obesity

factors affecting nutrition

• age

  • older adults take in less calorie, and more sodium (generally)

• gender (pregnancy, lactation)

  • increase calorie intake

• health/medications

• lifestyle/ alcohol abuse

• religion and culture

• cost of food/food fabs

• personal preferences

factors affecting nutrition

medications

• alter appetite

• disturb taste perception

• interfere with nutrients absorption or excretion

• alter nutrient metabolism

factors affecting nutrition

• dentition issues

• dysphagia

• GI issues —> anorexia, vomiting, diarrhea, and nausea

factors affecting nutrition

• alcohol and tobacco use

• advertising

• other

  • socioeconomic factors; social isolation, support system

nutrition and the older adult

• need fewer calories due to decrease in metabolism

• loss of teeth, loss of taste

• difficulties chewing and swallowing

• decreased thirst

• constipation

altered nutrition

• malnutrition: includes undernutrition and overnutrition

• anorexia nervosa and bulimia - medical diagnoses

• assessment: shared responsibility between physician, dietitian and nursing

  • keeping track of intake of patient

nursing diagnoses

• imbalanced nutrition: less than body requirements

• obesity

• overweight and risk for overweight

• readiness for enhanced nutrition (wellness diagnosis)

special diets

• clear liquid

  • apple, grape and cranberry juice

  • broth

  • popsicles

  • coffee/tea

• full liquid

  • ice cream

  • milk

  • cream soups

  • yogurt

  • pudding

  • sherbet

• mechanically altered

  • chopped, ground, mashed soft, thickened liquids for dysphagia

  • mashed potatoes

  • scrambled eggs

  • applesauce

• modifications

  • consistent carb (DM)

    • carb count

  • fat and calorie restricted (weight loss)

  • low salt (cardiac diet)

  • renal diet (low potassium)

• fats and label reading

  • more unsaturatered fats

  • increased fiber

assisting patients with meals

• weakened individuals: feeding vs assisting

• visually impaired, alternations in cognition (dementia)

• use of adaptive feeding aids

vitamins

water soluble

• vitamin C

• B- complex vitamins

  • B1 (thiamin)

  • B2 (riboflavin)

  • B3 (niacin)

  • B6 (pyridoxine)

  • B12 (cyanocobalamin), pantothenic acid and biotin

fat soluble

• Vitamins A, D, E, K

major minerals

• calcium

• phosphorus

• magnesium

• potassium

• sodium and chloride

trace minerals

• iron

  • red meat

  • oral supplements

• zinc

• manganese

• chromium, copper

• molybdenum and selenium

• fluoride, iodine

nursing care of the adult with needs r/t fluid balance

homeostasis

• the state of equilibrium in the internal environment of the body

• body fluids transport nutrients, electrolytes and oxygen to cells

• fluids carry wastes products away from the cells

• water regulated body temperature and lubricates joints and membranes

• water is the most common substance in the body

hydration

• state of fluid balance

• normal assessment

  • alert

  • moist eyes and mucous membranes

  • intake = output

  • adequate skin turgor

fluid and electrolytes imbalances

• may be caused by illness or injury or disease

• therapeutic measures

  • IV fluids (if less)

  • diuretics may cause or contribute to F/E imbalance (if too much)

kidneys

• regulate volume and composition of ECF

• acute renal failure can be cause by dehydration and hypovolemia

• potassium

• eliminate BUN and creatinine

• hypovolemia stimulates renin release

  • activates the renin-angiotensin-aldosterone system

heart and blood vessels

• natriuretic peptides

  • hormones secreted by special cells that line the atria and ventricles of the heart

• secreted in response to increased blood volume and BP

• ANF (atrial natriuretic factor)

  • primary actions: vasodilation and increased urinary excretion of Na and H20 which decreases blood volume

lungs

• regulates body temperature

• fluid excess

  • pulmonary congestion, pulmonary edema

• fluid deficit

  • increased resp rate due to decreased tissue perfusion and hypoxia

endocrine system

1. aldosterone

2. antidiuretic hormone (ADH)

3. natriuretic peptide (NP)

• the endocrine system is one of the two primary communicating and coordinating systems in the body

  • it communicates through chemical substances or hormones

• the endocrine system helps control F/E balance

  • 2 hormones that help control these critical balances are;

• fluid loss is adjusted by;

adrenal glands

• secrete aldosterone

  • essential for the maintenance of F/E balance

• maintain ECF volume

  • promote reabsorption of Na and excretion of K ions (kidney)

aldosterone

• hormone secreted by the adrenal cortex

• protects sodium balance by preventing sodium loss

• excretes K+

• helps regulate water balance

• in exchange for sodium —> potassium ions are excreted

pituitary

• a body fluid deficit or increased plasma osmolality releases ADH

• ADH regulates water retention and decreases osmolality

• small gland - about the size of a pea

• has been referred to as the master gland

  • located in base of the brain

    works closely with the hypothalamus

  • two lobes; anterior and posterior

• plasma osmolality = a measure of solute concentration of circulating blood

• syndrome of inappropriate antidiuretic hormone (SIADH)

  • causes water retention

• CNS disorder

  • brain tumors

  • brain injury

  • cancer

  • malignancies

antidiuretic hormone

• ADH or vasopressin

• synthesized in the hypothalamus and stored in the posterior pituitary

• causes water reabsorption

• POTENT VASOCONSTRICTOR

  • ADH acts in the renal distal and collecting tubules causing water reabsorption

  • thirst center —> hypothalamus

gastrointestinal (GI)

• think GI tract accounts for most water intake

• a small amount of water is eliminated by GI tract

• Diarrhea and vomiting can lead to significant F/E loss

• water intake includes fluids, and water pressent in solid foods

  • lean meats

  • fruits

  • vegetables

• most of the bodys water is excreted by the kidneys

• NG

parathyroid gland

• secrete PTH (parathyroid hormone)

• regulates blood level of calcium and phosphate

  • calcium and phosphate help to balance each other out (high CA, low phosphate and vice versa)

• increases calcium reabsorption and phosphate excretion in the kidneys

skin

• regulates body temperature

• excessive sweating caused by fever or high environmental temperatures may lead to large losses of water and electrolytes

fluid volume deficit - FVD - (hypovolemia)

assessment abnormalities

• poor skin turgor (dehydrated)

• rapid, weak and thready pulse

  • heart is working harder to perfuse bc not enough fluid

• hypotension

  • not enough fluid volume

• increased respirations

  • lungs are working harder to perfuse bc not enough fluid

• behavior, mental state

  • restlessness, indifference

third space fluid shift (third spacing)

• occurs when fluid accumulates in a portion of the body from which it is not easily exchanged with ECF (technically fluid loss)

  • ascites - the accumulation of serous fluid in the peritoneal or abdominal cavity

  • edema associated with burns

  • fluid in the abdominal cavity with peritonitis

• the fluid is trapped and unavailable for use

  • not being exchanged properly

• 3rd spaced fluid is trapped and essentially unavailable for functional use

risk factors for dehydration

• vomiting/ diarrhea

• burns

• large, draining wounds

• diabetes

• hemorrhage

• other; heat, exercise, decreased thirst sensation (poor oral intake)

  • insensible fluid loss from skin or lungs

    • invisible vaporization of water

    • amount increases by accelerating body metabolism

      • occurs in increased body temp and exercise

clinical manifestations of dehydration

• cardiovascular

  • increased HR

  • decreased BP

• respiratory

  • increased respirations

• skin —> assess

  • skin color

  • moisture

  • skin turgor

  • edema

• neurologic

  • confusion (esp. older people)

• renal

  • U.O less than 500ml/day

• other

  • wt loss

• the minimum amount of urine per day needed to dissolve and excrete toxic waste products is 400-600ml

  • if less wastes are retained and cause lethal electrolytes imbalances, acidosis and toxic build up of nitrogen

treatment

• IV therapy

• diet therapy, oral intake

• drug therapy

  • antiemetics

  • antipyretics - reduce temp

nursing interventions

• monitor lab values

  • electrolytes

  • increased hematocrit (percentage of red blood cells)

    • blood is “thick”, no fluid to “thin” it out

• increased urine specific gravity (weight of urine)

  • would be higher because of “thickness”, not enough fluid to “thin” out

  • normal is 1.005-1.03

• VS, I/O, daily weight

• adequate oral intake and routine mouth care

fluid volume excess - FVE - (hypervolemia)

assessment abnormalities

• pitting edema

  • lower extremities

• bounding pulse

  • strong (because of extra fluid)

• hypertension

  • more fluid volume

• lungs

  • SOB, moist crackles

• confusion, irritability

• weight gain

fluid volume excess - FVE

common causes

• renal failure

• CHF

treatment

• drug therapy

• diet therapy

  • fluid restriction

  • low sodium

treatment/ nursing interventions

• diruetics

• fluid and sodium restrictions

• monitor I/O, daily weights

• oral care

• elevate edematous extremities - promotes venous return and fluid reabsorption

• labs

  • decreased hemacrit

  • urine specific gravity

• COP - prevents skin breakdown

macronutrients

macronutrients

• carbs

• fats

• proteins - vital component of every living cell

  • milk

  • eggs

  • meats

  • nuts

anthoropometric mesurements

• height

• weight

• BMI

• waist/ wrist circumference

numbers used to look over general health and nutrition

2 fat soluble vitamins

• vitamin D - helps calcium to work better

• vitamin K - role in blood clotting