NSG 212 - Exam 5 KW

Intercellular fluid (ICF)

fluid within cells (70%)

Extracellular fluid (ECF)

fluid outside the cells (30%)

total body fluids representing -- to -- of body weight of normal adult

50%-60%

sources of fluids for the body

-Ingested liquids
-Food
-byproduct of Metabolism

Fluid losses include

-kidney=urine
-intestinal tract=feces
-skin=perspiration
-insensible water loss=evaporation, lungs via respiration, cannot be seen or measured

variations in fluid content

-Healthy person: total body water is 50% to 60% of body weight
-An infant has considerably more body fluid and ECF than an adult; more prone to fluid volume deficits
-Gender and amount of fat cells affect body water; women and obese people have less body water
-Average 1500-3500 ml gain/loss of fluid each day for an adult

what is the most accurate assessment of I&O

Daily Weight

I&O should balance within

2-3 days

fluid balance

-solvents
-solutes
-hormonal regulation
-vasoconstriction(kidneys)
-aldosterone

solvents

liquids that hold a substance in solution (water)

solutes

substances dissolved in a solution (electrolytes and non-electrolytes)

hormonal regulation

Antidiuretic hormone (ADH)(pituitary)
-vasoconstriction and reduction of urine output

vasoconstriction (kidneys)

-Renin converts Angiotensinogen to Angiotensin # 1 (hormone)
-Angiotensin Converting Enzyme (ACE) converts Angiotensin # 1 to Angiotensin # 2 (hormone and POTENT VASOCONSTICTOR)
-Angiotensin #2 stimulates release of Aldosterone (hormone)

Aldosterone (sodium regulating hormone)

excrete K and retain Na(H20)

transporting body fluids

-diffusion
-active transport
-capillary filtration
-osmosis

diffusion

-Tendency of solutes (particles) to move freely

throughout a solvent (fluid). (“downhill”)

-This is moving things from an area of HIGH concentration to

an area of LOW concentration.

-The body is trying to even things out.

osmosis

water passes from an area of lesser solute concentration to greater concentration until equilibrium is established

active transport

-Requires energy for movement of substances through the cell membrane from the lesser solute concentration to the higher solute concentration.

-Usually things move greater to lesser

-This is opposite

-Example: Sodium/Potassium pump

capillary filtration

passage of fluid through permeable membrane from the area of higher to lower pressure

the pushing force is

hydrostatic pressure

when the hydrostatic pressure inside the capillary exceeds the surrounding intestinal space....

fluids and solutes are forced out of the capillary wall and into the intestinal space

Edema

accumulation of fluid in the interstitial space

what can cause edema?

-Can be caused by: Venous obstruction (socks are too tight), sodium and water retention, increased fluid volume, low albumin, thrombophlebitis, hepatic obstruction, prolonged standing, CHF, renal failure

we need to reabsorb this. pull it back into the capillaries. the pulling force is the...

colloid osmotic pressure--pull the fluid back in

what is the different between hydrostatic pressure and colloid osmotic pressure?

the filtration pressure

osmolarity of a solution

-isotonic
-hypertonic
-hypotonic

isotonic

same concentration of particles as plasma

hypertonic

greater concentration of particles than plasma

hypotonic

lesser concentration of particles than plasma

primary organs of homeostasis

-kidneys
-cardio vascular
-lungs
-adrenal glands
-pituitary gland
-thyroid gland
-nervous system
-parathyroid gland
GI

the kidneys normally filter --- of plasma and excrete -- of urine.

-170 L of plasma
-15 L of urine

the cardiovascular system

pumps and carries nutrients and water in the body

the lungs regulate

oxygen and carbon dioxide levels in the blood

Adrenal glands help

the body conserve sodium, save chloride and water, and excrete potassium

the pituitary gland stores and released

ADH (anti-diuretic hormone)

the thyroid gland

increased the blood flow in the body and increases renal circulation

the nervous system

inhibits and stimulates mechanisms influencing fluid balance

the parathyroid glands

regulate the level of calcium in ECF

the GI tract

absorbs water and nutrients that enter the body through this route

The nurse would know that which of the following organs/glands help the body conserve sodium, save chloride and water, and excrete potassium?

adrenals

fluid imbalances

hypovolemia and hypervolemia

fluid volume deficit

Cell: Dehydration
Vessel: Hypovolemia

fluid volume excess

Cell: Over hydration
Vessel :Hypervolemia

Hypovolemia (Vascular)

-LOSS of water and electrolytes
-Can lead to hypovolemic shock
-Causes/Risk factors:
--GI losses
--Skin
--Renal losses
--Third spacing
--Altered PO intake
--BLEEDING

how and what to assess for Hypovolemia (Vascular)

Assessment
-Tachy/thready pulse
-Hypotension/orthostatic hypotension
-Thirst/dry mucous membranes
-Low H and H (IF THEY ARE BLEEDING)
-Increased H and H if they are not (because of loss of water in the vessel)
-Dizziness
-Oliguria
-Others: Sunken eyes, flattened neck veins, acute weight loss

hypovolemic shock

can lead to organ hypoxia/anoxia, decreased hemoglobin, decreased oxygen

nursing interventions for hypovolemic shock

Nursing Interventions:
-Shock Position: Place them on their back with legs elevated
-Oxygen
-Vasoconstrictors
-Monitor VS and hemodynamics
-Fluid replacement; oral and IV; Lactated Ringers solution, blood transfusion, etc.
-Monitor I/O. Monitor for less than 30 mL/h of urine...BAD
-Monitor LOC
-Treat cause
-Encourage slow position change

Dehydration (Cellular)

-Loss of water but NO loss of electrolytes
-Can be caused by increased sodium in the vascular space (hypernatremia)
-Water is drawn into the vascular space from the CELLS (water follows NA)
-Other causes: Hyperventilation, prolonged fever, DKA, enteral feeding

what do you assess for Dehydration?

increased serum (blood) sodium level
-water follows sodium=besties

fluid volume deficit nursing interventions - dehydration

nursing interventions
-Assess VS and I and O
-Daily weight
-Monitor for SOB/dyspnea
-O2 as needed/ordered
-Initiate and maintain IV access.
--Fluid replacement will be necessary to push fluid BACK into the CELL!...HYPOTONIC SOLUTION (more to come)
-Assess LOC...Think safety.
-Assess lab work for changes from baseline.

hypervolemia (vascular) causes

-Too much sodium (hypernatremia) and so too much water! Water will go where the salt is. If too much salt in the vessel, the water will go there!

-It will pull from the cell…Cellular Dehydration!

-CHF, cirrhosis, steroid use

-Abnormal renal function (NA retention)

-Excessive sodium intake

what to assess for hypervolemia

Assessment

-JVD

-Weight gain > 2 pounds in 24 hours

-BOUNDING pulse

-Tachypnea, dyspnea, orthopnea

-EVENTUALLY IT WILL SPILL OVER CAUSING:

--Edema (Increased hydrostatic pressure)

--Ascites: Accumulation of fluid in the peritoneal cavity that occurs with liver failure

pulmonary edema

-S/S: Ascending crackles, dyspnea at rest, confusion

-Treatment: Position in Fowler’s, REDUCE IV FLOW RATE, administer IV morphine via order, administer diuretics, may need to intubate the patient, limit sodium (hypervolemia)

too much pressure in the vessel (hydrostatic pressure) with PUSH fluid into the interstitial space...

the third space

-- can lead to hypovolemia, because all of the fluid has been pushed out of the vessel

Ascites

-may have hypotension

-low albumin levels cause the fluid to escape the vessels and go into the third space(ascites)

we need to Pull the fluid back into the vessels from thee -- or --

-peritoneal cavity (ascites)
-interstitial space (edema)

what can happen if we pull too much/too fast

hypertension

third-space fluid shift

distributional shift of body fluids into potential body spaces such as pleural spcae, peritoneal cavity(ascites), pericardial area, the bowel, pr the interstitial spaces
-may see edema or ascites

fluid is not lost, just not where it needs to be

-third spacing
-Albumin will Push the fluid back into the correct place

causes and treatment of third spacing edema

-caused by too much Sodium (hypernatremia) which pushes out into the normal areas.

-treated with Loop diuretics

causes and treatment of third space ascites

caused by Liver disease, low albumin, can be exacerbated by hypernatremia

treat with albumin

N-Naturetic Peptide (BNP)

normal is les than 100

causes of overhydration

-Causes

-Water intoxication

-Low serum (blood) NA (hyponatremia)

-The salt has move out of the vessel. If it moves into the cell, it will take the water with it!

-AIDS, tumors, barbiturates, pysch disorders

what to assess for overhydration

Assessment:

-Cerebral edema

-SEIZURE PRECAUTIONS!

-LOW serum sodium (because it is all pulled into the cell)

fluid volume excess nursing interventions (over hydration)

Nursing Interventions:
-Assess VS, ABG, breath sounds, and s/s of respiratory distress.
-Semi-Fowler's position
-Oxygen as needed
-Decrease IV flow rate.
-Limit water (cellular overhydration)
-Seizure precautions (cellular)
--Cerebral edema
-Administer diuretics (loops or osmotics) to PULL things back into the VESSEL and out of the body.

A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess?

moist crackles heard upon ausculatation

A nurse is performing physical assessments for patients with fluid imbalances. Her assessment reveals moist crackles, JVD, and a bounding pulse. Which of the following would be an appropriate nursing action at this time?

administer diuretics

IV solutions

-isotonic(equal)
-hypertonic (more parts)
-hypotonic (more water)
-given to treat imbalances

isotonic solution

-same concentration of particles as plasma
-normal saline (0.9% NS)
-Lactated Ringer's (Ringer's lactate)

Normal Saline (0.9% NS)

-Supplies free water to aid in renal excretion of solutes and expands intracellular fluid volumes.

-May be used to expand temporarily the extracellular compartment if circulatory insufficiency is a problem.

-May be used to treat hypovolemia, metabolic alkalosis, mild hyponatremia, hypercalcemia, burns, and diarrhea and used frequently in intra-op and post-op.

-Used with administration of blood transfusions.

Lactated Ringer's (Ringer's lactate)

-Contains multiple electrolytes in about the same concentrations as found in plasma
-Used in the treatment of hypovolemia, burns, and fluid lost from GI sources

hypotonic solution

-lesser concentration of particles than plasma, more water

-solutions

--0.45% NS (1/2 NS)

--0.33% NS (1/3 NS)

-Replaces intra-cellular fluid

--Hypo to treat a hyper.

--Hypotonic solution to treat hypervolemia.

--Will draw into the cell.

-Low osmolality: A hypotonic solution in the IV space moves out of the IV space and into the intracellular fluid causing the cells to swell and, possibly, burst.

-Used to treat INTRACELLULAR DEHYDRATION or HYPERVOLEMIA.

0.45% NA (1/2 NS)

-Provides NA and CL and free water.

-Used to treat cellular dehydration

-Promotes wastes and elimination by the kidneys

-Used as a basic fluid for maintenance needs

-Often used to treat hypernatremia (because this solution contains a small amount of Na+, it dilutes the plasma sodium while not allowing it to drop too rapidly)

0.33% NS (1/3 NS)

-Used to treat hypernatremia because it dilutes plasma NA, but not too rapidly

difference between hypertonic and hypotonic

hyper = greater concentration of particles than plasma; more particles

hypo=less concentration of particles than plasma; less particles

Blood and TPN are...

Hypertonic

5% 1/2 NS (5% D in 0.45 NS)

-used to treat hypovolemia
-used to maintain fluid intake
-expands vascular volume

treatment?

-Treat the imbalance until it equalizes.

-Assessment will tell you if the imbalanced is corrected.

-Once it is corrected, they will either stop the fluid or move to an isotonic solution.

A nurse is preparing an IV solution for a patient who has a sodium level of 155. Which solutions are the best choices for this condition? Select all that apply.

•5% dextrose in 0.9% NaCl

•0.9% NaCl (normal saline)

•Lactated Ringer’s solution

•0.33% NaCl (⅓-strength normal saline)

•0.45% NaCl (½-strength normal saline)

•5% dextrose in Lactated Ringer’s solution

What is it?

How do you treat it?

1. Identify the imbalance.
•Hypernatremia
2. Treatment for this imbalance?
•Hypotonic
3. Which of these are hypotonic?
•0.33% NaCl (⅓-strength normal saline)
•0.45% NaCl (½-strength normal saline)

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse’s priority intervention related to these symptoms?

­Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately.

­Slow the rate of infusion, notify the primary care provider immediately, and monitor vital signs.

­Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance.

­Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.

What is it?

How do you treat it?

Identify the imbalance
•Hypervolemia/IV infusion
2. Treatment for this imbalance?
•Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately.

ions

-cations
-anions

cations

positive charge ion

anions

negative charge ion

homeostasis

total cations equal to total anions

major electrolytes

-sodium
-potassium
-calcium
-magnesium
-chloride
-bicarbonate
-phosphate

sodium chief function

controls and regulates volume of body fluids

potassium chief function

chief regulator and cellular enzyme activity and water content

calcium chief function

nerve impulse, blood clotting, muscle contraction, B12 absorption

magnesium chief function

metabolism of carbohydrates and proteins, vital actions involving enzymes

chloride chief function

maintains osmotic pressure in blood, produces hydrochloric acid

bicarbonate chief function

body's primary buffer system

phosphate chief function

involved in imporant chemical reactions in the body, cell division, and hereditary traits

labs represent the amount of...

the particle in the vessel
-the normal represent how much should "normally" be there

water balance is maintained by...

Anti-Diuretic Hormone (ADH)

Sodium controls extracellular lfuid volume and...

is needed for muscle contraction, nerve impulses, and acid/base balance

sodium balance is maintained by...

Aldosterone
-so if low sodium levels, aldostereone will be secreted, to increase the reabsorption of NA and the secretion of K

hyponatremia

is less than 135 meg/dl
-gain of water or loss of sodium
-low sodium slows the depolarization of membranes
-sodium is mostly found ECF fluid

risk factors and causes of hyponatremia

•Abnormal GI losses, such as vomiting, NG drainage, suctioning, and diarrhea

•Hypotonic feedings

•Tap water enemas

•Renal losses, such as diuretics and kidney disease

•Skin losses, such as burns, wound drainage

•GI obstruction

•Edema; ascites

•Excessive water intake (dilutes the sodium), heart failure

•Excessive HYPOTONIC FLUIDS

oHypotonic — Lesser concentration of particles than plasma; inadequate sodium intake

oHypotonic solution in the IV space moves out of the IV space and into the intracellular space causing the cells to swell and, possibly, burst.

•SIADH (Syndrome of Inappropriate Anti-diuretic Hormone): EXCESSIVE SECRETION of ADH leading to retention of water and decreased sodium!

s/s of hyponatremia

•Hypothermia

•Tachycardia

•Hypotension

•Thready pulse

•Headache

•Muscle weakness

•Decreased deep tendon reflexes (low NA - low DTR)

•Hyperactive bowel sounds

•Abdominal cramping

•Nausea

•Severe: Lethargy, muscle twitching, hemiparesis, seizures

complications of hyponatremia

•Seizures
•Coma
•Respiratory arrest