NUR204 Unit 4 Content

Within the human body, body fluid is located where?

In the extracellular fluid and the intracellular fluid

What are the proportions of fluid in the human body?

2/3 intracellular fluid and 1/3 extracellular fluid (80% interstitial fluid and 20% plasma)

Osmolality

The amount of dissolved solute in water in the body fluid

Isotonic solution

Overall concentration are equal, cell remains constant

Hypotonic solution

Water moves into the cell, cells expand

Hypertonic solution

Water will move out of cell, cells expand will shrink

Colloid pressure

Proteins that must remain in the blood pull water into the serum

Hydrostatic pressure

Water pushing pressure which moves electrolytes in and out of cells

Factors that influence fluid and electrolyte balance

Age, environmental temperature, diet, stress, illness or trauma, medical treatment, medications, surgery

Volume imbalances

Disturbances of the amount of fluid in the extracellular compartment (serum and extracellular fluid)

Osmolality imbalances

Disturbances of the concentration of body fluids (too many solutes, not enough water)

Extracellular fluid volume deficit

Too little isotonic fluid in the extracellular compartment

Hypovolemia

Decreased vascular volume, aka FVD

Clinical dehydration

Extracellular fluid volume deficit in combination with hypernatremia

Extracellular fluid volume excess

Too much isotonic fluid in the extracellular compartment, aka FVE

Causes of fluid volume deficit

Vomiting, diarrhea, fever, and infection, excessive sweating, heat-related illness, excessive urination, blood loss from wounds, injuries, and bleeding disorders, severe burns, decreased or inadequate fluid intake

Causes of fluid volume excess

Water intoxication, too rapid/large volume infusions, heart failure, cirrhosis, kidney failure, nephrotic syndrome

Intake is

Fluids taken into the body

Output is

Fluids that leave the body

Insensible loss

Loss from the skin and respiratory system, can’t be measured, estimated to be 600mL/day

Intake examples from least to most invasive

PO fluids, PO liquid foods, tube feeding, IV fluids and flushes, blood products, bladder irrigation, enemas, peritoneal dialysis

Output examples

Urine, stool, GI tube output, emesis, wound drainage, chest tube drainage

Output vs input in fluid deficit

Output > input

Output vs input in fluid overload

Input > output

Edema

A collection of excess fluid in the interstitial space, commonly presents when a person is fluid volume overloaded but can exist in fluid volume deficit patients

Labs to assess for fluid balance

Urine specific gravity, serum electrolytes, serum hematocrit, serum BUN/creatinine, blood gases

Urine specific gravity normal range

1.010-1.030

Increased urine specific gravity

Suspect fluid deficit or dehydration

Decreased urine specific gravity

Suspect well hydrated or correlate with fluid excess

Fluid volume deficit vitals

Increased and weak pulse, decreased BP, orthostatic hypotension, increased temperature unless in shock

Fluid volume deficit symptoms

Changes in awareness and mental status, weakness, thirst, weight loss, dark urine, low urine output, dry mucous membranes, reduced skin turgor, capillary refill of more than 3 seconds

Fluid volume deficit labs

Increased urine specific gravity, Hct, BUN and osmolality

Fluid volume deficit treatment

Identification of vulnerable patients, oral fluids (force fluids), IVFs, protect from injury due to decrease in BP

Fluid volume excess vitals

Increased pulse, bounding pulse, increase RR, dyspnea, increased BP

Fluid volume excess symptoms

Peripheral edema, weight gain, JVD, moist crackles in lungs, SOA, intake > output, headache

Fluid volume excess labs

Decreased urine specific gravity, Hct, BUN, osmolality

Fluid volume excess treatment

Identify and treat underlying pathology, administer diuretics, restrict fluids

Electrolytes

Positively or negatively charged particles that dissolve in the body’s water, measured in mEq/L an mmol/L

Hypervolemia effect on concentration of electrolytes

Too much fluid would cause a low concentration of electroltes

Hypovolemia effect on concentration of electrolytes

Too little fluid would cause a high concentration of electrolytes

When to evaluate electrolytes

Any illness that can cause electrolyte alterations, arrhythmias, cardiac arrest, use of diuretics, TPN and Lipid therapy

Serum osmolality tests

Used as a measurement to determine the number of solutes present in the blood, evaluates hyponatremia

Osmolality with hydration

Decreases wth over hydration and increases with dehydration

Sodium range

135-145 mEq/L

Hyponatremia range

Less than 135

Hypernatremia range

More than 145

Hypovolemic hyponatremia is when

The body loses sodium and water

Hypovolemic hyponatremia causes

Vomiting, diarrhea, NG suction, diuretic therapy, burns, sweating, and drugs

Hypervolemic hyponatremia is when

The body has increased in fluid and sodium

Hypervolemic hyponatremia cause

Congestive heart failure, kidney failure, IV infusion of saline, liver failure

Hyponatremia signs/symptoms

SALT LOSS, seizures, abdominal cramping, lethargic, trouble concentrating, loss of urine and appetite, orthostatic hypotension, shallow respirations, spasms of muscles

Treatment and nursing care of hyponatremia

Assess cardiac respiratory nuero and GI status, monitor cardiac telemetry and vitals, instruct to increase oral sodium intake, restrict fluid intake, administer diuretics, if critical then give hypertonic IV solution in central line

Hypernatremia causes

Endocrine disorders, loss of fluids, infection, sweating, diarrhea, diabetes insipidus, thirst impairment

Signs and symptoms of hypernatremia

FRIED, fever/flushed skin, restlessness and confusion, increased fluid retention, edema, decreased urine output/dry mouth and skin

Hypernatremia treatment and nursing care

Assess neuro and oral cavity, monitor neuro and vitals, force fluids, sodium restriction, hypotonic IV fluids SLOWLY

Potassium safe range

3.5-5.0 mEq/L

Hypokalemia range

Less than 3.5

Hyperkalemia range

Greater than 5.0

Hypokalemia causes

Heavy fluid loss, diarrhea, wound drainage, sweating, drugs

Hypokalemia signs and symptoms

The 7 L’s, lethargy, low shallow respirations, lethal cardiac dysrhythmias, lots of urine, leg cramps, limp muscles, low BP and HR

Hypokalemia treatment and nursing care ASSESSMENT

Cardiac, respiratory, neuro, GI, urinary output and renal status (BUN and creatinine levels)

Hypokalemia treatment and nursing care monitoring

Cardiac monitor/telemetry, vitals, magnesium level

Other hypokalemia nursing care

PO potassium, IV potassium, avoid lasix and thiazides, potassium rich diet

Hyperkalemia causes

Renal failure, excessive potassium intake, drugs

Hyperkalemia signs and symptoms

MURDER, muscle weakness, little or no urine, respiratory failure, decreased cardiac contractility, early signs of muscle twitches and cramps, rhythm changes (EKG)

Hyperkalemia treatment and nursing care ASSESSMENT

Cardiac, respiratory, neuromuscular, renal, GI

Hyperkalemia other treatment and nursing care

Monitor telemetry and vitals, avoid potassium sparing drugs, kayexalate, potassium wasting drugs, glucose and regular insulin, dialysis

Magnesium range

1.3-2.1 mg/dL

Hypomagnesmia range

Less than 1.3

Hypermagnesmia range

Greater than 2.1

Hypomagnesmia causes

Hypokalemia, hypocalcemia, alcohol dependence, malabsorption or insufficient dietary intake

Hypomagnesmia signs and symptoms

TWITCHING, trouesseau’s, weak respirations, torsades de pointes and tetany (seizures), cardiac changes, hypertension and hyperreflexia, involuntary movements, nausea, GI issues (decreased bowel sounds and mobility)

Hypomagnesmia treatment and nursing care

Assess cardiac respiratory neuro and GI, monitor telemetry vitals and other electrolytes, avoid PO magnesium, administer magnesium sulfate IV route and monitor magnesium level closely, use seizure precautions

Hypermagnesmia causes

Overcorrection with magnesium supplements

Hypermagnesmia signs and symptoms

LETHARGIC, lethargy, EKG changes, tendon reflexes absent or diminished, hypotension, arrhythmias, respiratory arrest, GI issues, impaired breathing, cardiac arrest

Hypermagnesmia treatment and nursing care

Assess cardiac respiratory neuro GI and renal, monitor telemetry vitals and other electrolytes, avoid further magnesium infusions, ensure safety

Phosphate and calcium are stored and regulated where

Stored mainly in the bones and mainly regulated by the kidneys and parathyroid

Phosphate range

3.0-4.5 mg/dL

Hypophosphatemia range

Less than 3.0

Hypophosphatemia causes

Antacids, hyperparathyroidism, malabsorption or insufficient dietary intake, other electrolyte issues, alcoholism, bone cancers

Hypophosphatemia signs and symptoms

Breathing problems, neuro status changes, decreased cardiac output

Hypophosphatemia nursing care and treatment

Assess cardiac respiratory and muscular, monitor vitals and calcium, caution giving more calcium, treat with PO or IV phosphate, IV phosphate must be given slowly in a dedicated central line

Calcium range

9.0-10.5 mg/dL

Hypocalcemia range

Less than 9.0

Hypercalcemia range

Greater than 10.5

Hypocalcemia causes

Hypoparathyroid, malabsorption including alcoholism and bulimia, electrolyte abnormalities (phosphate), pancreatitis and kidney issues

Hypocalcemia signs and symptoms

CRAMPS, Cvostek’s sign positive, reflexes hyperactive, arrhythmias, muscle spams and seizures, positive trousseaus sign

Hypocalcemia treatment and nursing care

Assess cardiac and neuro, monitor telemetry vitals and other electrolytes, administer calcium IV route, monitor calcium and phosphate level closely

Hypercalcemia causes

Hyperparathyroid, glucocorticoids usage, endocrine and kidney disorders

Hypercalcemia signs and symptoms

WEAK, weakness of muscles, EKG changes, Absent reflexes or absent minded or abdominal distention from constipation, kidney stone formation

Hypercalcemia treatment and nursing care

Assess cardiac nuero GI and renal, monitor telemetry vitals and other electrolytes, avoid further magnesium infusions, mild avoid calcium rich foods and hydrate, moderate administer calcium reabsorption inhibitors, severe use dialysis

IV therapy indications

Supply fluid when patients are unable to take in adequate volumes by mouth, provide salts and other electrolytes to maintain electrolyte balance, provide glucose, provide water soluble vitamins and medications, establish a lifeline for rapidly needed medications

Peripheral IV

Most common and least invasive, over the needle catheter, choose the most distal site, avoid areas of flexion, use straight and soft veins

Nursing care of PIVs

Clean and safe insertion, label site and IV sets, dispose of equipment safely, assess IV every head to toe assessment, requires clean dressing changes

CLABSI

Central line associated bloodstream infection, lab confirmed, develops within 48 hours of central line placement, sterile dressings, daily chlorahexadine baths and wipes

Fluid volume overload with IVs

Stop IVF and notify provider, recommend labs, diuretics to get rid of fluid

Fluid volume deficit with IVs

Notify provider, anticipate IV orders, check electrolytes and replace or lower as needed

Local infection of IV/central line

Redness, heat, swelling, drainage, skin is the entry point

Local infection of IV/central line nursing care

Culture if ordered, discontinue IV and save for culture, notify provider, initiate wound care, antibiotics as ordered

Air embolism

Bubble of air directly infused into the blood stream is large enough to block blood flow, central lines are more at risk, chest pain, dyspnea, tachycardia, hypotension, stroke, death