NR - 324, Fluid & Electrolytes Questions with 100% accurate solutions - Chamberlain University

define osmolality

measurement of solute concentration in fluid

normal urine specific gravity

1.010 - 1.025

Plasma / Serum Osmolality (normal range)

275-295 mOsm/kg

sodium normal levels

135-145 mEq/L

lab values in fluid volume excess

decrease - because the fluid is diluting the labs

-↓ Na, serum/plasma osmolality, Urine spec. gravity, Hct, BUN

manifestations of FVE

• Headache, confusion, lethargy, seizures, coma (Neurological)

• Peripheral edema: fluid leaking out (hydrostatic pressure)

• Jugular venous distention (JVD)

• S3 heart sound

- HTN

• Bounding pulse, ↑ BP, ↑ CVP

• Polyuria (with normal renal function)

• Dyspnea, crackles, pulmonary edema (Primary Concern HYPOXIA)

• Muscle spasms

• Weight gain

• Tachycardia because it is overworking

nursing management of FVE

Fluid Restrictions

Daily Weight: best indicator, important to be accurate

I & O

Lab Findings: What should you

Cardiovascular Care, Vital Signs, JVD, Edema

Respiratory Care; Crackles, congestion, hypoxia

Skin Care: Risk for breakdown

Patient Safety

R.E.S.T.R.I.C.T

management of FVE

for FVE

Reduce/stop IV

Evaluate breath sounds & ABGs

Semifowlers

Treat w/ Oxygen & diruetics

Reduce fluid

I & Os

Circulation, color, presence of edema

Turn - reposition q2

What is a cornerstone treatment for FVE?

Diuretics

-gets fluid out of the body

expected outcomes of nursing interventions w/ FVE

-Pulse Ox: ↑

-Resp rate: ↓

-Lung sounds: No crackles

-Skin: no edema, pink, warm, dry

-Weight: ↓

-BP: ↓

-HR: ↓

-LOC: ↑

Osmosis / Osmotic Pressure

the ability of the solute concentration to pull water

- the concentration (osmolality) of the solution determines the strength of the osmotic pull

- The higher the concentration, the greater the solution's PULL, or osmotic pressure

Hydrostatic pressure

the force exerted by a fluid against a wall

- causes movement of fluid between compartments

- The hydrostatic pressure of blood is the pressure exerted by blood against the walls of the blood vessels by the pumping action of the heart

3 functions of the Renin-Angiotensin-Aldosterone pathway

1) maintain a proper BP / Blood flow

2) maintain the right concentration of Na in the blood

3) maintain the right amount of water in the blood

aldosterone

"salt-retaining hormone" which promotes the retention of Na+ by the kidneys.

- Na+ retention promotes water retention, which promotes a higher blood volume and pressure

-secreted by adrenal cortex

antidiuretic hormone (ADH)

Hormone produced by the neurosecretory cells in the hypothalamus that stimulates water reabsorption from kidney tubule cells into the blood and vasoconstriction of arterioles.

- retain / hold onto water

A 78 year-old client is admitted with dehydration and urinary tract infection. After IV infusion of 750 mL normal saline, the client begins to cough and asks for the head of the bed to be raised to ease breathing. The nurse's assessment notes jugular vein distention (JVD) and increased respiratory rate. How should the nurse interpret this data?

a.The fluid volume deficit is worsening.

b.The patient is developing hypervolemia.

c.Hypotonic water intoxication is beginning.

d.The infection is causing respiratory compromise.

B

- we have over-corrected

- Hypervolemia = extra volume

- Normal saline is isotonic

Which client to be at highest risk for developing fluid volume deficit?

a.A 52 year-old female receiving corticosteroid therapy for bronchitis.

b.A 60 year-old male S/P left inguinal herniorrhaphy 12 hours ago.

c.A 76 year-old male who has a nasogastric (NG) tube to intermittent suction following colon resection.

d.A 68 year-old female who is NPO and receiving bowel prep for a flexible sigmoidoscopy procedure.

c

3 reasons

-75 + y/o = elderly

-Has NG tube

-and lost part of colon (resorbs water)

A nurse is caring for an elderly adult who is weak and confused; temperature is 38.3C (100.9F), pulse, 92, respirations 20/min, and blood pressure 108/60. He has lost ¾ of a pound and reports dizziness when assisted to the bathroom. Which action should the nurse take?

a. Initiate fluid restrictions and monitor urine output.

b. Observe for signs of peripheral edema.

c. Encourage the client to ambulate to promote oxygenation.

d. Monitor for orthostatic hypotension

d

A nurse is admitting a client experiencing dyspnea, weakness, weight gain of 2 lb. and 1+ bilateral edema of the LE. The client's temp. is 37.2C (99.0F), HR 96, BP 152/96, RR 26, O2 Sat. 94% on O2 at 3L N/C. Which manifestations of FVE should the nurse expect. (Select all that apply)

a. Serum osmolality of 301 mOsm/L

b. Auscultation of crackles

c. Urine specific gravity of 1.003

d. Distended neck veins

e. Cool clammy skin

f. Hematocrit 55%

g. Thready pulse

b, c, d

- in fluid excess lab values go down

a. Serum should be below 275 in FVE

b. True

c. True (normal UGS 1.010-1.025)

d. True

e. cool, clammy caused by vasoconstriction d/t FVdeficit

f. Hct should be low (below 35ish)

g. Pulse would be bounding in FVE

What do we need sodium for?

- Regulate body fluids

- Regulate BP

- Absorption of nutrients

- Nerve and muscle functions

Which interventions does the nurse complete when caring for an elderly client admitted with a sodium level of 152 mEq/L? (Select all that apply)

a.Provide extra blankets for warmth

b.Observe client for nausea and malaise

c.Observe and prepare for possible seizures

d.Restrict additional fluids to 1000 mL per day

e.Monitor serum osmolality

f.Daily weights

b, c, e, f

In caring for a client who is experiencing hyponatremia, which factors probably contributed to this electrolyte imbalance. (Select all that apply)

a.Diuretic therapy

b.Fever

c.Fluid retention

d.Excessive intravenous infusion of hypertonic fluid

e.Heart Failure

f.Nasogastric tube connected to low-intermittent suction.

a, c, e, f

- hypertonic fluid would pull more sodium out of cells increasing Na more

The nurse is caring for a client with heart failure who has received large doses of diuretic therapy. Assessment reveals flat neck veins, generalized muscle weakness, and fatigue. The nurse suspects hyponatremia, what other clinical manifestations would you anticipate?

a. Hyperactive bowel sounds

b. Increased thirst

c. Decreased urine output

d. Increased urine specific gravity

a

-think FVE

-increased urine output and decreased urine specific gravity

The nurse anticipates the client with which condition would be most at risk to develop hyperkalemia? (Select all that apply)

a.Chronic renal failure

b.Newly diagnosed cirrhosis

c.A client involved in a trauma in which a crush injury was sustained

d.A client with a severe MRSA infection of the skin

e.Partial bowel obstruction requiring nasogastric suctioning

f.Diarrhea for the last 4 days

a, c, d

d- bacterial cells die and release potassium when antibiotics are given

Which of the following statements by the client indicates a need for further instruction regarding treatment for hypokalemia?

a."I will eat more bananas and cantaloupes for breakfast."

b."I will eat more bran flakes to increase my potassium level."

c."I will take my potassium in the morning after breakfast so it does not upset my stomach."

d."I will tell my primary care provider if I start having muscle cramps or weakness."

b

A client with hypocalcemia has been started on intravenous (IV) corticosteroids. Which findings indicate to the nurse a further decrease in calcium level in the client?

(Select all that apply)

a.Absence of Trousseau sign

b.Tetany

c.Muscle weakness

d.ECG Changes

e.Abdominal distension and hypoactive bowel sounds

B, D

a. Trousseau sign should be there

b. true

c. muscles are excited not weak

d. true

e. hypOactive bowel sounds = hypERcalcemia

-HypOcalcemia = excitability

The nurse determines that a client with a serum calcium level of 12 mg/dL understands client teaching when the client makes which statement?

a."If my stomach becomes upset, I can just take more Tums."

b."I will need to take my phosphorus supplements once a day."

c."I will need to be on strict bed rest to help with this problem."

d."I will need to drink many more fluids than I have been, even up to two to three liters each day."

d

- to get rid of the excess Calcium and to prevent kidney stone formation

potassium normal levels

3.5-5

hematocrit normal levels

M: 39- 50%

W: 35- 47%

Normal BUN

6-20

Normal Calcium levels

8.6-10.2 mg/dL

lab values in fluid excess

decrease

- all go down cuz they're diluted

lab values in fluid deficit

increase

- all go up cuz they're more concentrated

Causes of FVD

· Fluid intake

· Polypharmacy

· Burns

· Diarrhea

· Trauma, large wounds

· Bleeding

· Surgery

· Chemotherapy

· NG tubes

Diuretics

what drives the plan of care in FVD?

Orthostatic Hypotension

What drives the plan of care in FVE?

Weight gain

manifestations of FVD

· Orthostatic Hypotenion - drive for POC

· Cool extremities - blood shift to organs

· Mental status changes

· Decreased skin turgor

· Dry mucous membranes

· Low-grade fever

· Tachycardia

· Weak pulses

· Increased capillary refill (>3 sec)

· Increased Thirst

· Confusion, dizziness

· Weight loss

- Dark, amber urine

Lab values associated w/ FVD

Concentrated - Increased levels

Sodium = >145

Serum Osmolality = >295

Urine Specific Gravity = >1.025

Hct = ↑ (M>50%; F>47%) [look for number in the 50s]

Hgb = ↑

BUN = >20

F. L. U. I. D. S.

management of FVD

For FVD

Fluid ↑ orally & IV

LOC

Urine - want it > 30 mL/hr

IV fluids & I&Os

Document & monitor VS

Shock - hypovolemic shock

S. A. L. T.

manifestations of hypernatremia/FVD

skin flushed

agitation

low grade fever

thrist

When we see sodium we should think?

Neuro

- neuro changes

Causes of Hypernatremia

Think Fluid volume Deficit

· NPO

· Excess Sodium intake

· Inadequate water intake

· Excess Water loss (↑ sodium concentration)

· Diseases (Diabetes insipidus, primary hypoeraldosteronism, Cushing's, uncontrolled diabetes)

· Infection, fever

· Coma

- Kidney failure

Manifestations of hypernatremia

· Restlessness, Agitation, Lethargy, Coma

· Seizure

· Weakness, muscle cramps

· Intense thirst, dry swollen tongue, sticky mucous membranes

· Postural hypotension, weight loss, tachycardia

· Confusion

· Irritable

· Nausea & vomiting

· Tremors

Hyperreflexia

Nursing interventions for hypernatremia

· Freq neuro assessments

· Document seizures, if happen

· Daily weights, I&Os

· Replace fluids slowly so you don't cause increased shift (avoid shock)

· Restrict salt if it was caused d/t increased salt intake

When we see hyponatremia we think

Fluid volume Excess

causes of hyponatremia

· Excess sodium loss

· GI loss (diarrhea, vomiting, fistulas, NG suctioning)

· Renal loss (diuretics, adrenal insufficiency, Na+ wasting renal disease)

· Skin loss (burns, wound drainage)

· Inadequate sodium intake (fasting diets)

· Excess water gain (↓ sodium dilution) (Excess hypotonic fluids, primary polydipsia)

· Diseases (SIADH, heart failure, primary hypOaldosteronism, cirrhosis)

manifestations of hyponatremia

think Neuro

· Neuro (irritability, confusion)

· Muscle twitching, tremors,

· Coma

· Delirium

· Possible seizures

· Lethargy

· Headache

· Apprehension

· Dry mucous membranes

· Postural hypotenion

· Tachycardia, thread pulse

nursing interventions for hyponatremia

· Neuro assessments

· Document seizures

· Daily weights

· I&Os

· Check for bounding pulses or bulging neck veins

· Check for BP and Resp changes

· Changes in sensorium and signs of cerebral edema

Check for pitting edema

when we see potassium we think the

heart

Causes of hyperkalemia: MACHINE

M: meds (ACE inhibitors, NSAIDs)

A: acidosis (in acidosis, there is cell death → ↑K+)

C: cellular destruction (burns, injury)

H: hypoaldosteronism, hemolysis

I: intake excessive

N: nephrons (renal) failure

E: excretion impaired

manifestations of hyperkalemia

· Muscle twitching (stomach, heart) → cramps (abdominal cramps, diarrhea) → Paresthesia

· Irritability, fatigue, & anxiety

· Decreased reflexes

· ↓BP

· EKG changes - peaked T waves

· Dysrhythmias - irregular rhythm

· Abdominal cramping

· Diarrhea - stomach trying to get rid of excess K+

Confusion, tetany

nursing interventions for hyperkalemia: KIND

· Kayexalate* (binds to excess K+ and is secreted via diarrhea)

· Insulin - given to push K+ back into cells

· Na & Bicarb (Pt at risk for acidosis)

· Dialysis is sometimes needed

- Avoid foods high in K+ (banana, avocado, dried fruit, cantaloupe, broccoli)

- Telemonitor

Which hormones are associated with calcium?

Parathyroid hormone and Calitonin

PTH

pulls Calcium from bones

Calcitonin

keeps Calcium inside bones

causes oh hypokalemia

· GI loss: diarrhea, vomiting, fistulas, NG suctioning, ileostomy drainage

· Diaphoresis

· Diuretics (loop, thiazide, antibiotics, insulin, over-use of laxatives)

· Dig toxicity - causes bradycardia, dysrhythmias

· Hyperventilation

· Severe vomiting & diarrhea

↓intake of K+ rich foods

manifestations of hypokalemia: SUCTION

Skeletal muscle weakness

U waves - Dysrhythmias

Constipation

Toxic effects of digoxin

Irregular, weak pulse

Orthostatic hypotension

Numbness; paresthesia

· Shallow respirations - weakness in diaphragm

· ↓ intestinal motility, ↓bowel sounds, possible ileus, nausea, vomiting

· Tachycardia, tachypnea, anorexiA

Nursing interventions for hypokalemia

· Oral or IV potassium chloride (KCl) supplements and increased intake of K

· Never given IV push

· Monitor urine output - to ensure kidney function

Pt on cardiac monitor

Calcium plays a key role in

- skeletal muscle contraction

- Cardiac muscle contraction

- Smooth muscle contraction

- Blood clotting

- Transmission of nerve impulses

causes of hypocalcemia

Increased Excitability

· HypOparathyroidsim

· Decreased intake

· Excess laxatives

· Crohn's disease

· Some meds (dilantin)

· Chronic renal disease/failure

· Loop diuretics

· Lack of Vit. D

· Lactose intolerance

· Tumor lysis syndrome

· Chronic alcohol use

Alkalosis

Manifestations of hypocalcemia

· Increased excitability

· Paresthesias fingers & toes

· Chvostek & Trousseau's sign

· Anxiety, muscle twitching

· Confusion, depression, irritability

· Dementia

· Increased risk for fracture if prolonged hypocalcemia

· At risk for laryngospasms and bronchospasms - can compromise the airway

Convulsions

Arrhythmias

Tetany

Spasm & Stridor

Nursing management of hypocalcemia

· Increase dietary Ca and Vit d (canned sardines, salmon, green leafy veggies, beans)

· Monitor for bleeding (gums, mucous membranes, not clotting appropriately)

· IV calcium Gluconate if symptomatic

· Calcium oral replacement (w/ milk if GI upset)

· Exercise if able

· Seizure precautions

· Oxygen, trach tray & suction, bag mask → for Laryngospasm & bronchospasm

· Cardiac monitor

· Respiratory status

Tetany

causes of hypercalcemia

· Primary hypERparathyroid hormone (too much pulling from bone into blood)

· Lack of weight bearing

· Immobility

· Meds (Ca-containing antacids)

· Cardiac arrest

· Excess Ca supplements

· Hematologic cancer

· Cancers w/ bone metastasis

Acidosis

manifestations of hypercalcemia

Decreased excitability

· HypOactivity

· HypOreflexia

· Fatigue

· Lethargy

· Confusion

· Depression

· Px changes

· Bone pain, fractures

· HTN

· Bradycardia

· Arrhythmias

· 1st complain of GI issues - ↑ thirst, nausea, vomiting, ↓bowel sounds

Polyuria, dehydration, kidney stones - kidneys working to get rid of Ca - can sometimes lead to renal failure

Nursing interventions for hypercalcemia

· Fluids 2 - 4 L, to promote excretion of Ca and ↓ chance of kidney stone formation

· Encourage weight bearing exercise

Fall safety

increased excitability is associated with

hypOcalcemia

decreased excitability is associated with

hypERcalcemia