NSG 212 exam 3

Hypervolemia

Fluid Overload

Hypervolemia Causes

Retention of sodium and water

Hypervolemia Labs:

Decreased hemoglobin, albumin, sodium and serum osmolarity (diluted)

Hypervolemia Clinical manifestations

Weight gain, ascites, edema, increased urine output, HTN, Tachycardia, S3 heart sounds, jugular vein distention, cough, tachypnea, adventitious sounds (wheeze, crackles), decreased O2 sat.

Hypervolemia Medical and nursing management:

Prevent, correct, manage underlying cause

If at risk, limit fluid and sodium intake, monitor daily weight (early recognition), Diuretics may need dialysis if renal compromise.

Hypervolemia Risk

- pulmonary edema, progressive hypoxia

Hypervolemia nursing actions:

History, physical assessment, O2 therapy, position in semi-fowlers; reposition to prevent skin breakdown, calculate I & O (foley), Patient education, daily weight (2.2 lbs = 1L of fluid).

Hypovolemia

Fluid volume Deficit

Hypovolemia Causes

: Loss, poor intake, fluid shifts (third spacing) Excess sweating, vomiting, diarrhea

Hypovolemia Labs

Increased sodium, Serum osmolarity, BUN, urine specific gravity, urine osmolarity, hematocrit is falsely elevated because of lack of fluid. Decreased potassium

Hypovolemia Clinical manifestations

: depends on cause, can develop quickly, Weight loss, loss of skin turgor, concentrated urine, low urine output, dry mucous membranes.

SEVERE AND RAPID hypovolemia symptoms= weak, rapid peripheral pulses, flattened neck veins, hypotension, anxiety, restlessness; cool, clammy, pale skin.

Dehydration (FVD) symptoms

: Thirst, less frequent dark urine, muscle cramps, headache, irritable, dizzy, rapid heartbeat.

Medical and nursing management Hypovolemia:

Identify and correct cause, oral fluids if not severe, IV isotonic fluids (0.9% NS or lactated ringers = expand plasma volume) Infuse at rate to correct

Nursing actions for hypovolemia:

Assess - urine output, VS, neuro and resp status

Hypovolemia Risk/ how to fix it =

hypovolemic shock

Significant loss of body fluid (blood flow and perfusion are slowed and the cells no longer able to carry O2 to the blood).Maintain IV access - #1, monitor O2 sat and administer O2, stay with unstable patient, monitor VS every 15 mins, fluid replacement (Colloids- whole blood, PRBCs, plasma and Crystalloids - LR, NS), Vasoconstrictors, improve myocardial perfusion and positive inotropic meds, hemodynamic monitoring.

History, physical assessment, review labs, fluid replacement as ordered, calculate I & O may be hourly, daily weight.

SODIUM (NA+ 135-145)

Levels controlled by thirst, ADH & RAAS

Sodium potassium pump: transfer of sodium from ECF to ICF and potassium from ICF to ECF = action potential = Cardiac and skeletal muscle contractions.

Sodium ions are + charge and chloride are - charge

Intake sodium through food and fluids: daily recommendations 1500-2300 mg.

Hyponatremia

- LOW sodium

Hyponatremia Clinical manifestations

depend on severity, cause and rapidity of onset.

If acute, start treatment quickly to prevent cerebral edema and neuro decline (osmotic gradient favors movement into cells) Slow onset = treat more conservatively

Hyponatremia Nursing management

: Figure out who is at risk, monitor weight and I & O, observe for neuro changes, patient education.

Hyponatremia Causes:

GI suctioning, diarrhea, vomiting, decreased sodium intake, excessive sweating, kidney disease, hyperglycemia, heart failure, SSRIs, adrenal insufficiency

Hyponatremia Clinical manifestations

: Headache, lethargy, confusion, convulsions, nausea, vomiting, seizures, muscle twitching, abdominal cramps, coma.

Hyponatremia Treatment

= Fluid restriction, if severe: 3% NS, Oral sodium supplements, Loop diuretics.

Hypernatremia

- HIGH sodium

Hypernatremia Causes

: Water deficits from hypertonic enteral feeding, diabetes insipidus, cushings, neoplasms, meds, burn injuries, febrile states, exercise, excessive sodium ingestion, use of sodium bicarb.

Hypernatremia Treatment:

hypotonic fluids; prevent rade correction = fluid shifts to brain = cerebral edema (GIVE SLOWLY), Fluid replacement (½ NS or D5W) Treat underlying cause

Hypernatremia Clinical manifestations

: Disorientation, hallucinations, agitation, restlessness, confusion, lethargy, tachycardia, dry mucous membranes, flushed skin, thirst, elevated body temp, lethargy (stupor, coma), seizure, muscle irritability.

Hypernatremia Nursing actions:

Monitor LOC, VS, auscultate lung sounds, provide oral hygiene, monitor I & O and sodium levels.

POTASSIUM (K+ 3.5- 5):

Major ICF electrolyte of body (98% in cell: 2 extracellular for neuromuscular function)

Sodium potassium pump, Normal renal function needed to maintain normal potassium (80% of daily loss through kidneys) - cardiac related

Hypokalemia

- LOW POTASSIUM

Hypokalemia Causes:

Secondary to losses through GI tract (Suctioning) and renal system, actions of meds, transcellular shifts, inadequate intake of K+. Metabolic alkalosis - lose K+ ions, Also see with hyperaldosteronism; hyper insulin secretion; release of catecholamines.Cardiac, pulmonary, neuromuscular and GI symptoms can develop quickly!!

Hypokalemia Symptoms

: Weakness, lethargy, hyporeflexia, EKG changes, PVC’s, nausea, vomiting, constipation.

Hypokalemia Nursing management:

Monitor patients at risk, assess for leg cramps and muscle weakness, cardiac rhythms- flat t-wave, prominent U waves, ST depression, patient education and K+ replacement.

NO IV BOLUS (cardiac arrest) = NEVER PUSH K+

K+ rich foods, watch diuretics and laxatives

Hypokalemia Treatment:

Increase intake (supplements), Slow K, KCL liquid, power or tablets, Peripheral IV or central line over 1 hour.

NS or D5W

Hyperkalemia

- HIGH POTASSIUM

Hyperkalemia Causes

: Acute or chronic renal failure, meds, excessive intake, increased use of salt substitutes,Diabetic ketoacidosis, tissue damage

Hyperkalemia Symptoms:

Muscle cramps, paresthesia to weakness, abdominal cramping, EKG changes (abnormal rhythms, wide QRS).

Oliguria, respiratory distress, hyperreflexia

Hyperkalemia Treatment

: check EKG, prompt dialysis if R/T renal failure, modify diet, If R/T acidosis - correct underlying cause to shift K+ back into cell.

Kayexalate, 50% dextrose and IV regular insulin IVP bolus, sodium bicarb, calcium gluconate, albuterol, loop diuretic.

Hyperkalemia Nursing management

:Identify high risk patients, asses for dysrhythmias and muscle weakness, telemetry monitoring, administer meds.

MAGNESIUM (Mg 1.6-2.6)-

Carbohydrate and protein metabolism, Alters effects of calcium on smooth muscles, causing them to relax.

Needed for healthy bones, teeth, nerve and muscle function, and coagulation.May have a role in regulating BP and release insulin

Hypomagnesemia

- LOW MG

Hyperkalemia Causes:

chronic alcohol use (poor intake), loss via NGT suction meds that use diuresis, glycosuria; antibiotics. May be seen with low potassium and calcium

Hyperkalemia Symptoms:

Paresthesias, tetany, twitching, tachycardia, nausea, vomiting, seizures, anorexia, dysrhythmias, increased deep tendon reflexes, cardiac changes, disorientation, may see dysphagia

Hyperkalemia Nursing management:

Recognize pts at risk, monitor cardiac rhythm; seizure precautions, monitor I & O.

Hyperkalemia Treatment:

labs may indicate before symptoms, replace through dietary measures, meds, be aware of cardiac arrest and V-fib.

IV replacement - D5W over an hour

Magnesium tabs, IVP during code blue

Hypermagnesemia

- HIGH MG

Hypermagnesemia causes:

Acute renal failure or kidney disease (MOST COMMON), excessive intake, excessive administration of IV, seizure, Gestational hypertension, preterm labor.

Hypermagnesemia Symptoms

: Lethargy/ drowsiness, depression, neuromuscular activity, depressed respirations, hypoactive DTR’s, hypotension, bradycardia, cardiac arrest, coma.Arrhythmias, decreased deep tendon reflexes, serum Mg greater than 10 = respiratory muscle paralysis

Hypermagnesemia Treatment:

Oral or IV fluids to clear, loop diuretics; if mag toxicity give 10 calcium gluconate, mechanical vent as needed (if code), Loop diuretic

Hypermagnesemia Nursing management →

Monitor for a sharp drop in BP and respiration, monitor cardiac rhythm; assess mental status changes.

CALCIUM (8.5 - 10.2)

- Used in cardiac contraction, blood coagulation, transmit nerve impulses and muscle contractions.99% found in bone. Calcium is regulated on basis of functions of parathyroid and thyroid glands. An increase in PTH leads to increase calcium

Hypocalcemia

- LOW CALCIUM

Hypocalcemia Causes:

Vit D deficiency, hypoparathyroidism, diarrhea, malnutrition, pancreatitis, lactation, pregnancy, chronic renal failure, bone disease, chronic alc abuse.

Hypocalcemia Symptoms

: Numbness, tingling of extremities around mouth, muscle tremors/cramps, hyperactive DTRs, anxiety, + trousses (BP CUFF) and Chvostek's (FACIAL TWITCH) signs, convulsions, tetany, spasms. Seizure, decreased contractility = decreased cardiac output, hypotension.

Hypocalcemia Treatment:

Protect and maintain airway, cardiac monitoring, IV catheter, correct electrolyte imbalance, IV calcium and oral supplementation

Hypocalcemia Nursing management:

Monitor for at-risk pts, emergency equipment nearby, quiet environment, increase calcium foods, smoking cessation and limit caffeine and alc.

Hypercalcemia

- HIGH CALCIUM

Hypercalcemia Causes:

Malignancy, hyperparathyroid, prolonged immobilization, excessive calcium intake, diuretics.

Hypercalcemia Symptoms:

Lethargy, weakness, constipation, depressed deep tendon reflexes, flank pain secondary to renal calculi, reduced neuromuscular excitability, anorexia, nausea, vomiting. Polyuria and polydipsia, bradycardia

Hypercalcemia Treatment:

stop meds, 0.9% NS, Dialysis, IV Bisphophates, calcitonin, limit calcium foods, good hydration, exercise, movement, surgery.

Hypercalcemia Nursing management:

Monitor at risk pts, changes in mental status and cardiac rhythms, encourage ambulation, adequate hydration but monitor for fluid excess.

PHOSPHOROUS (2.5-4.5)-

Used in muscle function, RBC, and nervous system, Inverse relationship with calcium, Forms bones and teeth, Utilization of carbs and fats,Production of ATP energy source of cells

Hypophosphatemia

Used in muscle function, RBC, and nervous system, Inverse relationship with calcium, Forms bones and teeth, Utilization of carbs and fats,Production of ATP energy source of cells

Hyperphosphatemia:

Renal failure most common cause, Chemotherapy (shift from ICF to ECF), Increased phosphate intake, Manifestations: tetany, renal impairment