NUR 226 - Test 2

Water content

50-60% in adults

45-55% in older adults

70-80% in infants

Fluid compartments

Intracellular fluid (70%)

Extracellular (30%)

interstitial fluid

fluid between organs and tissues

intravascular fluid

blood plasma; fluid within blood vessels

transcellular fluid

cerebrospinal canals, lymphatic tissues, synovial joints, ocular, pleural, peritoneal

crystalloids

solids that dissolve easily

colloids

substances that don't dissolve easily; ex: proteins

2 types of fluid volume deficit

isotonic - hypovolemia

hypertonic - dehydration

isotonic deficit (hypovolemia)

Water and sodium are lost at the same rate; ex: hemorrhage, burns, vomiting, diarrhea, fever

hypertonic deficit (dehydration)

Water loss > electrolyte loss; diabetes insipidus (DI), DKA, osmotic diuresis, prolonged vomiting and diarrhea, fevers

fluid volume excess causes

Heart failure

Renal failure

Cirrhosis

Excessive water or sodium intake

SIADH

Inadequately controlled IV therapy

Long-term corticosteroid therapy

SIADH

syndrome of inappropriate antidiuretic hormone

temperature changes

hypertonic fluid deficit (dehydration) = increased temp

isotonic fluid deficit = decreased temp

pulse changes

Fluid volume deficit = weak, thready pulse

Fluid overload = strong, bounding pulse

respiration changes

Fluid deficit = high resp

Fluid overload = low resp

BP changes

Fluid deficit = low BP

Fluid overload = high BP

how to obtain accurate weight

Same time, same clothes, post-void, usually in the morning

pitting edema stages

1+ = 2mm

2+ = 4mm

3+ = 6mm lasts several seconds

4+ = 8mm lasts several minutes

IV potassium precautions

never IV push or IV bolus

always dilute and administer slowly, usually by infusion

peripheral IV

located commonly in arms, sometimes legs; superficial vein

Central IV

PICC

CVC

PICC

peripherally inserted central catheter; used for long-term therapy has multiple lumens and can simultaneously infuse incompatible medications, fluid, blood, or TPN

commonly inserted in arm, tip rests at SVC

CVC

in major vein like neck or chest, tip rests at SVC

what do you need in peripheral and central lines before administering meds?

blood return

IV infection

warm to touch, redness, systemic = fever, pain

IV occlusion

blockage

Phlebitis

inflammation of the vein; red streaking going up the arm

IV infiltration

fluid seeps into the tissues surrounding the vein; swelling

IV extravasation

similar to infiltration but with a vesicant drug; ex: vancomycin

infiltration treatment

Apply thermal applications and elevate as appropriate.

Outline the area of visible damage with a marker to assess changes

vesicant medications

dopamine, norepinephrine, high concentrations of electrolytes, and several antibiotics (vancomycin)

Extravasation treatment

Never apply pressure to the area

Infusion is discontinued immediately

Notify PCP and obtain orders for extravasation treatment and/or antidote

Use a skin marker to track area of damage

Cautiously apply cold or warm compresses and elevate the extremity

phlebitis treatment

Use standardized phlebitis assessment tool

Discontinue catheter immediately if phlebitis suspected and contact PCP

Apply warm, moist compresses for 20 min three or four times per day per orders

occlusion treatment

Assess tubing and site for obstructions such as kinked tubing or arm position

Attempt to flush catheter with normal saline; don't force!!

Forcing the flush can dislodge the clot, which becomes an embolism

If peripheral IV, discontinue the site and restart a new site

If a CVC, notify PCP or IV team

hypotonic IV solutions

.33% NS

.45% NS

isotonic IV solutions

0.9% Normal Saline

5% dextrose in water (D5W)

Lactated Ringers

hypertonic IV solutions

D10W

D5 .45% NS

D5 .9% NS

D5LR

3% NS (close monitoring)

caution with 3% NS

given in ICU b/c it can cause brain damage

normal lab values

Na: 135-145

K: 3.5-5.0

Ca: 9.0-10.5

Mg: 1.3-2.1

hypovolemic hyponatremia

losing water and salt both

loss of sodium is greater than water loss

hypervolemic hyponatremia

water intake > sodium intake

hyponatremia causes

Hypovolemic hyponatremia

Diuretics

GI fluid loss (vomiting, diarrhea)

Profuse diaphoresis

Water intoxication

Prolonged use of hypotonic IV solutions

SIADH

hyponatremia manifestations

Lethargy, confusion, weakness

Muscle cramping

Seizures

Anorexia, nausea, vomiting

hyponatremia treatment

Monitor vital signs

Monitor intake and output

Monitor laboratory results, especially serum sodium and serum osmolality

Encourage foods high in sodium

Restrict water intake

Administer hypertonic IV saline solutions as ordered

Na administration precautions

Monitor to ensure that Na+ levels increase by only 4 to 6 mEq/L in any 24-hour period

Increasing too fast can cause brain damage due to osmotic demyelination syndrome (ODS)

hypernatremia causes

Excessive sodium intake

Hypertonic IV solutions

Hypertonic enteral feedings without adequate water

Excessive loss of water due to:

Diarrhea

Inadequate intake of water

Insensible loss due to fever

hypernatremia manifestations

Thirst, dry and sticky mucous membranes, weakness, elevated temperature

Confusion and irritability, decreased levels of consciousness, hallucinations, and seizures

hypernatremia treatment

Limit salt intake and foods high in sodium

Increase water intake

Administer hypotonic IV solutions as ordered

hypokalemia causes

Vomiting, gastric suction, diarrhea

Laxative abuse, frequent enemas

Use of potassium-wasting diuretics

Inadequate intake seen in anorexia, alcoholism, debilitated patients

Hyperaldosteronism

hypokalemia manifestations

Weak, irregular pulse

Fatigue, lethargy

Anorexia, nausea, vomiting

Decreased peristalsis, hypoactive bowel sounds

Paresthesia

Cardiac dysrhythmias

Increased risk for digitalis toxicity

hypokalemia treatment

Assess for signs of digitalis toxicity

Encourage foods high in potassium

Administer potassium supplements as ordered

hyperkalemia causes

Renal failure

Massive trauma, crushing injuries, burns

Hemolysis

IV potassium

Potassium-sparing diuretics

Acidosis, especially diabetic ketoacidosis

hyperkalemia manifestations

Anxiety, irritability, confusion

Dysrhythmias, including bradycardia and heart block

Muscle weakness, flaccid paralysis

Paresthesia

Abdominal cramping

hyperkalemia treatment

Limit potassium-rich foods

Administer cation-exchange resins (Kayexalate) as ordered

Administer glucose and insulin as ordered (potassium moves back into cell)

hypocalcemia causes

Hypoparathyroidism

Pancreatitis

Vitamin D deficiency

Inadequate intake of calcium-rich foods

Hyperphosphatemia

Chronic alcoholism

hypocalcemia manifestations

Confusion, anxiety

Numbness and tingling of extremities

Muscle cramps that progress to tetany and seizures

Hyperactive reflexes

Cardiac dysrhythmias

Positive Chvostek and Trousseau signs

hypocalcemia treatment

Monitor heart rate and rhythm

Monitor cardiac rhythm with ECG

Institute fall and seizure precautions

Administer oral and/or IV calcium supplements as ordered

Encourage calcium-rich foods

hypercalcemia causes

Prolonged bed rest

Hyperparathyroidism

Bone malignancy

Paget disease

Osteoporosis

hypercalcemia manifestations

Lethargy, stupor, coma

Decreased muscle strength and tone

Anorexia, nausea, and vomiting

Constipation

Pathologic fractures

Dysrhythmias

Renal calculi

hypercalcemia treatment

Monitor HR and rhythm

EKG

Encourage increased fluid intake

Increase patient activity, including active ROM

Hypomagnesemia causes

Decreased intake

TPN without magnesium

Decreased absorption

Nasogastric suction

Draining fistulas

Prolonged diarrhea

Laxative abuse

Malabsorption syndrome

Ulcerative colitis

Crohn's disease

Increased renal excretion

Diuresis

Loop and thiazide diuretics

hypomagnesemia manifestations

Irritable nerves and muscles

Hyperactive deep tendon reflexes

Seizures

Dysrhythmias, especially tachyarrhythmias

ECG changes

Altered level of consciousness, hallucinations

Mood swings

Dysphagia, nausea, and vomiting

hypomagnesemia treatment

EKG

Assess mental status

Monitor potassium and calcium levels

Assess swallowing

Institute seizure precautions

Administer oral or IV supplements as ordered

hypermagnesemia causes

Excessive intake of magnesium-containing antacids or cathartics

TPN with too much magnesium

Prolonged use of intravenous magnesium sulfate

Renal failure

Severe dehydration

Adrenal insufficiency

Leukemia

hypermagnesemia manifestations

Warm, flushed appearance

Nausea, vomiting

Drowsiness, lethargy

Decreased deep tendon reflexes and weakness

Hypotension

Dysrhythmias, especially bradycardia and heart block

Slow, shallow respirations; respiratory arrest

hypermagnesemia treatment

EKG

Assess mental status

Assess neuromuscular strength and activity

Encourage increased oral intake, increased IV fluids

Loop diuretics

O2 as needed

who is more susceptible to fluid imbalance

infants and elderly

Positive Trousseau's sign

hand/finger spasms with sustained blood pressure cuff inflation

Chovstek's sign

Tap facial nerve --> Muscle spasm

salt foods

Breads, cereals, chips, cheese, processed meats such as lunch meats, hot dogs, bacon, ham

Commercially canned foods

Table salt

potassium foods

Fish, excluding shellfish; whole grains, nuts, broccoli, cabbage, carrots, celery, cucumbers, potatoes with skins, spinach, tomatoes, apricots, bananas, cantaloupe, nectarines, oranges, tangerines

calcium foods

Cheese, ice cream, milk, yogurt, rhubarb, spinach, tofu

magnesium foods

Cashews, halibut, Swiss chard and other green leafy vegetables, tofu, wheat germ, dried fruit

respiratory acidosis causes

Hypoventilation due to:

Chest injury

Asthma attack

Pulmonary edema

Brainstem injury

Medications: Anesthetics, opioids, sedatives

respiratory acidosis manifestations

Headache

Altered level of consciousness, irritability, confusion

Dyspnea

Tachycardia

Muscle twitching

respiratory acidosis treatment

Assess vital signs, especially rate and depth of respirations, pulse oximetry.

Assess breath sounds.

Assess cardiac rhythm.

Administer oxygen as ordered.

Monitor ABG results.

Have mechanical ventilation available.

Encourage deep breathing and coughing.

Encourage fluid intake.

respiratory alkalosis causes

Pain

Hyperventilation

Salicylate overdose

Nicotine overdose

Increased metabolic states

respiratory alkalosis manifestations

Tachypnea (rapid, shallow breathing)

Numbness, tingling of fingers

Muscle cramping

Palpitations

Anxiety, restlessness

respiratory alkalosis treatment

Assess vital signs.

Encourage patient who is tachypneic to take slow, deep breaths. Have patient breathe into a paper bag.

Monitor ABGs.

Provide reassurance and emotional support to anxious patient.

metabolic acidosis causes

Shock

Trauma

Cardiac arrest

Diabetic ketoacidosis

Chronic renal failure

Salicylate overdose

Sepsis

Chronic diarrhea

metabolic acidosis manifestations

Kussmaul respirations

Hypotension

Headache

Decreased level of consciousness

Weakness

Nausea, vomiting, anorexia

metabolic acidosis treatment

Assess vital signs, especially respiratory rate and rhythm, blood pressure, and pulse oximetry.

Monitor cardiac rhythm.

Monitor ABGs and serum electrolytes, glucose, and BUN or creatinine.

Monitor level of consciousness.

Have mechanical ventilation available as needed.

Administer sodium bicarbonate as ordered.

metabolic alkalosis causes

Vomiting

Nasogastric suctioning

Overuse of bicarbonate antacids

Hypokalemia

Loop and thiazide diuretics

metabolic alkalosis manifestations

Hypotension

Mental confusion

Muscle twitching, tetany

Increased deep tendon reflexes

Numbness, tingling of fingers and toes

Seizures

Anorexia, nausea, vomiting

Polyuria

metabolic alkalosis treatment

Assess vital signs, especially cardiac rate and rhythm, respiration rate and depth, pulse oximetry, blood pressure.

Monitor ABGs and serum electrolytes, especially potassium.

Assess level of consciousness.

Administer oxygen as ordered.

Initiate seizure precautions.

Treat hypokalemia if appropriate.

BUN/creatinine with fluid imbalance

fluid volume deficit: elevated

fluid volume excess: potentially normal unless caused by renal dysfunction

serum osmolality with fluid imbalance

FVD: May be elevated with hypertonic FVD

FVE: Normal with isotonic FVE but low with hypotonic FVE

hemoglobin and hematocrit with fluid imbalance

FVD: Elevated with FVD that develops rapidly (concentration of blood cells, too little circulating fluid)

FVE: Normal or low

urinalysis with fluid imbalance

FVD: Urine specific gravity and osmolality increase (unless caused by antidiuretic hormone [ADH] deficiency)

FVE: Urine specific gravity is low with hypotonic fluid volume excess; serum osmolality is normal or decreased

isotonic fluid volume excess

overload of fluid in both the interstitial and intravascular spaces; excess water and sodium are retained in the same proportion

hypertonic fluid volume excess

excess water is retained in a higher proportion than sodium; there is an increase in circulating blood volume with a decreased serum osmolality