NURS 107 Knowledge Check Exam Two (Part One)

What is the nurse's primary goal with fluid and electrolyte balances?

help prevent imbalances, treat fluid and electrolyte disturbances

Examples of extracellular fluid

1. Intravascular~ plasma, cells

2. Interstitial~ lymph

3. Transcellular~ cerebrospinal fluid, pericardial

What is "third spacing"

loss of extracellular fluid into space that does not contribute to equilibrium

occurs during severe burns; ascites

leads to hypovolemia and hypotension

*common third space= abdomen

What is hypovolemia?

Loss of extracellular fluid and electrolytes

**Not the same as dehydration where water is lost alone with increased sodium

Hypovolemia: Causes

Causes:

~Abnormal fluid losses (vomiting, diarrhea, sweating, GI suctioning)

~Decreased intake (nausea, lack of access)

~Third space fluid shifts

~Additional (adrenal insufficiency, hemorrhage, diabetes insipidus)

Hypovolemia: S&S

~Rapid weight loss

~Decreased skin turgor

~Oliguria/concentrated urine

~Rapid weak pulse

~Postural hypotension

~Cool clammy skin

~Thirst

~Muscle weakness/cramps

~Elevated BUN, increased hematocrit

Hypovolemia: Treatments & Nursing Interventions

Treatments:

~Oral/IV fluids

Nursing Interventions:

~Strict I&O

~Daily weight

~Vital signs closely monitored (watch for decreased BP)

~Assess skin and tongue turgor, mucosa, mental status

~Administer fluids

~Give meds (antidiarrheal, antinausea)

What is hypervolemia?

isotonic expansion of extra cellular fluid caused by abnormal retention of water and sodium

secondary to an increase in the total body sodium content

Hypervolemia: Causes

Causes:

~Fluid overload

~Diminished homeostatic mechanisms

~HF, kidney injury, cirrhosis of liver

Contributing factors:

~High consumption of salt

~Excessive administration of sodium containing fluids

Hypervolemia: S&S

~Edema

~Distended neck veins (JVD)

~Crackles in lungs

~Ascites

~Bounding pulses

Hypervolemia: Treatments & Nursing Interventions

Treatments:

~FR & Na+ restriction

~Diuretics

Nursing Intervention:

~Strict I&O

~Daily weights

~Assess lung sounds (crackles), edema, responses to medications (diuretics)

~Teach pt about FR & Na+ reduction

~Promote rest

~Posturing/turning

~Semi fowlers position for orthopnea

How is fluid gained?

~Dietary intake of fluid, food or enteral feeding

~Parenteral fluids (IV, IVPB)

How is fluid lost?

1. Kidneys~ urine output 1mL/kg/hr (usually 1500mL/day)

2. Skin~ sensible (sweating), insensible (fever, exercise, burns)

3. Lungs~ 300mL/day, increases when RR increases

4. GI tract~ large losses w/ diarrhea, vomiting and fistulas

Fluid balance: Gerontologic Considerations

1.Reduced homeostatic mechanisms

~Decreased cardiac reserve to pump fluid

~Decreased renal function (lowered output; K+ excretion, Na+ retention)

~Decreased skin turgor, elasticity

2. Medication use

~Cautious use with diuretics

3. Clinical manifestations of imbalances may be subtle

4. Dehydration is common

What is osmosis?

water moves from area of low concentration to high

exerted by protein in plasma

What does hydrostatic pressure and osmosis do?

moves fluid through capillary walls

What is diffusion?

solutes move from area of high concentration to low concentration

What is active transport?

physiologic pump that moves fluid from area of lower concentration to higher concentration

requires ATP (energy)

sodium potassium pump: maintains higher concentration extracellular sodium, intracellular potassium

What is filtration?

movement of water; solutes move from high to low hydrostatic pressure

**kidneys

Isotonic solutions: Uses & Examples

Used: to expand ECF volume

For: Intravascular dehydration

Ex: 0.9% NaCl, LR, D5W

Hypotonic solutions: Uses & Examples

Used: Replenish cellular fluid

For: Dehydration

Ex: 0.45% NaCl

Hypertonic solutions: Uses & Examples

Used: to bring excess fluid out of intracellular space

For: Hyponatremia, hypovolemia

Ex: Dextrose 5% in 0.9% NS, Dextrose 5% in Lactated Ringers

**Administer slowly (can cause intravascular volume overload)

**Carefully monitor sodium levels, lung sounds, and BP

Kidneys: Labs

1. Hydrogen ions

~High acid

~Renal failure causes backup

2. Urea

~Liver converts ammonia to urea then pushes into blood to be excreted by kidneys; high levels show poor kidney function

3. BUN

~10-20

~Byproduct of protein waste

4. Creatinine

~Critical lab

~Over 1.3= BAD KIDNEY

~End product of muscle metabolism

~High levels show high renal impairment

5. Specific gravity

~Shows kidneys ability to concentrate urine

Kidneys: Regulation of Fluid & Electrolytes

1. Antidiuretic hormone:

~Regulates amount of H2O the kidneys absorb

~Released in response to low blood volume or increase in Na+

2. RAAS:

~Controls fluid volume by increasing retention of Na+ and secretion of K+

3. Alters the amount of H+ (acid) and HCO3- (base) excreted in urine

Hyponatremia: Causes

x < 135 (135-145 norm)

~Adrenal insufficiency

~Water intoxication

~SIADH

~Losses by vomiting, diarrhea, sweating, diuretics

(Neuro affected)

Hyponatremia: S&S

~Poor skin turgor

~Dry mucosa

~Headache

~Decreased BP

~Nausea

~Abdominal cramping

~Neurologic changes

Hyponatremia: Treatment & Nursing Interventions

Treatment:

~Fluid restriction

~Careful oral/NG sodium replacement

~IV 0.9% NaCl or LR

~3% NaCl in critical situations

Nursing interventions:

~Assess S&S to prevent worsening (especially in the most vulnerable)

~Adherence to FR & Na+ restriction

~Assess urine samples (specific gravity) and blood sodium levels

~Monitor effects of diuretics

Hypernatremia: Causes

x > 145 (135-145 norm)

~Excess water loss

~Excess sodium administration

~Diabetes insipidus

~Heat stroke

~Hypertonic IV solutions

*Most affected are very old, very young, or cognitively impaired

(Neuro affected)

Hypernatremia: S&S

~Increased thirst (elderly/cog. impaired pts may not report this)

~Elevated temperature

~Dry, swollen tongue

~Sticky mucosa

~Altered mental status

~Restlessness

~Weakness

Hypernatremia: Treatment & Nursing Interventions

Treatment:

~Hypertonic electrolyte solution, D5W

Nursing interventions:

~Assess & prevent the most vulnerable

~Ask if pt is taking OTC sodium supplements/meds that include sodium

~Encourage fluids

~Provide sufficient water intake w/ tube feedings if necessary

Hypokalemia: Causes

x < 3.5 (3.5-5.0 norm)

~GI losses (diarrhea, vomiting, GI suction)

~Medications (thiazide diuretics, laxatives)

~Hyperaldosterism

~Poor dietary intake

Hypokalemia: S&S

~Fatigue

~N/V

~Ventricular systole or fibrillation

~Muscle weakness

~Paresthesia

~Polyuria

~Decreased bowel motility

~Cramps

(Cardiac & muscular affected)

Hypokalemia: Treatment & Nursing Interventions

Treatment:

~Increase potassium (medication, dietary, IV)

**Never given IV push; IVPB over AT LEAST one hour

Nursing interventions:

~Frequent EKG (monitor for cardiac changes) and ABGs

~Check urine output

~Give IV pot. SLOWLY

~Close monitoring

Hyperkalemia: Causes

x > 5.0 (3.5-5.0 norm)

~Impaired renal function

~Hypoaldosteronism

~Tissue trauma (ex: getting legs cut off during accident)

~Acidosis

Hyperkalemia: S&S

~Cardiac changes (dysrhythmias)

~Tachycardia/bradycardia dysrhythmias

~Muscle weakness

~Potential respiratory impairment

~Parensthesia

~Anxiety

~GI issues

Hyperkalemia: Treatment & Nursing Interventions

Treatment:

~IV sodium bicarbonate, calcium gluconate, hypertonic dextrose

**Calcium gluconate can cause tissues to slough; ensure it is in the vein

~Dialysis

~Insulin (stimulates activity of Na+H+ antiporter which promotes Na+ into cells thus decreasing K+)

Nursing interventions:

~Frequent EKGs

~Assess labs

~Limit potassium intake (no salt substitutes)

Hypocalcemia: Causes

x < 8.6 (8.6-10.2 norm)

~Hypoparathyroidism

~Malabsorption

~Osteoporosis

~Pancreatitis

~Alkalosis

~Massive transfusion of citrated blood

~Kidney injury

~Medications

Hypocalcemia: S&S

~Tetany

~Circumoral numbness

~Tingling

~Paresthesias

~Hyperactive DTRs

~Trousseau's sign

~Chovstek's sign

~Seizures

~Dyspnea

~Laryngospasm

~Abnormal clotting

~Anxiety

Hypocalcemia: Treatment & Nursing Interventions

Treatment:

~IV calcium gluconate

~Oral calcium and vitamin D supplements

~Diet (increase calcium intake)

Nursing Interventions:

~Constant assessment

~Weight bearing exercises to decrease bone calcium loss

~Pt teaching (increase calcium in diet, meds)

Hypercalcemia: Causes

x > 10.2 (8.6-10.2 norm)

~Malignancy

~Hyperparathyroidism

~Bone loss related to immobility

~Diuretics

Hypercalcemia: S&S

~Muscle weakness

~Incoordination

~Anorexia

~Constipation

~N/V

~Abdominal and bone pain

~Polyuria

~Thirst

~ECG changes

~Dysrhythmias

Hypercalcemia: Treatment & Nursing Interventions

Treatment:

~Treat underlying cause

~Fluids

~Furosemide

~Phosphates

~Calcitonin

~Bisphosphonates

Nursing interventions:

~Encourage ambulation

~Fluids of 3-4 L/day

~Provide fluids containing sodium

~Fiber for constipation

~Ensure safety

Hypomagnesemia: Causes

x < 1.3 (1.3-3.0 norm)

~Alcoholism

~GI losses

~Medications

~Enteral/parenteral feeding deficient in mag

Contributing causes:

~DKA

~Sepsis

~Burns

~Hypothermia

**Hypomagnesemia often accompanied by hypocalcemia

Hypomagnesemia: S&S

~Chvostek and Trousseau signs

~Apathy

~Depressed mood

~Psychosis

~Neuromuscular irritability

~Muscle weakness

~Tremors

~ECG changes

~Dysrhythmias

Hypomagnesemia: Treatment & Nursing Interventions

Treatment:

~Increase mag in diet

~Oral magnesium

~Magnesium sulfate IV (IV pump)

~Seizure precautions

Nursing management:

~Ensure safety

~Pt teachings on diet, medications, alcohol use

~Check albumin levels

Hypermagnesemia: Causes

x > 3.0 (1.3-3.0 norm)

~Kidney injury

~DKA

~Excessive administration of mag

~Extensive soft tissue injury

**RARE

Hypermagnesemia: S&S

~Flushing

~Hypotension

~N/V

~Hypoactive reflexes

~Drowsiness

~Muscle weakness

~Depressed respirations

~EKG changes

~Dysrhythmias

~Cardiac arrest

Hypermagnesemia: Treatment & Nursing Interventions

Treatment:

~IV calcium gluconate

~Loop diuretics

Nursing interventions:

~Do not administer any more mag

~Pt teaching regarding OTC meds containing mag

~Observe DTRs and changes in LOC

Hypophosphatemia: Causes

x < 2.5 mg/dL (2.5-4.5 norm)

~Alcoholism

~Refeeding of pts after starvation

~Pain

~Heat stroke

~Respiratory alkalosis

~Hyperventilation

~DKA

~Hepatic encephalopathy

~Major burns

~Diarrhea

~Vit. D deficiency

~Low mag/K+

Hypophosphatemia: S&S

~Neurologic symptoms

~Confusion

~Muscle weakness

~Tissue hypoxia

~Muscle and bone pain

~Increased susceptibility to infection

Hypophosphatemia: Treatment & Nursing Interventions

Treatment:

~Oral or IV phosphorus replacement

Nursing interventions:

~Encourage foods high in phosphorus (poultry, seafood, dairy)

~Gradually increase calories for malnourished patients receiving parenteral nutrition

Hyperphosphatemia: Causes

x > 4.5 mg/dL (2.5-4.5 norm)

~Kidney injury

~Excess phosphorus, vit. D

~Acidosis

~Hypoparathyroidism

~Chemotherapy

Hyperphosphatemia: S&S

Few symptoms; symptoms usually occur due to associated hypocalcemia

~Soft tissue calcifications

Hyperphosphatemia: Treatment & Nursing Interventions

Treatment:

~Treat underlying disorder

~Vit. D preparations

~Calcium binding antacids

~Phosphate binding gels or antacids

~Loop diuretics

~Dialysis

Nursing interventions:

~Avoid high phosphorus foods

~Patient teaching related to diet

~Watch for signs of hypocalcemia

Hypochloremia: Causes

x < 97 mEq/L (97-107 norm)

~Addison's disease

~Reduced chloride intake

~GI loss

~DKA

~Excessive sweating

~Fever

~Burns

~Metabolic alkalosis

Hypochloremia: S&S

~agitation

~irritability

~weakness

~hyperexcitability of muscles

~dysrhythmias

~seizure

~coma

Hypochloremia: Treatment & Nursing Interventions

Treatment:

~Replace chloride (IV NS or 0.45% NS)

Nursing interventions:

~Avoid free water

~Encourage increased table salt intake

~Pt teaching on diet

Hyperchloremia: Causes

x > 107 mEq/L (97-107 norm)

~Excess NaCl infusions w/ water loss

~Head injury

~Hypernatremia

~Dehydration

~Severe diarrhea

~Respiratory alkalosis

~Metabolic acidosis

~Hyperparathyroidism

Hyperchloremia: S&S

~Tachypnea

~Lethargy

~Weakness

~Rapid deep respirations

~Hypertension

~Cognitive changes

Hyperchloremia: Treatment & Nursing Interventions

Treatment:

~Restore electrolye and fluid balance

~LR IV

~Sodium bicarbonate

~Diuretics

Nursing interventions:

~Assessment

~Pt teaching related to diet and hydration

Maintaining Acid-Base Balance

Kidneys regulate bicarbonate in ECF

~HCO3

Lungs under control of medulla regulate carbonic acid in ECF

~PaCO2

**Most common buffer system in body= Bicarbonate-carbonic acid

What is uncompensated vs partially compensated vs compensated?

Uncompensated= the opposite value (PaCO2 or HCO3) is NORMAL (isn't trying to compensate yet); pH ABNORMAL

Partially compensated= the opposite value (PaCO2 or HCO3) is ABNORMAL (trying to compensate); pH is ABNORMAL

Fully compensated= the opposite value (PaCO2 or HCO3) is ABNORMAL; pH is NORMAL

Acid-Base Balance: Explain the ROME method

Respiratory

Opposite

Metabolic

Equal

Respiratory opposite: CO2 high, pH low= resp. acidosis

CO2 low, pH high= resp. alkalosis

Metabolic equal:

HCO3 low, pH low= metabolic acidosis

HCO3 high, pH high=

metabolic alkalosis

Metabolic Acidosis: Values

Low pH <7.35

Low bicarbonate <22 mEq/L

Metabolic Acidosis: Causes

~Kidney injury**

~Starvation

~Shock

~Hypoxemia

Metabolic Acidosis: S&S

~Headache

~Confusion

~Drowsiness

~Increased RR & depth

~Decreased BP & CO

~Dysrhythmias

~Shock

**Pt may be asymptomatic until bicarbonate is 15 mEq/L or less

Metabolic Acidosis: Treatment

~Correct underlying problem/imbalance

~Kidneys respond by excreting hydrogen and retaining bicarbonate

~Monitor potassium levels (increase during problem, decrease during correction)

~Monitor calcium levels (may be low with chronic metabolic acidosis)

Metabolic Alkalosis: Values

High pH > 7.45

High HCO3 > 26

Metabolic Alkalosis: Causes

~Vomiting

~Gastric suctioning

~May also be due to long term diabetic medications

~Hypokalemia

Metabolic Alkalosis: S&S

~Decreased calcium

~Respiratory depression

~Tachycardia

~Hypokalemia symptoms

Metabolic Alkalosis: Treatment

~Correct underlying cause

~Supply chloride to allow excretion of excess bicarbonate

~Restore fluid volume with sodium chloride solutions

Respiratory Acidosis: Values

Low pH <7.35

PaCo2 >42 mmHg

Respiratory Acidosis: Causes

Always due to respiratory problem with inadequate excretion of CO2

Ex: COPD, asthma

Respiratory Acidosis: S&S

~With chronic respiratory acidosis, body may compensate becoming asymptomatic

~If symptomatic= sudden increased pulse, RR & BP, mental changes, feeling of fullness in head

~Potential increased intracranial pressure

Respiratory Acidosis: Treatment

~Improve ventilation

Respiratory Alkalosis: Values

High pH > 7.45

PaCO2 <35 mmHg

Respiratory Alkalosis: Causes

Hyperventilation

Ex: anxiety attack

Respiratory Alkalosis: S&S

~Lightheadedness

~Inability to concentrate

~Numbness and tingling

~Sometimes loss of consciousness

Respiratory Alkalosis: Treatment

Correct cause of hyperventilation

"breathe into the paper bag"

Arterial Blood Gases (ABGs): Value Ranges

pH 7.35 - (7.4) - 7.45

PaCO2 35 - (40) - 45

HCO3 22 - (24) - 26

PaO2 80-100 mmHg

O2 sat > 94%

ABG: Value Meaning

1. pH 7.35-7.45

low= acidosis

high= alkalosis

2. PaCO2 35-45

low= alkalosis

high= acidosis

3. HCO3 22-26

low= acidosis

high= alkalosis

Parenteral Fluid Therapy

~Provides water, electrolytes, nutrients

~Fluids= isotonic, hypertonic, hypotonic

~Medications can also be administered

Complications of IV therapy

~Fluid overload

~Air embolism

~Septicemia

~Infiltration (leakage into tissues)

~Extravasation (leakage into vessels)

~Phlebitis (area around will be red, tender, tracking up vein)

~Thrombophlebitis

~Hematoma

~Clotting

What is shock?

"inadequate tissue perfusion"

life threatening condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function

**May develop rapidly or slowly. MUST ACT QUICKLY!

What are the three types of shock?

1. Hypovolemic (low blood volume)

Ex: hemorrhage, blood loss

2. Cardiogenic (myocardium not pumping effectively)

Ex: MI/necrosis

3. Circulatory (vasodilation leading to decreased cell perfusion)

a. Septic (infection)

b. Neurogenic (loss of sympathetic tone)

c. Anaphylactic (severe allergic reaction)

**Regardless of the initial cause of shock, these reactions are common to all forms of shock: hypoperfusion of tissues, hypermetabolism, and activation of the inflammatory response

What are the three stages of shock?

1. Compensatory (body tries to preserve tissue perfusion with various mechanisms)

2. Progressive (mechanisms begin to fail leading to hypo perfusion and deterioration)

3. Irreversible (organs fail, pt dies)

Stages of Shock: Compensatory

The body tries to compensate for damage

The SNS causes: VASOCONSTRICTION, INCREASED HR, AND INCREASED HEART CONTRACTABILITY

(BP remains normal)

The body then shunts blood from skin (cool/clammy), kidneys (decreased urine output), & GI tract (hypoactive bowel sounds) to protect main areas (heart, brain)

Stages of Shock: Compensatory S&S

~Cool, clammy skin

~Decreased urine output

~Hypoactive bowel sounds

~Acidosis

~Increased RR & HR

~Normal BP

~Confusion

Stages of Shock: Progressive

Mechanisms that regulate BP can no longer compensate, causing BP and MAP to DECREASE

All organs begin to suffer

Stages of Shock: Progressive S&S

Heart: decreased BP & MAP, dysrhythmias, ischemia

Kidneys: acute kidney injury

Neuro: further decreased mental status due to decreased cerebral perfusion and hypoxia

Lungs: decreased pulmonary blood flow causes hypoxia, increased CO2 levels, alveoli collapse, pulmonary edema

DIC (disseminated intravascular coagulation) may occur

**Every patient has different levels of normal. Always refer back to the patients specific baseline

Stages of Shock: Irreversible

Organ damage is so severe that patient does not respond to treatment and will ultimately die

BP remains low, renal/liver fails, anaerobic metabolism worsens acidosis, complete organ failure

What is Multiple Organ Dysfunction Syndrome (MODs)?

presence of altered function of two or more organs in acutely ill patients such that interventions are necessary to support continued organ function

MODS: Treatment

~Control initiating event

~Promote adequate tissue perfusion (positioning, IV fluids, monitor urine output, maintain CO)

~Provide nutritional support

Shock: General Treatment

**EARLY IDENTIFICATION (Identify & treat underlying cause before it worsens)

1. Fluid replacement (restores intravascular volume)

~Crystalloid, colloid solutions

2. Vasoactive medication therapy to restore vasomotor tone and improve cardiac function

3. Nutritional support (parenteral or enteral to support and address metabolic requirements)

Fluid Replacement for Shock

1. Crystalloids

Ex: 0.9% NS, lactated Ringers, hypertonic solutions

2. Colloids

Ex: Albumin, dextran (may interfere w/ platelet aggregation)

3. Blood components for hypovolemic shock

Complications= fluid overload, pulmonary edema

Vasoactive Medications for Shock

~Used when fluid therapy alone does not maintain MAP

~Stimulates SNS and supports hemodynamic status

~Give through central line if possible

*Monitor VS Q15min (BP drops, need to increase)

Nutritional Therapy for Shock

~Nutritional support is needed to meet increased metabolic and energy requirements

~Support with parenteral or enteral nutrition

*Administer glutamine (amino acid), H2 blockers, or proton pump inhibitors

Psychological Support of Patients and Families

~Ease anxiety

~Support family with coping mechanisms and through their grief process

~Educate patient and family on what is going on/what to expect

~Communicate changes

~Discuss end of life issues

Hypovolemic Shock: Medical/Nursing Management

Medical:

~Treat underlying cause

~Fluid, blood replacement

~Redistribution of fluid

~Pharmacologic therapy

Nursing management:

~Administer blood & fluids safely

~Continuously monitor patient

~Position patient in modified Trendelenburg (increased venous return to important areas like the heart and brain)

Cardiogenic Shock: Medical Management

Medical:

~Oxygenation

~Pain control

~Hemodynamic monitoring

~Laboratory marker monitoring

~Fluid therapy

~Mechanical assistive devices (gets heart to circulate better)

~Medication (morphine for pain & vasodilation; antiarrhythmics, nitroglycerin, dopamine)