Fluid and Electrolytes SG NUR 453
Fluid and Electrolytes SG NUR 453 NUR 453
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This 15 page Class Notes was uploaded by Kelly Carroll on Saturday January 31, 2015. The Class Notes belongs to NUR 453 at University of Miami taught by Dr. Ortega in Fall. Since its upload, it has received 165 views. For similar materials see Role Synthesis in Nursing and Health Sciences at University of Miami.
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Date Created: 01/31/15
Fluid and Electrolytes Body Fluids 0 lntraceuar Fluid ICF 0 23 of body uids 0 Major lCF electrolytes Potassium K Phosphorous P04 Magnesium o Extracellular Fluid ECF 0 13 of body uid 0 Major ECF electrolytes Sodium Na Chloride CI Bicardonate Normal Serum Values 0 Na 135145 mEqL K 35 50 mEqL CI 95 105 mEqL o Mag 15 25 mEqL P04 2845 mgdl Ca 85105 mgdl Urine osmol 285300 Glucose Maintaining Fluid and Electrolyte Balance Kidneys 0 Play a major role in controlling all types of balance in uids and electrolytes o RAAS system maintains BP esp in rst stage of shock Adrenal Glands 0 Through the secretion of adosterone the adrenal glands also aid in controlling ECF volume by regulating the amount of sodium reabsorbed by the kidneys o Cortex Hormones excreted by cortex Cortisol amp adosterone both retains Na and excrete K usually an inverse relationship between Na and K o Antidiuretic hormone ADH o ADH from the posterior pituitary gland regulates the osmotic pressure of ECF by regulating the amount of water reabsorbed by the kidney Increases water reabsorption in the distal tubes affects BA secondary o Triggered when hypovolemic 0 Efforts to make the body have a lower serum Na DKA pt 0 presents with HIGH blood glucose hyperosmol hyponatremia o pulls water from the cell ICF l ECF 0 do not treat the sodium level tx the glucose pt will look confused altered mental status thirsty o in response to this thirtsy and INCREASE ADH PRODUCTION TO SHUNT THE LOSS OF WATER minimal urine output BP increases rst step in hypotensive pt is to always push uids I even before vasoconstrictive drugs bc if there is no uids there is nothing to be pushed out Hypotensive pt by the RAAS system 1 decreased kidney perfusion bc of the loss of volume 2 renin is released from the juxtaglomerular apparatus in the Hdney a signals angiotensinogen in the liver to activate angiotension I b angio I travels to the lungs where angiol is converted to angio II by ACE c Angio II main side effect is a potent vasoconstrictor d Angio II travels to the adrenal cortex increases the secretion of aldosterone increase Na reabsorption and K excretion 3 Decrease kidney perfusion ADH secretion for high urine osmol and hypovolemic 4 Done to retain water and increase BP in pts Hypernatremic pts Atrial Natriuretic PeptideHormone ANPH released in efforts to excrete Na and water volume 0 Secreted by the atrium of the heart 0 Increased plasma volume increased atrial stretching preload o All volume travels through heart increased volume of atrium as the atrium stretches ANP is released 0 ANP released travels to kidneys triggers the increase GFR peeing o In the proximal tubules decreased Na reabsorption decrease serum Na 0 decrease in BP IV Solutions Isotonic same tonicity as body uids 0 given to try to avoid uid shift 0 ex 09 Normal Saline Lactated Ringers Dextrose 5 isotonic dehydration water and dissolved electrolytes are lost in equal proportion aka hypovolemia 0 Results in decreased circulating blood volume and inadequate tissue perfusion Hypotonic 0 less tonicity than the uid within the bodys cells 0 ex 12 Normal Saline 033 NaCl Hype onk 0 Greater tonicity than the uid within the bodys cells 0 Ex Hyperalimentation solutions 10 dextrose solution D5 12 Normal Saline 3 NaCl only given in ICUs Edema An excess accumulation of uid in the interstitial spaces Localized edema occurs as a result of traumatic inury from accidents or surgery local in ammation processes or burns Generalized edema anasarca is an excessive accumulation of uid in the interstitial space throughout the body as a result of a condition such as cardiac renal or liver failure 3 processes that cause edema 1 Capillary oncotic pressure a The force that keeps uid in the vascular system b Force that keeps uid INSIDE the vasculature i Occur bc of capillary injury lack of protein hypoalbuminemia malnutrition 2 Capillary hydrostatic pressure a Force exerted by the wall that keeps uid OUTSIDE the vascular system i Occurs with increase in pressure common in CHF pts 3 Lymph node obstruction a Block lymph system seen a lot in mastectomy pts Hypertonic dehydration Water loss exceeds electrolyte loss 0 Fluid mves from the intracellular compartment intot he plasma and interstitial uid spaces causing cellular dehydration and sh nkage Hypotonic dehydration Electrolytes loss exceeds water loss Fluid shifts into the cells causing the cells to swell Fluid Volume DEFICIT assessment 0 Cardiovascular 0 Thread increase HR 0 Decrease BP and orthostatic hypotension o Diminished peripheral pulses Respiratory 0 Increase rate and depth of respiration Neuromuscular o Decrease CNS activity fever 0 Renal o Decrease urinary output increase speci c gravity 0 Integumentary 0 Dry skin poor turgor dry mouth 0 GI o Decrease motility and decrease bowel sounds o Constipation o Thirst BEST way to assess uid volume de cit ORTHOSTATIC VITALS lying sitting standing 2 mucous membranes 3 skin turgor Treatment 1 Replace uids a Isotonic Normal Saline b Hypotonic c Hypertonic 2 Treatment of Shock a After lots of uids expect them to get ionotropicdrugspressors 3 Monitor urine output and BP 4 Daily weights Q24 hours 5 Treat underlying cause Fluid Volume Excess Isotonic overhydration 0 Know as hypervolemia 0 Results from excessive uid in the extracellular compartment 0 Fluid does not shift between compartments 0 Causes circulatory overload and interstitial edema Causes Inadequate controlled IV therapy 0 Renal failure 0 Hypertonic overhydration 0 Rare as a result of excess Na intake 0 Fluid is drawn from ICF compartment Causes 0 Excessive Na ingestion 0 Rapid infusion of hypertonic saline 0 Excessive sodium bicarbonate therapy 0 Hypotonic Overyhydration 0 Know as water intoxication o Fluid moves into the intracellular space and all bdy uids compartment expands Assessment Volume Excess Cardiovascular o Bounding increase HR 0 Elevated BP 0 Distended neck veins 0 Elevated central venous pressue CVP 0 Respiratory o Dyspnea moist crackles on auscultation Neuromuscular 0 Altered LOC headache skeletal muscle weakness paresthesias o lntegumentary o Pitting edema in dependent areas 0 Skin pale and cool to touch 0 GI 0 Increased motility o Isotonic over hydration iver enlargement ascites o Hypotonic overhydration polyuria diarrhea nonpitting edema Treatment of Fluid overload Administer diuretics as ordered 0 Monitor uid and electrolyte balance Loop diuretic Lasix Thiazidelike diuretics hydrochlorthiazide K sparing diuretics spirolomide o Restrict uid intake 0 Maintain strict ampOs Low sodium diet 0 Avoid processed meats canned soups and vegetables 0 Maintain in semifowlers position 0 For maximum lung expansion to improve gas exchange 0 Assess breath sounds frequently cracklesrails in lungs Check for pitting edema 0 Daily weights Sodium Na 0 Major cation in ECF 0 Normal serum level of 135145 0 Primary determinant of plasma osmolality 0 In uence water distribution along with Chloride Essential for nerve impulses Essential for nerve impulse transmission muscle contraction and the movement of glucose insulin and aminoacids Hyponatremia Less then 135 mEqL Sodium imbalance are usually associated with uid volume imbalances 0 Causes Excessive diaphoresis diuretics GI suctioning decrease secretion of aldosterone renal disease Inadequate sodium intake NPO low salt diet Dilution of serum sodium 0 Excessive ingestion of hypotonic uids or irrigation with hypotonic uids 0 Renal failure 0 SIADH o SampS hyponatremia Cardiovascular tachycardia postural hypoTN Respiratory shallow ineffective respiratory movement late Neuromuscular generalized skeletal muscle weakness Cerebral function headache personality changes GI increase motility and hyperactive bowel sounds abdominal cramps and diarrhea nv Renal decrease speci c gravity 0 Nursing interventions Provide foods high in Na if below 135110 lf Na lt 110 mEql give 35 NaCl IV hypertonic solution Monitor vitals If client is taking lithium monitor lithium levels because h yponatremia can cause a diminished excretion resulting in toxicity Psych question lithium toxicity exacerbates hyponatremia 0 Food sources high in sodium Bacon butter canned foods cheese frankfurter ketchup milk mustard processed foods soy sauce bread Hypernatremia Serum Na levels gt 145 0 Causes Decreased Na excretion Cushing syndrome Renal Failure hyperaldosteronism lncrease Na intake 0 Excessive oral sodium ingestion Hypertonic saline solutions 3 NS Decreased water intake NPO infants elderly comatose lncrease water loss 0 Severe burns or fever Cardiovascular assess HR and BP Respiratory pulmonary edema if hypervolemia is present Neuromuscular 0 Early spontaneous muscle twitches irregular muscle contractions Late skeletal muscle weakness deep tendon re exes diminished or absent CNS Altered cerebral function is the most common manifestation of hypernatremia Renal increase speci c gravity decrease urine output lntegumentary dry skin 0 Nursing Interventions Decrease sodium intake in the diet Increase free water intake drink water If Neurological changes give 045 NaCI or D5 W hypotonic uids 0 3 NaCI is given at a very slow infusion of about 2030 mIhr of high concentration so you don t worry about uid overload just increase serum Na level 0 To dilute the amount of sodium Prevent brain damage Monitor serum Na levels Assess neuro status Potassium K 0 Major cation in the lCF Normal serum level 3550 mEqL Transmission of electrical impulses and muscle contraction Maintains acid base balance 0 INSULIN drops the serum K level pulling K into the cell 0 Therefore you want to monitor the serum level for hypokalemia evident in the EKG will see ST depression depression atinverted T waves amp prominent U wave 0 lnsulin needs glucose and K to go into the cell Hypokalemia Serum K less then 35 mEqL 0 Causes Body potassium loss Diuretics thiazides Increase secretion of aldosterone Cushing disease 0 Vomiting diarrhea NG suctioning Renal disease impairing reabsorption of K Inadequate K intake NPO Movement of K from the ECF to the ICF 0 Ex Hyperinsulinemia o SampS Cardiovascular thread weak irregular pulse 0 Weak peripheral pulses Cardiac arrhythmias ST depression atinverted T wave depression U wave Respiratory shallow ineffective respirations that result from profound weakness of skeletal muscles of respiration Neuromuscular anxiety lethargy confusion coma GI nv abdominal cramping ileus 0 Nursing Interventions Monitor for arrhythmias all pts should be on telemetry Monitor electrolyte imbalance Administer K supplements P0 or IV as prescribed 0 IV K given 10 mEqL in 1 hour max 40 mEqL given in 4 hours 0 Will NEVER see K given IVP SubQ or IM Instruct client about foods that are high in K content Strict IampOs o K IV NEVER given IVP IM or SubQ After adding K to an IV solution shake the bag and invert it to ensure that the potassium is distributed evenly throughout the IV solution The maximum recommended infusion rate is 5 to 10 mEqhr never to exceed 20 mEqhr under any circumstances A client receiving more than 10 mEqhr should be placed on telemetry monitoring Monitor for phlebitis if occurs STOP the infusion Nurse should assess renal function before infusion and monitor IampO o K rich food sources Avocado bananas cantaloupe carrots sh mushrooms oranges potatoes pork beef veal raisins spinach strawberries tomatoes Hyperkalemia Serum K level that exceeds 50 mEqL Causes 0 Excessive K intake overingestions of K foods or meds o Decrease potassium secretion Potassium sparing diuretics Renal failure Adrenal insufficiency Addison s diseasehypoaldosterone 0 Movement of K from the ICF to the ECF Acidosis causes hyperkalemia K comes out of the cell and H goes into the cell tissue damage 0 SampS 0 Cardiovascular slow weak irregular HR decreased BP EKG changes tall peaked T waves widened QRS complexes prolonged PR interval at P waves 0 Respiratory profound weakness of the skeletal muscle causes respiratory failure 0 Neuromuscular Early muscle twitches cramps paresthesias Late profound weakness ascending accid paralysis in the arms and legs When the level is lethal 0 GI increase motility hyperactive bowel sounds diarrhea 0 Nursing Interventions 0 Place patient on cardiac monitor 0 Discontinue IV K and hold oral K supplements o K restricted diet 0 Prepare to administer K excreting diuretics if renal function is not impaired loop Lasix Kayaxelate if K level less then 6 o a cation exchange resin that promotes GI sodium absorption and K excretion 0 will give pt diarrhea prepare client for dialysis if K level are critically high 0 glucose with regular insulin to move K into the cell if higher then 6 will give glucose 1 then give insulin that will push the K into the cells 0 do this bc by giving insulin you don t want to put the pt into hypoglycemic shock 0 Calcium IV and Sodium Bicardbonate 0 Calcium 0 Normal serum level 85105 mgdl Bone and tooth formation 0 Muscle contraction including heart 0 Transmission of neural impulses Hypocalcemia Causes 0 Inhibition of calcium absorption from the GI tract Inadequate oral intake lactose intolerance malabsorption syndromes ex Chron s disease 0 Increase Calcium excretion Renal failure diarrhea steatorrhea attach to fat instead of intestinal oxalate 0 Conditions that decrease the ionized fraction of calcium Hyperproteinemia Acute pancreatitis Hyperphosphatemia Removal or destruction of the Parathyroid glands Liver cirrhosis puts ionized calcium free calcium into body low serum levels Too much protein in the blood will have low serum calcium 0 SampS o Chvostek s sign twitching of facial nerve in response to a tap on the nerve o Trousseau s sign spasm of forearm on obstruction of its blood supply Think of this when applying the BP cuff o Tetany worst form of laryngospasm 0 Muscle twitching 0 Later signs arrhythmias prolonged ST interval prolonged QT interval 0 Nursing Intervention 0 Place client on a cardiac monitor 0 Administer calcium supplements P0 or IV 0 Calcium IV Warm injection to body temp before administration Administer slowly monitor for hypercalcemia Monitor for EKG changes 0 Administer meds that increase calcium absorption 0 Keep 10 calcium gluconate available for tx of acute calcium de cit o Seizure precautions Calcium Rich Food Sources 0 Cheese collard greens milksoy milk rhubard sardines spinach tofu yogurt Hypercalcemia Serum calcium greater then 105 0 Causes Increase calcium absorption 0 Excessive oral intake of calcium excessive intake of vitamin D Decrease calcium excretion Renal failure use of thiazide diuretics Increase bone reabsorption of calcium Hyperparathyroidism malignancy immobility Cardiovascular 0 increase HR in early phase decrease HR in late phase bounding full peripheral pulses EKG changes shortened ST segment widened T wave Respiratory Ineffective respiratory movement as a result of profound skeletal weakness Renal Increase urine output leading to dehydration 0 Formation of renal calculi GI decrease motility amp bowel sounds anorexia nv abdominal distention constipation 0 Nursing Interventions Place client in cardiac monitoring Discontinue PO and IV meds that contain Calcium or vitamin D Discontinue thiazide diuretics use loops diuretics instead Administer medications as prescribed that inhibit calcium reabsorption from the bone Phosphorous calcitonin and prostaglandin synthesis inhibitors ASA NSAIDs Prepare the client if severe hypercalcemia for dialysis Assess for fractures Monitor for kidney stones Instruct client to avoid food with calcium Magnesium Normal serum levels 1525 mEgL Bone and tooth formation 0 Muscle nerve irritability Intracellular electrolyte Hypomagnesemia 0 Causes 0 Insufficient magnesium intake Malnutrition and starvation vd Malabsorption syndrome Chron s disease Celiac Disease 0 Increase Magnesium secretion Diuretics chronic alcoholism o Intracellular movement of magnesium Hyperglycemia insulin administration sepsis o SampS o EKG changes tall T waves 0 Convulsions o Paresthesias 0 Muscle spasms 0 Positive Trousseau s and Chvostek s signs 0 Tetany seizures 0 Nursing interventions 0 Increase intake of magnesium rich foods 0 Monitor pt for laryngeal stridor o Administer magnesium sulfate IV as prescribed o Initiate seizure precautions Magnesium Rich Foods 0 Avocado canned white tuna cauli ower cooked rolled oats green leafy vegetables spinach and broccoli low fat yougurt milk peanut butter peas pork beef chicken potatoes raisins Hypermagnesemia Serum Magnesium greater then 25 0 Causes Increased magnesium intake 0 Magnesium containing antiacids and laxatives 0 Excessive IV magnesium Decrease renal excretion of magnesium as a result of renal insufficiency o SampS Lethargy nv muscle weakness decrease deep tendon re exes 0 Nursing Interventions Diuretics as prescribed to increase renal excretion of magnesium Withhold magnesium containing drugsfoods If patellar re exes are absent notify HCP Hypophosphatemia Serum phosphorus less then 27 mgdl A decrease in the serum phosphorus level is accompanied by an increase in the serum calcium level 0 Causes Insufficient phosphorus intake malnutrition malabsorption Increase phosphorus excretion Hyperparathyroidism malignancy use of aluminum hydroxidebased or magnesium based antacids Intracellular shift respiratory alkalosis Decrease contractility and cardiac output Slowed peripheral pulses Decrease deep tendon re exes Decrease bone density lrritability confusion seziures immunosuppression 0 Nursing interventions Discontinue medications that contribute to hypophostphatemia Administer phosphorus PO along with a vitamin D supplement Prepare to adm phosphorus IV if level is less the 1 mgdl Administer SLOWLY Move client carefully monitor for possible fractures Instruct pt to increase intake of phosphorus contain foods Hyperphosphatemia Serum phosphorus level that exceeds 45 mgdl Most body systems tolerate elevate serum phosphorus levels well 0 Hypocalcemia is the problem 0 Causes Decreased renal excretion Tumor lysis syndrome Increased intake Hypoparathyroidism o SampS same as hypocalcemia 0 Nursing Interventions Entail the management of hypocalcemia Administer phosphate binding meds that increase fecal excretion of phosphorus by binding phosphorus from food in the GI tract Instruct the client to avoid phosphate containing medication including laxatives amp enemas lnstruct client to decrease the intake of food high in phosphorus