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Fluid and Electrolyte Alterations
Med-Surg Exam I
Terms in this set (85)
What percentage of the body is water?
What does ECF consist of?
Intravascular space (IVS): Plasma ~3L
Interstitial space (ISS): Blood/lymph ~ 10L
Transcellular space: CSF, sweat, pericardial, synovial, peritoneal ~1L
What is first spacing?
normal distribution of fluids in ICF and ECF
What is second spacing?
increase in interstitial fluid (edema)
What is third spacing?
Fluid accumulation in ECF (asceites)
In which spacing is fluid not available for functional use?
What are manifestations of fluid shifts?
How many lbs does 1L weigh?
Do cells shrink or swell with hypotonic solution?
Do cells shrink or swell with hypertonic solution
List isotonic some isotonic solutions.
0.9%NaCl (NS), Lactated Ringers (LR), 5% Dextrose in water (D5W)
What do isotonic solutions do in the body? What do you assess for?
- Remains in vascular circulation, expanding vascular volume
- Assess for s/s of hypervolemia: bounding puls, SOB, crackles
List some hypertonic solutions.
5% dextrose in NS (D5NS), 5% dextrose in 0.45%NaCl (D5 1/2 NS), 5% dextrose in lactated ringers (D5LR), hypertonic saline
What do hypertonic solutions do in the body? What do you assess for?
- Draw fluid out of ICF and interstitial compartments into vascular space, expanding vascular volume.
- Do not admin to clients with kidney or heart disease
- Do not admin to clients who are dehydrated
List some hypotonic solutions.
0.45% NaCl, 0.33% NaCl
What do hypotonic solutions do in the body? What do you assess for?
- provide free water and tx cellular dehydration
- promote waste elimination in the kidneys
- Do not admin to pts at risk for incr ICF or 3rd space fluid shifts (correct these first)
How does the renal system impact fluid balance?
- Na+, K+, H+, HCO3-, CL-
- acid base balance
- hormones (renin)
What parts of the brain impact fluid balance?
- Hypothalamus: osmolality, "thirst" center, ADH synthesis
- Pituitary (posterior): ADH storage
What other organs impact fluid balance?
- Adrenal gland: regulated by ACTH
- incr in aldosterone = incr in NA & H2O, decr in K+
Where are the baroreceptors located?
- Carotid, aortic arch, atria, kidneys
What are some causes of hypovolemia?
- insensible water loss
- GI loss (suction)
- poor PO intake
- fluid shifts (edema, 3rd spacing)
What are some causes of hypervolemia?
- increased IV fluid replacement
- heart/renal failure
- SIADH (ADH is too much or too little regardless of osmolarity)
- corticosteroids (long term use)
- psychiatric disorders
- water intoxication
What are s/s of hypovolemia?
- incr HR, RR
- decr BP
- decr UO, skin turgor, weight
- restlessness, lethargy
What are s/s of hypervolemia
- incr HR, BP
- incr weight, edema
- neck vein distention (JVD, pulsing by jaw)
- crackles, HA, confusion
What does renin do?
- controls production of angiotensin II, a powerful vasoconstrictor that causes an increase in TPR and cuases cells of adrenal cortex to synthesize aldosterone
What does aldosterone do?
- Increases sodium reabsorption in cells of distal tubule.
- water follows salt, leading to increase in plasma volume
What does ADH do?
- aka vasopressin
- response to increased plasma osmolality or decr BP
- potent vasocostrictor
- incr BP by incr resistance to blood flow
- controls reabsorption of water in the collecting ducts of the kidney
How do you assess fluid balance?
- Fluid I/O
- weight changes (2.2lbs = 1L)
- edema, tissue turgor
- JVD, pulse quality, BP
- crackles, RR
- labs: CBC, serum electrolytes, urine pH & specific gravity, ABGs
What is normal I/O?
- 2000-3000 mL/day
- I: 1200mL fluids, 1000mL solid food, 300mL oxidation
- O: 900mL insensible from skin/lungs, 100mL feces, 1500mL urine
- (GI tract secretes and reabsorbs about 8000 mL/day)
What are collaborative care and nursing interventions for fluid volume imbalances?
- Record I/Os
- Monitor VS, CV changes
- Assess RR
- Assess neuro status/changes
- Daily weights
- Skin assessment
- Monitor IV fluid replacements
List the electrolytes of main concern.
- Cations: K+, Na+, Ca+, Mg+
- Anions: Cl-, HCO3-, PO4-
Which electrolytes are usually more in the ICF?
- K+, Mg+, PO4-
Which electrolytes are usually more in the ECF?
- Na+, Cl-, HCO3-
Who is at greatest risk for severe imbalances?
- chronic renal, endocrine and sick
- geriatric pts
- psych pts
What are NL for sodium?
What does sodium do?
- primary electrolyte in ECF
- loss or gain usu accompanied by H2O
- generation/transmission of nerve impulses and acid/base balance
- GI tract absorbs from foods
What are the causes of hypernatremia?
- altered mentation (can't respond to thirst)
- watery diarrhea
- fluid restrictions
- heat stroke, fever, osmotic diuresis
- hyperglycemia causing the polys
- disease states (DI)
- hyperosmolar tube feeds with minimal H2O
- excessive Na+ intake
- hypertonic Na+ solution
- renal failure
- steriod use
What are clinical manifestations of hypernatremia?
- Neuro: restlesness, agitation, disorientation
- dry mucous membranes
- incr HR, decr BP, postural hypotension
- incr muscle tone
- incr UO related to osmotic diuresis
What are nursing interventions/collaborative care for hypernatremia?
- If dehydrated, replace water slowly, so cells (esp. brain) don't swell too quickly
- treat underlying cause
- IV hypotonic fluids like 1/2NS
- DDAVP (synthetic ADH, Desmopressin acetate)
- decr dietary intake of sodium
- adequate fluid intake
What are causes of hyponatremia?
- NG suctioning
- water enemas
- draining fistulas
- excessive sweating
- excessive diuretics
- incr in free water (usu PO or IV D5W)
- disease states (head trauma, liver failure)
- renal disease (changes in fxn in eldely)
What are clinical manifestations of hyponatremia?
- the faster the drop, the more severe the symptoms
- confusion, changing LOC, HA, cerebral edema, seizures
- nausea, abd cramps
- muscle cramps/twitching progressing to no muscle tone/fatigue, and eventually respiratory failure
- postural hypotention, tachy, thready pulse
- weight gain due to H2O retention
What are nursing interventions/collaborative care for hyponatremia?
- restrict water, replace Na+
- Rx: loop diuretics, ADH antagonizing agents
- CAUTION: Hypertonic Na (3%) can cause rapid shifts in fluid from ICF to ECF causing CV overload and cerebral injury
What are normal limits for potassium?
- 3.5-5.0 mEq/L
What does potassium do?
- Essential to cardiac electrical fxn, major factor in resting potential
- Source is diet
- Kidneys are primary route of loss
- low K+ = irritability, premature arrhythmia, weak thready pulse
- high K+ = slowed cardiac activity, asystole, Vfib
What are causes of hyperkalemia?
- Excess or rapid parenteral infusion
- impaired renal excretion: causes cellular excitability
- shift from ICF to ECF
- burns, tumor lysis or crushing injuries
- rapid transfusion of stored, hemolyzed blood
- use of potassium sparing diuretics
- adrenal insufficiency
- uncontrolled DM
What are clinical manifestations of hyperkalemia?
- abdominal cramping and diarrhea from smooth muscle hyperactivity
- weakness of lower extremities
- irregular pulse
- cardiac arrest
What are nursing interventions/collaborative care for hyperkalemia?
- eliminate intake
- IV insulin and glucose
What are causes of hypokalemia?
- gastric suction
- new ileostomy
- incr insulin therapy
- early renal failure
What are clinical manifestations of hypokalemia?
- cardiac irritability, irregular HR
- fatigue, lethargy
- muscle weakness
- leg cramps
- slow shallow resp
- ileous (decr peristalsis)
- ECG changes (decr ST, PVCs)
What are nursing interventions/collaborative care for hypokalemia?
- replete K+ PO or IV
- monitor labs
- do not crush tablets, IV: 10-20 mEq/hr
- may need cardiac monitor, must use pump
- educate on high K+ foods
What are some things to know about potassium?
- assess UO b/c elimination regulated by kidneys and if UO decr, give less
- fusions caustic to vessel, slower = less pain
- check Mg: if low, kidneys excrete K to preserve Mg
What are NL for calcium?
What does calcium do?
- transmits nerve impulses
- myocardial/skeletal muscle contractions
- maintain bone strength and density
- enzyme activation
- requires active Vitamin D
- absorbed in gut
- >99% bound with phos in skeletal. 1% in serum
What are causes of hypercalcemia?
- malignancies with bone metastasis
- prolonged immobility
- renal failure
- dig toxicity
- incr intake of calcium antacids
- vit D OD
What are clinical manifestations of hypercalcemia?
- depressed neuromuscular excitability - muscle weakness
- cardiac arrhythmias
- anorexia, N/V, constipation, ileus
- confusion, slurred speech, lethargy, coma
- bone pain/fractures
- incr clotting time, excessive clot formation
What are nursing interventions/collaborative care for hypercalcemia?
- admin diuretics to promote excretion
- calcium chelators
- IVF (0.9NS) to hydrate, dilute and incr renal excretion
- restrict diet (milk, broccoli)
What does PTH do?
movement of Ca+ from bone to plasma. Incr GI absorption. needs Vit D to regulate Ca+
What does calcitonin do?
Stops release of Ca+ from bone, stops GI absorption
What are causes of hypocalcemia?
What are clinical manifestations of hypocalcemia?
What are nursing interventions/collaborative care for hypocalcemia?
Describe Chvostek's sign.
Describe Trousseau's sign.
What are NL for magnesium?
What does magnesium do?
What are causes of hypermagnesemia?
What are clinical manifestations of hypermagnesemia?
What are nursing interventions/collaborative care for hypermagnesemia?
What are causes of hypomagnesemia?
What are clinical manifestations of hypomagnesemia?
What are nursing interventions/collaborative care for hypomagnesemia?
What are NL for phosphate?
What is phosphate's role in the body?
What are causes of low PO4?
What are clinical manifestations of low PO4?
What is tx for low PO4?
What is normal lab for WBC?
What is normal lab for BUN?
What is normal lab for creatinine?
What is normal lab for Hgb?
What is normal lab for Hct?
What is normal lab for PT?
What is normal lab for INR?
2 but < 3
What is normal lab for PTT?
What is normal plts?
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