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Combo with "Fluid and Electrolytes/CV #2" and 1 other
Terms in this set (113)
Potassium, phosphate, magnesium, protein, and sulfate ions
Sodium, chloride, plasma, insterstitial fluids.
Hyperkalemia clinical manifestations
Musculo : Initially :Cramping leg pain, then weakness/paralysis
CV : BRADYcardia, irregular HR, HYPOtension
ECG : Peak T wave, flat P wave, wide QRS, vfib
GI : Ab cramp, INCREASED motility, diarrhea, n/v
Increase fluid intake
Diuretics, dialysis(for very toxic levels), Kayexalate
IV insulin (Push K from ECF to ICF)
D50W (to prevent hypoglycemia with IV insulin tx)
Calcium gluconate IV to reverse cardiac effects of high K
Hyperkalemia pt education
What foods to avoid
With K-sparing diuretics, use low K foods
Avoid orange juice/banana
Neuromusculo: weakness to rep collapse/paralysis, cramping paresthesia, confusion.
*General Muscle Weakness
CV : weak, irregular pulse, HYPOtension, BRADYcardia
RESP : shallow breathing
ECG : Flat T wave, U wave emerge
GI : DECREASED motility, ab dist, constipation, n/v, anorexia
GU : Polyuria
True of false : Hypokalemia and Hyperkalemia both exhibit HYPOtention and BRADYcardia
Foods high in K+
Avocados, broccoli, banana, cantaloupe, dairy, dry fruits
Oral K supplements
IV Potassium (never bolus : cardiac arrest)
Max recommended rate for IV potassium?
DO NOT EXCEED 20 mEq
MUST be diluted (NaCl)
Digoxin toxicity increases if K level is
Neuromusc : restless/irritable (d/t cell dehydration), twitching to weakness, lethargy, LOC seizures, coma, DECREASED DTR
CV : HYPOtension, TACHYcardia
TEMP : HYPERthermia, flushed skin
GI : Thirst, ab cramps, nausea, oliguria
Hypernatremia : if oral fluids cannot be ingested, what type of IV solution should be administered?
Hypotonic : 0.45% NaCl or
Isotonic : D5W (turns hypotonic in body) or NS
Increase water intake
Pt. education regarding weight with hypernatremia
Notify Dr. 1-2 lb gain in 24hr or 3lb in 1 week
Neuromusc : confusion, headache, lethargy, muscle weakness to resp distress, fatigue, DECREASED DTR, seizures
CV : Ortho HYPOtension, TACHYcardia, rapid/thready pulse
TEMP : HYPOthermia
GI : INCREASED motility (hyper bowel sounds), nausea, cramps
Decrease water intake
If HF: Loop diuretic & Ace Inhibitors
High Na foods
- Maybe hypertonice fluids
Foods high in Na?
Fish, cheese, egg and milk, processed foods, table salt
Hyponatremia with too much fluid IV solution tx?
Hypertonic : 3% NaCl slowly
Hyponatremia with abnormal fluid loss tx?
Fluids with sodium containing solution
Drugs that block ADH activity
Causes increased urine output without electrolyte loss thus increasing blood volume
Define Mean Arterial Pressure
MAP : avg pressure within arterial system felt by vital organs
MAP greater than 60 required to adequately perfuse and sustain organs
MAP <60 = Possible shock
Symptom of Inappropriate ADH secretion
Causes water retention, decreased urine volume, decreased sodium level (sodium stays with water)
Glucocorticoid (Cortisol) function
Regulates water and electrolytes
Cortisol is an anti-inflammatory and increases glucose levels
Increase Na retention and K excretion
Can detect and localize MI areas in 3D.
Can assist in final dx of MI/prediction of recovery
Dx of congenital and aortic disorders
Tests for hypocalcemia
Chvostek's (facial muscle) sign
Trousseau's (carpal spasm)
How to test for Chvostek's sign
Tap over facial nerve in front of ear: facial muscle contraction indicates positive
How to test for Trousseau's sign
Inflate BF cuff on arm : carpal spasms indicate positive
Neuromusc: Decreased memory, disorientation, confusion, fatigue
CV : Dysrrhytmia (Decreased muscle contraction)
GI : Constipation
- Bone pain & fractures
- Stupor, coma
Ambulation (decrease loss of ca from bone)
Fluid intake 3000-4000ml daily
Recommended fluid intake for Hypercalcemia?
Positive Trousseau's and Chvostek's
Neuromuscular : Dysphagia, tingling around mouth/extremities, seizures
RESP : Laryngeal stridor
Why hypocalcemia can cause seizures?
Decreased excitation threshold
Normal Ca level
Foods high in calcium (with milk allergy)
Broccoli, green beans
Oral/IV supplements (not IM to avoid local reactions)
Treat pain/anxiety to prevent hyperventilation-induced respiratory alkalosis
- Vitamin D to increase reabsorption
What does a T-wave inversion and ST-wave depression indicate during a stress test on a treadmill?
What should be done immediately?
Coronary ischemia : Heart not getting adequate O2
STOP TEST IMMEDIATELY
CV assessment in geriatrics (Heart sounds)
Bruit : swish sound d/t narrowed artery
Murmur : Regurgitation of blood when cardiac valve should be closed or valve narrowing (stenosis)
the net diffusion or movement of water across the cell membrane from lesser concentration to higher concentration.
refers to the concentration of solute in body water, reflects hydration status.
refers to the solute concentration per volume of water
Difference between Osmolality & Osmolarity
Osmolality refers to fluid inside body while osmolarity refers to fluid outside body.
- Also, osmolality specifically done to evaluate concentration of plasma & urine.
Capillary Hydrostatic Pressure & Interstital Oncotic Pressure
Move water out of capillaries...
Plasma Oncotic & Interstital Hydrostatic Pressure
Move fluid into the capillaries
Accumulation of fluid in the interstitum when venous hydrostatic pressure rises, plasma oncotic pressure decreases, or interstitatl oncotic pressure rises.
Cause of Increased VHP
- Fluid overload
- Liver failure
- Obstruction of venous return to the heart (tourniquet, venus thrombosis)
Fluid accumulates in the transcellular portion of the body where it is not easily excahnged with the rest of ECF
- Trapped and unavailable for functional use.
- Seen in burns, trauma, sepsis
- Manifested by ascitis, pleural & pericardial effusion
- Causes water reabsorption
- If there is water excess, secretion of ADH is supressed
Diabetes Insipidus (307, lec)
- Caused by reduction in the release, production, or action of ADH
- Copious amount of dilute urine excreted because renal tubules & collecting ducts dont appropriately reabsorb water.
- Symptoms: Polyuria (>200 ml/hr), Polydipsia if patient is alert, decreased urine specific gravity;< 1.005
- Symptoms of dehydration and hypernatremia greater than 145
- Primarily antiinflammatory
- Increase serum glucose levels
- Enhance sodium retention and potassium excretion
- Most abundant glucocorticoid.
- In larger doses it has both mineralcorticoid, sodium retention and glucocorticoid, glucose elevating & antiinflammatory
- Sodium retaining and potassium excreting
- Secreted with decreased renal perfusion or decreased sodium delivery to distal portion of renal tubule.
↑ Urine specific gravity and serum sodium
Tachycardia, bounding pulse, HTN, tachypnea, increased central venous pressure, confusion, muscle weakness, weight gain, dyspnea, orthopnea, crackles, diminished breath sounds, edema, distended neck veins.
Serum Calcium less than 9.0 mg/dL or ionized calcium less than 4.5 mg.dL
End stage kidney disease
Vitamin D deficiency
Paresthesia of fingers and lips (early symptom)
Frequent, painful muscle spasms at rest
Hyperactive deep tendon reflexes
Positive Chvostek's sign- tapping on facial nerve triggering facial twitching
Positive Trousseau's sign--
ECF Deficit s/s (Hypovalemia)
Restlessness, drowsiness, lethargy, confusion.
Thirst, dry mucous membranes
Decreased skin turgor, decreased cap refill
Postural hypotension, increased pulse
Increased respiratory rate, hypoxia
ECF Excess s/s (Hypervolemia)
Headache, confusion, lethargy,
Dyspnea, crackles, PE
Seizures and coma
Resp: pulmonary congestion w/ SOB, cough and moist crackles
Urine Specific Gravity
Greater than 1.025 indicated concentrated urine while less than 1.010 indicates diluted urine
Increase of 1kg (2.2 lb)= 1000mL. of fluid retention
Abnormal GI Losses: vomiting, NG suctioning, diarrhea, inappropriate laxative use.
✧Renal Losses- excessive use of diuretics (lasix, cortiocosteroids)
✧Skin losses- Diaphoresis, wound losses
✧Prolonged administration of non-electrolyte containing IV solutions
✧Older clients at risk due to increased use of diuretics & laxatives.
✧ Pt. has an impaired level of consciousness or an inability to obtain fluids.
✧ Decrease in kidney responsiveness to ADH can result in diuresis producing water deficit and hypernatremia.
✧ Excessive sweating, increased sensible losses (from high fever,heatstroke, prolonged hyperventiliation), excessive Na+ intake
✧IV Fluids: Hypertonic NaCl, excessive isotonic NaCl, IV sodium bicarb
✧ hypertonic tube feedings without water supplements
✧ Diseases: DI, Cushing syndrome, uncontrolled DM
✧ Indicates water balance of the body
✧ Normal 275-295 mOsm/kg
✧ >295 = indicates water content in body is too little (water deficit)
✧ <275 = indicates too much water (water excess)
Hypernatremia Manifestations w/ decreased ECF Volume
✧Restlessness, agitation, twitching, seizures, coma
✧ Intense thirst; dry/swollen tongue, sticky mucous membranes.
✧ OH, Decreased CVP, Weight loss
✧ Weakness & lethargy
Hypernatremia Manifestations w/ increased ECF Volume
✧ Restlessness, agitation, twitching, seizures, coma
✧ Intense thirst, flushed skin
✧ Weight gain, PE & Pulmonary Edema, Increased BP, Increased CVP
Excessive Sodium Loss:
✧ Gi losses- diarrhea vomiting, fistulas, NG suction
✧ Renal losses- diuretics, adrenal insufficiency, Na+ wasting diuretic
✧ Skin losses- burns, wound drainage
✧ Fasting diet
✧ Excessive hypotonic IV fluids, primary polydisia
✧ SIADH, heart failure
Hyponatremia Manifestations w/ Decreased ECF Volume
✧ Irritability, apprehension, confusion, dizziness, personality changes, tremors, seizures, coma
✧ Dry mucous membranes, OH, Decreased CVP, ↓ JVD filling, tachycardia, thready pulse
✧ Cold clammy skin
Hyponatremia Manifestations w/ Increased ECF Volume
✧ Headache, apathy, confusion, muscle spasms, seizures, coma.
✧ N & V, diarrhea, ab cramps,
✧ Weight Gain, ↑ BP, ↑ CVP
✧ If caused by excess water fluid restriction is all that is needed unless symptoms progress (seizure) then small amount of IV Hypertonic saline solution (3% NaCl) given.
✧ Used to treat hyponatremia associated with SIADH
Hypernatremia treatment (313)
✧ In water deficit- replace water, if fluids cant be digested give IV solution of D5 dextrose or hypotonic saline.
- PO recommended because it is easier to control the balance
- Sterile or free water
✧ Reduce Na+ gradually
✧ If reduced rapidly, cerebral edema can occur.
✧ Administer diuretics to promote excretion.
✧ Limit dietary Na+ intake.
✧ Neruo & cardiac fxn commonly affected.
✧ Kidneys lose 90% of daily K intake and remainer is lost in stool and sweat.
Potassium Containing Foods
✧ Fruits, dried fruits, veggies
✧ Avocados, broccoli, cantaloupe, bananas
✧ Dark leafy greens (Spinach)
Hyperkalemia Causes: Shift K+ Out of Cells
✧ Tissue catobolism (fever, sepsis, burns)
✧ Crush injury
✧ Tumor lysis syndrome
Hyperkalemia Causes: Excess Intake
✧ Excessive/rapid parenteral admin
✧ Potassium-containing drugs (potassium penicillin)
✧ Potassium-containing salt substitue
Hyperkalemia CausesL Failure to Eliminate K
✧ Renal disease
✧ K-sparking diuretics
✧ adrenal insufficiency
✧ ACE inhibitors
✧ weakness of lower extremeties (Leg muscles affected initially)
✧ ab cramping, diarrhea
✧ irregular pulse
✧ cardiac arrest if sudden onset or severe
Hyperkalemia ECG Changes
✧ tall, peaked t wave
✧ prolonged pr interval
✧ st segment depression
✧ loss of p wave
✧ widening QRS
✧ Ventricular fibrillation/standstill
✧ Mild (If kidneys are fxn): Withhold K+ from diet and IV sources and increase renal elimination by administering fluids & diuretics.
✧ Moderate: administer IV insulin and glucose.
✧ With dangerous dysrhythmias administer IV calcium gluconate. In ATI says CaCl in general.
✧ Use hemodialysis w/ renal failure pts.
✧ Kayexalate works as a laxative and excretes K_ from body.
HypoKalemia Loss Causes
✧ GI: diarrhea, vomiting, fistulas, NG suction
✧ Renal: diuretics, hperaldosteronism (causes Na+ retention and k+ excretion in uring), MG depletion
✧ Skin: Diopheresis
Hypokalemia Cause: Shift INTO Cells
✧ Increased insulin (IV dextrose overload)
✧ tissue repair
✧ increased epinephrine (stress)
✧ muscle weakness, leg cramps,
✧ N&V, paralytic ileus
✧ paresthesias, decreased reflexes
✧ Weak, irregular pulse
Spirolactone (Aldactone) (314)
✧ Potassium sparing diuretic
✧ Causes hyperkalemia
✧ Causes loss of sodium bicarbonate and calcium while saving potassium and hydrogen ions by antagonizing aldosterone.
✧ NEVER IV bolus (Risk for cardiac arrest)
✧ Encourage high k+ food: dried fruits, Avocados, broccoli, cantaloupe, bananas, Dark leafy greens (Spinach)
✧ Administer IV potassium supplementation at rate of 5-10 mEq/hr
✧ Give KCl oral or IV: Urine output must be at least 0.5 mL/kg of body weight/hr.
Preferred concentration is 40 mEq/L, Higher for more severe cases.
KCl irritates veins so assess qhr for phlebitis.
Oral/IV supplements (not IM to avoid local reactions)
Treat pain/anxiety to prevent hyperventilation-induced respiratory alkalosis
✧ Reduced thirst mechanism= decreased fluid intake
✧ Structural changes in kidneys decrease ability to conserve water
✧ Hormonal changes lead to decrease in ADH
✧ Loss of subcu tissue leads to increased loss of moisture.
Pitting vs Non Pitting Edema
+1 = 2 mm indentation, disappear rapidly.
+2 = 4 mm indentation, disappear 10-15 seconds.
+3= 6 mm identation, disappear within 1-2 minutes.
+4= 8 mm identation. Disappear in 2-5 minutes.
-Shift fluids from intravascular compartment into intracellular compartments.
- ½ NS, 0.2%NS, 0.25% dextrose.
- shift fluids from ICF and ECF intravascular compartment.
- D51/2 NS, D10, 3% NS.
- Remember that D5 ½ NS is initially hypertonic, once in the body, becomes hypotonic.
Chloride Normal Range
95-105 meq / L
- associated with loss of HCO3.
Phosphate General Patho
- Requires proper renal functioning because it is mainly excreted through the kidneys.
- High serum phosphate level causes low calcium serum level.
- Major condition is acute or chronic renal failure
- Chemo for certain malignancies,
- Excessive ingestion of milk or phosphate containing laxatives
- Large intake of Vitamin D that increase GI absorption of phosphorus
- Muscle probs: tetany
- Deposition of calcium phosphate precipitous in skin, soft tissue, cornea, viscera, blood vessels,
Hyperphosphatemia Management (319)
- Treat underlying cause
- High intake: need to limit intake
- Adequate hydration and correction of hypocalcemic conditions increases phosphate excretion by PTH
- With renal failure: include calcium supplements, phosphate binding agents or gels, and dietary phosphate restrictions.
- Malabsorption syndrome
- Nutritional Recovery syndrome
- Glucose administration
- TPN without phosphorous replacement
- Alcohol withdrawal
- Phosphate binding antacids
- Recovery from DKA
- Respiratory alkalosis
- CNS dysfunction: confusion, coma
- Muscle weakness including respiratory muscle weakeness and difficulty weaning
- Renal tubular wasting of Mg, Ca, & bicarb
- Cardiac probs: dysrhythmias, decreased stroke volume
Hypophosphatemia Management (319)
- Mild deficiency take oral supplements like Neutra-phos
- Intake phosphate containing foods like dairy products.
- For severe deficiency: IV therapy with sodium phosphate or potassium phosphate.
- IV therapy potential complication is sudden symptomatic hypocalcemia due to increased calcium phosphorous binding.
Hypermagnesemia Causes (320)
- Renal failure especially if pt eats magnesium products like milk of magnesia
- Excessive administration of magnesium for treatment of eclampsia
- Adrenal insufficiency
- Major cause is prolonged fasting or starvation.
- Diarrhea and vomiting
- Chronic alcoholism
- prolonged malnutrition
- malabsorption syndrome
- ng suction
- Large urine output
- poorly controlled diabetes mellitus
- Mg deficiency predisposes one to dysrhythmias
- Focus on prevention
- Emergency treatment is IV administration of calcium chloride or calcium gluconate to physiologically oppose magnesium effects on cardiac muscle
- Promote urinary excretion
- Mild: treated with oral supplements and increased dietary intake of foods high in magnesium like green vegetables, nuts, bananas, oranges, peanut butter, chocolate.
- Severe: Parenteral IM or IV magnesium sulfate.
- Too rapid administration of magnesium can lead to cardiac respiratory arrest
- Regulates fluid by stimulating reabsorption of water in renal tubules.
- Also called vasopressin
- Plasma osmolality increase leads to increase in ADH
-Resembles and may cause hypocalcemia r/t PTH
Neuromuscular - increased nerve impulse transmission (hyperactive deep-tendon reflexes,
paresthesias, muscle tetany), positive Chvostek's and Trousseau's signs
-Gastrointestinal - hypoactive bowel sounds, constipation, abdominal distention,
- Initially: lethargy, drowsiness, nausea, and vomiting
- Deep tendon reflexes lost, somnolence (dizziness), respiratory and cardiac arrest.
Importance of Sodium (ati)
Sodium is essential for maintaining acid-base balance, active and passive transport mechanisms, and
maintaining irritability and conduction of nerve and muscle tissue.
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