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Fluid, Electrolyte, and acid-base balance

Terms in this set (95)

Nursing care for intake
-Fluids/foods - liquid at room temperature
-Sips need to be recorded
-IV's, GI feedings and flushes
-IV flush
Nursing care for output
-Urine, diarrhea, vomitus, fistulas, wounds and ulcers

-Use calibrated devices in toilets
Sodium
135 - 145 mEq/L
Functions of sodium
Maintains intracellular osmolarity.

Controls cell resting potential.

Needed for Na+/K+ pump.

Exchanged for H+ to buffer changes in blood pH.
regulation of sodium
Sources: primarily diet
Losses: GI tract, and kidneys
Hyponatremia
Na < 135 mEq/L
causes of hypoatremia
Vomiting
Diarrhea
Fistulas
Sweating
Medications (diuretics)
nursing care for hypoatremia
1. Assess for anorexia, nausea and vomiting, lethargy. Confusion, hypotension, muscle cramps, weakness

2. Assess for seizures (caused by cerebral edema)

3. Care includes restriction of fluids

4. Hypertonic saline 7.5% (very dangerous can lead to fluid excess)
Hypernatremia
Na > 145 mEq/L
causes of hypernatremia
Fluid deprivation
Lack of fluid
Diarrhea
Excess insensible fluid loss (burns, (hyperventilation)
nursing care for hypernatremia
1. Assess for signs of neurological impairment, restlessness, weakness, disorientation, delusion and hallucinations)
Permanent brain damage, especially in children, can occur
2. Restrict sodium foods
3. Increase water intake
Potassium
3.5 - 5 mEq/L
potassium causes
Maintains intracellular osmolarity

Controls cell resting potential
Needed for Na+/K+ pump

Exchanged for H+ to buffer changes in blood pH
potassium regulation
Sources: fruits, vegetables, dried peas and bens, whole grains, milk, and meats

1. Assess for numbness and tingling of fingers, mouth, or feet; tetany, muscle cramps and seizures
Hypokalemia
K+< 3.5 mEq/L
causes of hypokalemia
Vomiting
Gastric suction
Diarrhea
Alkalosis
Medications
nursing care for hypokalemia
1. Assess for muscle weakness, leg cramps, fatigue, parathesias, dysrhythmias
2. Use caution with ambulation (due to muscle weakness)
3. Administer IV potassium replacement very carefully (high alert)
Hyperkalemia
K+ > 5 mEq/L
causes of hyperkalemia
Renal failure
Hypoaldosteronism
Medications: potassium chloride, heparin, nonsteroidal)
nursing care for hyperkalemia
1. Assess for muscle weakness, leg cramps, fatigue, parasthesias, and cardiac irregularities
2. Perform ECG as needed
Calcium
8.6 - 10.2 mg/dL
causes of calcium
Bone strength and stability.

Membrane potentials

Contraction of all muscle types.

Clotting.
sources of calcium
Milk, milk products, cheese, dried beans, fortified orange juice, green leafy vegetables, dried peas
Hypocalcemia
Ca < 8.6 mg/dL)
causes of hypocalcemia
inadequate calcium intake
nursing care for hypocalcemia
1. Assess for numbness and tingling of fingers, mouth, or feet; tetany, muscle cramps and seizures
2. Perform Chvostek's sign
Tap on cheek - look for twitch
3. Perform Trousseau's sign
Pump cuff to 200 mm Hg
Look for hand flexion
Hypercalcemia
Ca > 10.2 mg/dL
causes of hypercalcemia
Cancer
Hyperparathyroidism
nursing care for hypercalcemia
Assess for nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy and slurred speech
Phosphate
1.8 mg/dL - 2.5 mg/dL
phosphate causes
administration of calories to malnourished patients, alcohol withdrawal, diabetic ketoacidosis, hyperventilation, insulin release, absorption problems, and diuretic use
phosphate regulation
Sources: green leafy vegetables, nuts, seafood, whole grains, dried peas and beans, cocoa
1. Assess deep tendon reflexes
Hypophosphatemia
Ph <1.8 mg/dL
causes of Hypophosphatemia
Decreased absorption: NGT suctioning, diarrhea
Alcohol
Tube feedings
nursing care for hypophosphatemia
Assess for irritability, fatigue, weakness, paresthesias, confusion, seizures, and coma.
Hyperphosphatemia
Ph >4.5 mg/dL
causes of hyperphosphatemia
Common causes are impaired kidney excretion and hypoparathyroidism
nursing care for hyperphosphatemia
Assess for tetany, anorexia, nausea, muscle weakness, and tachycardia.
Magnesium
1.3 - 2.3 mEq/L
magnesium causes
Metabolism and carbohydrates and proteins
Role in neuromuscular function
Acts on cardiac system - causes dilation
magnesium sources
Sources: green leafy vegetables, nuts, seafood, whole grains, dried peas and beans, cocoa
1. Assess deep tendon reflexes
Hypomagnesemia
Mg <1.3 mEq/L
causes of hypomagnesemia
Decreased absorption: NGT suctioning, diarrhea
Alcohol
Tube feedings
nursing care for hypomagnesemia
Assess for muscle weakness, tremors, tetany, seizures, heart block, change in mental status, hyperactive deep tendon reflexes
Perform deep tendon reflexes
Hypermagnesemia
Mg >2.1 mEq/L
causes of hypermagnesemia
Acute or chronic renal failure

Medications: magnesium based antacids, magnesium infusion for pre-eclampsia
nursing care of hypermagnesemia
Assess for magnesium toxicity (nausea, muscle weakness)
Loss of deep tendon reflexes
how to calculate intake and output
Deficient Fluid Volume
clinical manifestations
Weight loss, poor skin turgor,
Oliguria, dry and sticky mucous membranes, weak pulse, tachycardia
Deficient Fluid Volume
Nursing care
1. Assessment recap: Note elevated sodium, hematocrit, and blood urea nitrogen (BUN)
2. Implement pt. safety (patient may be lightheaded)
3. Strict intake and output
4. Oral hydration: water
5. Isotonic IV fluids normal saline or lactated Ringer's
6. Evaluate: urine output (should improve), daily weights
Excess Fluid Volume
clinical manifestation
1. Peripheral edema, increased bounding pulse, elevated BP, distended neck veins, dyspnea, crackles
2. Altered level of consciousness, confusion, aphasia
Excess Fluid Volume
Nursing care
1. Assess: note decreased sodium, hematocrit, and BUN
2. Implement: Position patient in high fowlers
3. Implement: fluid restriction; administer loop diuretics, intake and output, daily weights
4. Strict intake and output; sodium restricted diet
IV fluids:
Must be prescribed by physician or provider

Nurse must verify rates throughout shift
Isotonic Fluids: 0.9% (NSS), Lactated Ringer's
Nursing care:
Monitor electrolytes

LR monitor potassium

NSS monitor sodium

Monitor for signs of fluid overload: neck vein distention, increased blood pressure, lung sounds and respiratory distress.
Hypotonic Fluids: 0.45% saline (1/2 NSS)
Nursing care:
Assess for dehydration if patient is on for a while
Hypertonic: D5% 0.9%saline (D5NSS), D10%
Nursing care:
Assess for fluid volume overload: jugular vein distention, increased BP, crackles, respiratory distress.

Assess for hyperglycemia (increase urine output)
Infusion Regulation and Monitoring
Nursing care:
Health care provider orders the amount of solution and rate
If order is unclear it is the nurses responsibility to clarify before starting
Frequency of administration set tubing changing varies by facility
Complications of IV Infusions
Nursing care:
Discontinue the infusion immediately.
Apply warm, moist compresses to the affected site.
Avoid further use of the vein.
Restart the infusion in another vein.
Thrombus:
Local acute tenderness, redness, warmth, and slight edema of the vein above insertion site
Nursing care for thrombus
Stop the infusion immediately.
Apply warm compresses as ordered by the primary care provider.
Restart the IV at another site.
Do not rub or massage the affected area.
Fluid overload
1. Condition of too large a volume of fluid infuses into the circulatory system too rapidly
2. Engorged neck veins, increased blood pressure, and difficulty in breathing (dyspnea)
fluid overload
nursing care:
1. Notify the primary care provider immediately
2. Monitor vital signs
3. Carefully monitor the rate of fluid flow
4. Check rate for accuracy
Phlebitis
Local acute tenderness, redness, warmth, and slight edema of the vein above insertion site
Palpable venous cord
Phlebitis Nursing care:
1. Discontinue the infusion immediately
2. Apply warm. Moist compresses to the affected site
3. Avoid further use of the vein
4. Restart the infusion in another vein
Step 1 in Arterial Blood Gas Analysis
Determine whether the pH is alkalotic or acidotic
Normal value is 7.35 to 7.45.
Regulated by
Chemical buffer systems
Lungs: eliminate CO2
Kidneys: eliminate H+, reabsorb/generate HCO3−
Step 2 in Arterial Blood Gas Analysis
Check for the cause of the change in pH. Is it respiratory (PaCO2) or metabolic (HCO3)
In respiratory disorders: the pH and PaC02 are inverse

In metabolic disorders: the pH and HC03 value are both high or both low
Step 3 in Arterial Blood Gas Analysis
Determine whether the body is compensating for the pH change.
If the problem is respiratory, the renal system assists by in compensation by increasing or decreasing HCO3
If the problem is metabolic, the respiratory system assists in compensation by regulating CO2 levels.
When compensation occurs the PaCO2 and HCO3 always point in the same direction
Respiratory Acidosis
Primary disturbance
Increase in PCO2

Respiratory compensation
None

Renal compensation
Increased H+ excretion and increased HCO3- reabsorption
Causes of Respiratory Acidosis
Occurs in acute or chronic conditions that impair effective alveolar ventilation and cause an accumulation of PCO2
Impaired function of the respiratory center in the medulla; opiate (heroin, morphine, oxycodone)
Lung disease
Weakness of the respiratory muscles
Airway obstruction
Chest injury
Respiratory Alkalosis
Primary disturbance
Decrease in PCO2
Respiratory compensation
None
Renal compensation
Decreased H+ excretion and decreased HCO3- reabsorption
Causes of Respiratory Alkalosis
Excessive ventilation
Anxiety and psychogenic hyperventilation
Hypoxia and reflex stimulation of ventilation
Lung disease that reflexively stimulates ventilation
Stimulation of respiratory center
Mechanical ventilation
Metabolic Alkalosis
Primary disturbance
Increase in bicarbonate
Respiratory compensation
Hyperventilate to increase PCO2
Renal compensation
If no renal disease, decreased H+ excretion and decreased HCO3- reabsorption
Causes of Metabolic Alkalosis
Most common reasons
Excessive loss of hydrogen ions. Volume depletion (particularly when involving loss of gastric acid and chloride [Cl] due to recurrent vomiting or nasogastric suction)
Diuretic use
Others:
Excessive gain of bicarbonate or alkali: Excessive NaHC03 administration
Increased bicarbonate retention
Metabolic Acidosis
low pH (increased hydrogen ion concentration)

Primary disturbance:
low plasma bicarbonate concentration due to a gain of hydrogen or loss of bicarbonate.

Respiratory compensation:
lungs attempt to increase carbon dioxide excretion by increasing the rate and depth of respirations, which occurs within a short time

Renal compensation:
kidneys attempt to compensate by retaining bicarbonate and by excreting more hydrogen
Causes of Metabolic Acidosis
Excess metabolic acids

Excessive production of metabolic acids

Impaired elimination of metabolic acids

Excessive bicarbonate loss
Loss of intestinal secretions
Increased renal losses

Increased chloride levels
A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?
a. cardiac irregularities
b. muscle weakness
c. increased intracranial pressure (ICP)
d. metabolic acidosis
a. cardiac irregularities
27s

A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation?
a. Discontinue the IV and relocate it to another spot. b. Call the physician and ask if anti-inflammatory drugs should be administered.
c. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV.
d. Cleanse the site with alcohol and apply transparent polyurethane dressing over the entry site.
a. Discontinue the IV and relocate it to another spot.
What is the lab test commonly used in the assessment and treatment of acid-base balance?

a. Complete blood count
b. Basic metabolic panel
c. Arterial blood gas
d. Urinalysis
c. Arterial blood gas
Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of:
a. phlebitis.
b. an infiltration.
c. a systemic blood infection.
d. rapid fluid administration.
a. phlebitis.
The primary extracellular electrolytes are:
a. potassium, phosphate, and sulfate.
b. magnesium, sulfate, and carbon.
c. sodium, chloride, and bicarbonate.
d. phosphorous, calcium, and phosphate.
c. sodium, chloride, and bicarbonate.
The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what complications should the nurse be aware, related to the potassium level?
a. Fluid volume excess
b. Pulmonary embolus
c. Cardiac dysrhythmias
d. Tetany
c. Cardiac dysrhythmias
Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert?
a. Muscle weakness, fatigue, and dysrhythmias
b. Nausea, vomiting, and constipation
c. Diminished cognitive ability and hypertension
d. Muscle weakness, fatigue, and constipation
a. Muscle weakness, fatigue, and dysrhythmias
A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate?
a. Offer the client sugar-free candy to help combat thirst.
b. Give the client a fluid containing additional sodium to enhance the feeling of fullness.
c. Have the client use an alcohol-based mouthwash every 2 hours to reduce the thirst sensation.
d. Apply a petroleum-based gel to the client's lips to prevent cracking.
a. Offer the client sugar-free candy to help combat thirst.
The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice?
a. preparing solution for administration
b. ordering type of solution, additive, amount of infusion, and duration
c. performing venipuncture
d. regulating the rate of administration
b. ordering type of solution, additive, amount of infusion, and duration
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?

a. "Fluid inside cells."
b. "Fluid outside cells."
c. "Fluid in the tissue space between and around cells."
d. "Watery plasma, or serum, portion of blood."
c. "Fluid in the tissue space between and around cells."
A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

a. Slow the rate of IV fluids.
b. Remove the IV.
c. Apply a warm compress.
d. Elevate the arm.
b. Remove the IV.
Potassium is needed for neural, muscle, and:

a. optic function.
b. auditory function.
c. cardiac function.
d. skeletal function.
c. cardiac function.
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation?

a. Notify the primary care provider immediately because these are signs of speed shock.
b. Notify the primary care provider immediately for possible fluid overload.
c. Check all clamps on the tubing and check tubing for any kinking.
d. Place the client in the Trendelenburg position to keep the client's airway open.
b. Notify the primary care provider immediately for possible fluid overload.
A decrease in arterial blood pressure will result in the release of:
a. protein.
b. thrombus.
c. renin.
d. insulin.
c. renin.
A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

a. Sodium
b. Chloride
c. Phosphorous
d. Potassium
d. Potassium
A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?

daily weights
daily BUN and serum creatinine monitoring
output measurements
daily electrolyte monitoring
daily weights
During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible?

hypervolemia
hypovolemia
edema
circulatory overload
hypovolemia
x

The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing?

isotonic
hypotonic
hypertonic
plasma
hypertonic
The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome?

Bowel motility will be restored within 24 hours after beginning supplemental K+.
ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.
ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+.
Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet.
ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.
While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority?

Apply a tourniquet to the client's upper arm.
Apply pressure to the site with sterile gauze until hemostasis is achieved.
Have the client perform the Valsalva maneuver. Measure the catheter and compare it with the length listed in the chart.
Apply a tourniquet to the client's upper arm.
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