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Advanced MNT 2 > Parenteral Fluid & Electrolytes > Flashcards

Parenteral Fluid & Electrolytes Flashcards

1
Q

Total Body water is _____ % of body weight

A

50-60

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2
Q

total body water divided into three places, what are they and how much weight do they contain?

A

Extracellular fluid (1/3)
intracellular fluid (2/3)
transcellular (<3%)

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3
Q

extracellular fluid consists of what two spaces?
how much of ECF are they?

A

interstitial space (3/4)
intravascular space (1/4)

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4
Q

Equation of TBW of women ?
equation for males ?

A

TBW (women) = Wt in kg x 0.5
TBW (men) = Wt in kg x 0.6

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5
Q

How does Fat affect TBW

A

TBW decreases with increasing body fat

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6
Q

How does Age affect TBW

A

Muscle mass declines and the proportion of fat increases; thus, TBW decreases

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7
Q

The pressure required to maintain equilibrium with no net movement of solvent is _______

A

Osmotic pressure

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8
Q

How does Sex affect TBW

A

Women have proportionally higher body fat than men; thus, women have less TBW

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9
Q

Osmotic pressure has Prime importance in determining the distribution of water between the ECF and ICF

Each compartment contains a major ____________ that determines its osmotic pressure

A

osmotically active solute

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10
Q

______ is the dominant extracellular osmole holding water in the ECF

A

Na

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11
Q

_____ is the primary intracellular osmole holding water within the cells

A

K

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12
Q

Activity of the ____________ allows for the maintenance of these unique solute compositions of the ECF and ICF

A

Na+-K+-ATPase pump

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13
Q

two types of commonly prescribed intravenous solutions

A

crystalloids
colloids

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14
Q

Crystalloids:

Solutions that supply ______, ______, and/or _______

Contain _____ molecules that flow easily from the _____ into ______

A

water
sodium
dextrose

small
blood
cells and tissues

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15
Q

Colloids

Solutions containing _____, ______ molecules
generally ______ or ________

Increase ___________ pressure, move fluid from ____________ to __________

A

large insoluble
proteins or complex polysaccharides

intravascular oncotic
interstitial space
intravascular space

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16
Q

Free water (D5w)

A

Free water distributes evenly across all compartments

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17
Q

Isotonic (NS or LR)

A

100% will stay in the extracellular space

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18
Q

_______________ pressures govern the movement of fluid between the intravascular and interstitial spaces

Disruption in these pressure results in a flow of fluid from one compartment to another

When this favors an ________ to ________fluid shift third-spacing occurs

A

Plasma oncotic and hydrostatic

intravascular
interstitial

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19
Q

two types of Fluid Losses
_________ – visible and measureable
_________ – usually not seen or measured

A

Sensible
Insensible

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20
Q

Daily Assessment of hydration status:
_______ and ______

physical evaluation of ____, ____, ____

evaluation of _______ and _______

_______ and assessment for _________

A

weights
I/O records

skin, eyes, lips and oral cavity

respiratory rate
lung sounds

blood pressure
peripheral edema

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21
Q

Energy based formulas for fluid requirements
_____ per kcal required

A

1 mL

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22
Q

Weight based formulas for fluid
Equation 1:
Ages ____ years: ____ mL/kg
Ages ____ years: ____ mL/kg
Ages ____ years: ____ mL/kg
Fluid restricted adults: ____ mL/kg

A

18-55 years: 35 mL/kg
56-75 years: 30 mL/kg
>75 years: 25 mL/kg
Fluid restricted adults: ≤ 25 mL/kg

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23
Q

Weight based formulas for fluid
(Holliday-Segar formula adjusted for age):
Ages ≤ 50 years: ________
Ages > 50 years:

A

1500 mL for first 20 kg body wt + (20 mL x remaining kg body wt)

1500 mL for first 20 kg body wt + (15 mL x remaining kg body wt)

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24
Q

*The use of an ___________ should be used to calculate the fluid needs in obese patients to account for their increased percentage of body fat

A

obesity-adjusted weight

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25
Q

Volume disturbance that leads to gain or loss of fluid (water and solute) result in ________ or ______

A

hypovolemia
hypervolemia

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26
Q

concentration disturbance that results in gain or loss of water alone results in _______ or _________

A

dehydration
overhydration

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27
Q

composition disturbance results in gain or loss of electrolytes lead to ________

A

electrolyte disorders

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28
Q

Loss of fluid (ie, water and solute) can come from _____, _____, _____, or _________

A

GI tract
Skin
Urine
Prolonged inadequate intake

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29
Q

Loss of fluid (ie, water and solute) symptoms

A

dry oral mucosa
poor skin turgor
tachycardia
hypotension

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30
Q

Loss of fluid (ie, water and solute) treatment

Prescribed based on ___________
In severe cases: ________________

A

underlying cause for fluid deficit

replacement of ECF losses which require isotonic solution (NS or LR)

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31
Q

dehydration is ___________
Recognized by a change in ________ & ________

A

loss of water alone
serum sodium concentrations
plasma osmolality

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32
Q

Causes of Dehydration

A

Diabetes Insipidus
Prolonged fever
watery diarrhea
hyperglycemia

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33
Q

Treatment for Dehydration
Provision of ____________
Expands _________, predominately in the ___

A

free water (ex. 5% dextrose solution)
both fluid compartments
ICF

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34
Q

Hypervolemia is ________
Involves water retention with a _______

A

Volume overload
decrease in body sodium concentrations

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35
Q

Hypervolemia Causes:

A

decreased urinary output
excessive IVF

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36
Q

Hypervolemia Characterized by:

A

weight gain
edema
ascites
elevated blood pressure
pulmonary edema

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37
Q

Treatment for Hypervolemia

A

Correction of underlying cause

Limitation of sodium and fluid intake
In some cases, diuretic therapy may be required

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38
Q

Review of clinical laboratory

If inconsistent, the ______ of the specimen collection should be validated

If a collection error or specimen mishandling is confirmed, a repeat specimen should be collected

If the result is ____, a treatment regimen should be developed

A

accuracy
valid

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39
Q

Treatment for levels above the normal range

Remove _________
Discontinue _________ or ______
Facilitate elimination of _______
Treat ________ that may be contributing

A

exogenous sources

offending agents or meds

electrolyte

condition

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40
Q

Treatment for levels below the normal range
_________replacement

Treatment considerations:
Available administration ______
_______ function
______ functions
______ status
_________ availability
______________ abnormalities

A

Electrolyte

routes
GI tract
Renal
Fluid
Product
Concurrent electrolyte

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41
Q

Principal cation in the ECF

A

Na

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42
Q

Sodium normal range

A

135-145

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43
Q

Sodium Functions

Major osmotic determinant in regulating ____ volume and ______ distribution in the body

Determining ___________ of cells
__________ of molecules across cell membranes

A

ECF
water

membrane potential
Active transport

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44
Q

what organ plays a pivotal role in sodium balance

A

kidney

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45
Q

Hyponatremia is when sodium is less than _____

Symptoms include
_______, ______, ______, ______
_____, ______, _____
______, ________, _______

Clinical manifestations related to CNS dysfunction are more likely to occur when the serum Na+ drops ______ and when it falls below ____ mEq/L

A

135

Headache, nausea, vomiting, muscle cramps
lethargy, restlessness, disorientation
depressed reflexes, seizures, and coma

rapidly
125

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46
Q

Assessment of Sodium:
Clinicians should determine the patient’s serum Na concentration and volume status to identify the etiology of the hyponatremia

Serum osmolality can be _____ or _____
Serum Osmolality = 2 𝑥 [(𝑠𝑒𝑟𝑢𝑚 𝑁𝑎+𝑆𝑒𝑟𝑢𝑚 𝐺𝑙𝑢𝑐𝑜𝑠𝑒)/18)+(𝐵𝑈𝑁/2.8)]
___________: mOsm/kg
_______: mEq/L
______________: mg/dL

A

measured or calculated

Serum Osmolality
Serum Na
Serum Glucose and BUN

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47
Q

Hypotonic hyponatremia causes

A

volume depletion
SIADH
CHF
cirrhosis

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48
Q

isotonic hyponatremia causes

A

hyperglycemia
hyperlipidemia

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49
Q

hypertonic hyponatremia causes

A

severe hyperglycemia with dehydration

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50
Q

Hypovolemic Hypotonic Hyponatremia

What happens in this ?

Causes: _______

Treatment: ______

A

Patients lose more Na in relation to water, but both are going down still

renal and extrarenal losses

Isotonic Fluids

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51
Q

Hypervolemic Hypotonic Hyponatremia

What happens in this ?

Causes: _______

Treatment: ______

A

Patients retain more water than Na, but Na and water are both increasing

some element of end-organ failure resulting in fluid retention or third spacing

fluid and sodium restriction

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52
Q

Euvolemic hypotonic hyponatremia
What is this?

commonly associated with _____
Other causes?

Treatment ?

A

Na same in and out, but increased body water

SIAD (excess ADH = retain water)
psychogenic polydipsia, hypothyroidism

treatment of underlying cause and fluid restriction

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53
Q

In Eucolemic Hypotonic Hyponatremia … Urine osmolality is always_____serum osmolality and urine Na_____ mEq/L

Indicating the ______ are inappropriately concentrating urine and volume status is adequate

A

> 20
kidneys

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54
Q

hypernatremia is above ____ mEq/L

assessment includes….
_____ status
all hypernatremia is ____

A

145
volume
hypertonic

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55
Q

symptoms of hypernatremia

A

MILD: headache, dizziness, confusion

SEVERE: seizures, coma, death

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56
Q

HYPOVOLEMIC HYPERNATREMIA

what is it?

A

above normal serum osmolality
low Na and more low water

57
Q

HYPOVOLEMIC HYPERNATREMIA
Causes

A

Causes: renal and extrarenal losses

58
Q

HYPOVOLEMIC HYPERNATREMIA treatment

A

Treatment: hypotonic fluids via enteral or parenteral route

59
Q

EUVOLEMIC HYPERNATREMIA

what is it?

A

Patients have water losses that exceed sodium losses
Equal sodium but losing water

60
Q

EUVOLEMIC HYPERNATREMIA
Causes?

A

Causes: diabetes insipidus

61
Q

EUVOLEMIC HYPERNATREMIA
Treatment:

A

replacement of water via enteral or parenteral route and normalization of serum Ca and K+

62
Q

HYPERVOLEMIC HYPERNATREMIA

what is it?

A

more high Na
high TBW

63
Q

HYPERVOLEMIC HYPERNATREMIA
Causes?

A

Iatrogenic: excessive administration of isotonic or hypertonic sodium

Mineralocorticoid excess: Cushing’s syndrome or adrenal malignancy

64
Q

HYPERVOLEMIC HYPERNATREMIA
Treatment?

A

Correcting the underlying disorder
Administering diuretics
Replacing water

65
Q

What is the major Intracellular cation

A

potassium

66
Q

Functions of potassium

Plays a critical role in cell metabolism including _____ and ______ synthesis
Maintains ___________
Abnormal concentrations -> ______

A

protein and glycogen synthesis
resting membrane potential
EKG Changes

67
Q

Important to remember that ____ is a co-factor for the Na+-K+ATPase pump
Hypo__________ -> refractory hypokalemia

A

Mg
magnesemia

68
Q

Normal daily requirements of K+ : _____ mEq/kg

A

0.5-2

69
Q

H+/K+ ATPase Pump
Allows K to shift in/out of the cell in exchange for _______

A

hydrogen

70
Q

Metabolic Acidosis:

H+ ions _______ -> body corrects by moving H+ back __________ and pumping K+ _________ -> _____kalemia

A

outside of cell
into the cell
outside of the cell
Hyper

71
Q

Metabolic Alkalosis:
not enough H+ ions _________ -> pump moves H+ ions ______________ and K+ will move _________ -> _____kalemia

A

in the plasma
outside of the cell into the plasma
into the cell
Hypo

72
Q

Hypokalemia (_____mEq/L)

A

<3.5

73
Q

Hypokalemia Causes:

A

Abnormal losses via urine and stool
Inadequate intake
Medications

Transcellular shifts from ECF into cells
Causes: Metabolic alkalosis and increases in insulin and catecholamines

74
Q

Hypokalemia Clinical Presentation:

A

Generalized weakness, Lethargy, Constipation

More severe consequences:
Muscle necrosis, Paralysis, Arrhythmias, Death

75
Q

Hypokalemia Treatment Goals:

A

Avoidance/resolution of symptoms
Restoring serum K+ to normal
Preventing hyperkalemia

76
Q

Treatment Options for Hypokalemia

A

Oral or IV potassium supplements

77
Q

HYPOKALEMIA TREATMENT
______ correction is generally safer and reduces the risk of rebound hyperkalemia

Commonly used oral K+ replacements:
_______ and ______

A

Oral

potassium chloride
potasium phosphate

78
Q

IV supplementation is reserved for treatment of severe hypokalemia or when the condition of the GI tract precludes use of oral agents

Infusion rates typically will not exceed ____ mEq/hr
Rates higher than ___ mEq/hr, continuous _____ monitoring is recommended to detect signs of hyperkalemia

If possible, ______ solutions should be avoided
________ deficit should be corrected

A

10-20
10
cardiac

dextrose
Magnesium

79
Q

IV K+ supplements are available in ____, _____, and ______

A
80
Q

IV treatment recommendatons:
Serum K 3-3.5: _____ mEq
Serum K 2.5-2.9: _____ mEq
Serum K <2.5: _____ mEq

Decrease dose by ___% for renal insufficiency

10 mEq K+ should increase serum K+ by ____

A

20-40
40-80
80-120

50%
0.1

81
Q

Hyperkalemia (>____ mEq/L)

A

5.0

82
Q

Hyperkalemia Causes

A

Most often occurs in CKD

Shifts in K+ from ICF to ECF: metabolic acidosis, tissue catabolism, pseudohyperkalemia

Increased K+ intake alone rarely causes hyperkalemia

Medications

83
Q

Hyperkalemia Clinical Presentation:

A

Muscle twitching, cramping, weakness, paralysis, arrhythmias, cardiac arrest

84
Q

Hyperkalemia Treatment goals:

A

Prevent cardiac effects
Reversing symptoms
Returning serum K+ to normal

85
Q

HYPERKALEMIA TREATMENT
If feasible, discontinuation of all exogenous _______ and ________ that can cause hyperkalemia

Consider use of ____________

A

K+ sources and medications

loop or thiazide diuretic

86
Q

HYPERKALEMIA TREATMENT for asymptomatic patients

A

Sodium Bicarbonate (50-100 mEq)

Dextrose infusion (25-100 gm with 5-10 units insulin)

87
Q

HYPERKALEMIA TREATMENT for symptomatic patients or EKG changes

A

IV Calcium gluconate: 1-2 gm

88
Q

Magnesium (Mg 2+)Normal range: ____ mg/dL
Found predominantly in the ____

Absorption occurs primarily in ____ and ____
Regulated by the ___, ___, and ___

A

1.8-2.4
ICF

distal jejunum and ileum
GI tract, kidney, and bone

89
Q

MAGNESIUM

Essential in the activation of >300 _______
_________ metabolism
________ synthesis and breakdown
____ and ______ metabolism

Co-factor for __________

A

enzymatic reactions
Glucose
fatty acid
DNA and protein

Na+-K+ATPase pump

90
Q

Hypomagnesemia (<____ mg/dL)

A

1.8

91
Q

Hypomagnesemia causes

A

Decreased absorption or intake
- Protein-calorie malnutrition
- Malabsorption syndromes
- Alcoholism
- SBS

GI or renal losses
- Acute tubular necrosis
- Hyperaldosteronism
- Drug-induced

Intracellular Shifts
- Refeeding Syndrome
- Diabetic ketoacidosis
- Hyperparathyroidism
- MI

92
Q

Hypomagnesemia clinical manifestations

A

Neuromuscular hyperexcitability
Cardiac complications
May reduce insulin sensitivity

93
Q

Hypomagnesemia treatment goals

A

IV route preferred due to GI side effects of PO supplementation

94
Q

HYPOMAGNESEMIA TREATMENT

Commonly used oral Mg replacements: (3)

A

Magnesium chloride
Magnesium Gluconate
Magnesium Oxide

95
Q

IV treatment recommendations (Magnesium _____)
Serum Mg 1.0-1.5: ____________
Serum Mg <1.0: ___________

Decrease dose by ___% for renal insufficiency
____ mEq Mg sulfate should increase serum Mg by 0.1

Maximum infusion rate: ________

A

Sulfate
6-32 mEq, <1 mEq/kg
32-80 mEq, <1.5 mEq/kg

50
8

≤ 8 mEq/hr (1 g)

96
Q

Hypermagnesemia (>____ mg/dL)

A

2.4

97
Q

Hypermagnesemia causes

A

Primarily in the setting of CKD in combination with Mg intake

98
Q

clinical presentation for hypermagnesemia

A

Generally well tolerated

Levels >4.8 mg/dL can affect neurologic, neuromuscular and cardiac function

99
Q

hypermagnesemia treatment
Asymptomatic patients ?
symptomatic patients ?

A

Removal of exogenous sources of Mg
Mg restriction
Loop diuretics

IV Calcium

100
Q

Calcium (Ca 2+)Normal range: ______ mg/dL
One of the most abundant cations in the body
99% of total body Ca is found in teeth and bones

Serum calcium exists in 3 forms: _______

A

8.6-10.2

complexed
protein bound
ionized

101
Q

Calcium Functions:
Essential for ____ metabolism
_____ conduction
functionality of _______

coagulation cascade and regulation of ______functions

A

bone
nerve
cell membranes

secretory

102
Q

Hypocalcemia
Serum Ca <____ mg/dL
Ionized Ca <____ mmol/L

A

8.6
1.12

103
Q

Hypocalcemia Causes:

A

Decreased Vitamin D activity
Decreased PTH activity
Renal Impairment
Critical Illness

Medications: bisphosphonates, calcitonin, furosemide, long-term use of phenobarbital and phenytoin

104
Q

Hypocalcemia clinical presentation

A

Cardiovascular (hypotension)
Neuromuscular (muscle cramps, tetany or seizures)

105
Q

Hypocalcemia Treatment:

A

Oral or IV replacement and vit D for asymptomatic patients

106
Q

Commonly used Ca supplements (3)

A

Calcium acetate:25% elemental Ca
Calcium carbonate: 40% elemental Ca
Calcium citrate: 21% elemental Ca

107
Q

Acute Symptomatic patients with hypocalcemia

IV treatment recommendations:
Ionized Ca 1-1.12 mmol/L: __________
Ionized Ca <1 mmol/L: __________

A

1-2 g calcium carbonate over 1-2 hours

2-4 g calcium carbonate over 2-4 hours

108
Q

Hypercalcemia
- Serum Ca >_____ mg/dL
- Ionized Ca >___ mmol/L

A

10.2
1.3

109
Q

Hypercalcemia

A

Hyperparathyroidism
Cancer with bone metastases
Toxic levels Vitamin A or Vitamin D

Chronic ingestion of milk or Ca containing antacids in the setting of renal insufficiency

110
Q

Hypercalcemia Clinical Presentation:

A

Fatigue, nausea, vomiting, anorexia, confusion, cardiac arrhythmias

111
Q

Hypercalcemia mild is _____ mg/dL
severe is _____ mg/dL

A

10.3-11.9 mg/dL
>14 mg/dL

112
Q

Hypercalcemia treatment for mild

A

Hydration and ambulation

113
Q

Hypercalcemia treatment for severe

A

IV hydration using 0.9% NS at 200-300 ml/hr
- to reverse volume depletion caused by hypocalcemia

Controversial treatment: Once adequate hydration is achieved, 40-80 mg IV furosemide to enhance renal Ca excretion

*HD may be necessary

114
Q

what is the main intracellular anion

A

phosphorous

115
Q

Phosphorus normal range is _______ mg/dL

found mostly in ____ and _____

A

2.5-4.5

bones and soft tissue

116
Q

Phosphorus functions
____ and ____ membrane composition
Maintenance of normal ___
Required in all cellular functions that require ____

A

bone and cell
pH
energy

117
Q

Hypophosphatemia (<____ mg/dL)

A

2.5

117
Q

Hypophosphatemia Causes

A

Chronic alcoholism, critical illness, respiratory & metabolic alkalosis, refeeding syndrome, pt’s receiving phosphate binding medications

118
Q

Hypophosphatemia clinical presentation

A

Neurologic: ataxia, confusion

Neuromuscular: weakness, myalgia

Cardiopulmonary: cardiac and ventilatory failure

Hematologic: hemolysis

119
Q

Hypophosphatemia treatment

A

Oral or IV replacement

120
Q

Asymptomatic mild hypophosphatemia treatment is ___________.

Symptomatic moderate/severe hypophosphatemia treatment is _________.

A

oral supplements
IV phos unles K+ is >4 or renal insufficiency

121
Q

Commonly used oral phosphate supplements?

Maximum infusion ratefor IV: ____ mmol/hr

A

K-Phos
Phos-NaK
OsmoPrep

7

122
Q

Hyperphosphatemia (>____ mg/dL)

A

4.5

123
Q

Hyperphosphatemia causes

A

CKD

Endogenous release of Phos into ECF from cellular destruction
- Massive trauma, cytotoxic agetns, hypercatabolism, hemolysis, malignant hyperthermia

Transcellular shifts from the ICF to the ECF
- Respiratory and metabolic acidosis

124
Q

Hyperphosphatemia clinical presentation

A

Anorexia, nausea, vomiting, dehydration

125
Q

Hyperphosphatemia complications

A

Soft tissue and vascular calcification
- when total serum Ca x serum Phos exceeds 55 mg/dL

Secondary hyperparathyroidism

Renal osteodystrophy

126
Q

Hyperphosphatemia treatment

A

Decrease or eliminate exogenous sources
Phosphate binders
HD may be necessary

127
Q

Clinical Conditions Warranting Cautious Use of PN

Glucose >_____ mg/dL ?
BUN >____ mg/dL
Osmolarity > ____ mOsm/kg
Na >____ mEq/L
K < _____ mEq/L
Phos <_____ mg /dL
Cl >______ mEq/L
Cl <_____ mEq/L

A

300 Hyperglycemia
100 Azotemia
350 Hyperosmolarity
150 Hypernatremia
3 Hypokalemia
2 Hypophosphatemia
115 Hyperchloremic metabolic acidosis
85 Hypochloremic metabolic alkalosis

128
Q

Sodium daily requirement is ____mEq/kg
what are factors that increase needs?

A

1-2

Diarrhea
vomiting
NG suction
GI losses

129
Q

Potassium daily requirement is ____mEq/kg
what are factors that increase needs?

A

1-2

Diarrhea
Vomiting
NG suction
Medications
Refeeding
GI losses

130
Q

Calcium daily requirement is ____mEq
what are factors that increase needs?

A

10-15

high protein intake

131
Q

Magnesium daily requirement is ____mEq
what are factors that increase needs?

A

8-20

GI losses
Medications
Refeeding

132
Q

Phosphorous daily requirement is ____mMol
what are factors that increase needs?

A

20-40

High dextrose intake
refeeding

133
Q

Electrolyte Requirements

Na: NS = ____ mEq/L
½ NS = ____ mEq/L

Mg: 1 gm Mg = ___ mEq Mg
Ca: 1 gm Ca = ____ mEq

KPO4: 1 mMol KPO4 contains _____ mEq K
NaPO4: 1 mMol NaPO4 contains _____ mEq Na

A

154
77

8
4.56

1.47
1.33

134
Q

Monitor these every…
Capillary blood glucose?
grams of fat?
Mg, K+, Ph?
serum CO2?
triglyceride?

A

6 hrs until stable
daily
daily until stable
daily
at baseline then weekly

135
Q

BG - Start with low dose sliding scale insulin. If BG >180, recommend increasing insulin in PN. Initial dose of ____ previous day’s sliding scale.

FAT - Calculate as fat gm/kg/day. If no lipids given, check for last date of dose given. If ______, recommend adding lipids.

MAGNESIUM, K+, PHOSPHOROUS - If Mg, K and Phos are all low, recommend adding __________ daily for possible re-feeding syndrome. Give replacement therapy.

SERUM CO2 - If >______, evaluate for possible ______

TRIGLYCERIDES - If >____ at baseline, hold lipids and re-check in 1 week. If >____ at repeat, consider giving minimal lipid dose to prevent EFAD

A

2/3

> 3 weeks

thiamine 100 mg

30
overfeeding

400
400

136
Q

If glucose ≥ _____ mg/dL -> stop TPN -> run _____ at ordered TPN rate

If glucose <____ mg/dL -> Initiation of ____, Administration of ________ & stop ______

If TPN stopped, taper rate by ________ then infuse ________at the TPN rate until new bag hung

If TPN must be stopped suddenly, infuse ______ at TPN rate x ___ hour then ______ at the TPN rate until new bag hung

A

400
½ NS

70
D10
1 amp, 50% dextrose
insulin

½ x 1 hour
D5 ½ NS

D10
1
D5 ½ NS

137
Q
A

Advanced MNT 2 (17 decks)

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