Ch. 39 Disorders of Fluid & Electrolyte Balance Flashcards Preview

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Flashcards in Ch. 39 Disorders of Fluid & Electrolyte Balance Deck (253):
1

Sodium nl range

135-145 mEq/L

2

Potassium nl range

3.5-5.0 mEq/L

3

Calcium nl range

9-11 mg/dL

4

Magnesium nl range

1.5-2.5 mEq/L

5

Phosphate nl range

2.5-4.5 mg/dL

6

Chloride nl range

96-106 mEq/L

7

pH nl range

7.35-7.45 (no units)

8

Carbon dioxide

35-45 mmHg

9

Bicarbonate

22-26 mEq/L

10

Oxygen

80-100 mmHg

11

In the lungs there is __ __ __, which is water lost through __.

insensible water loss; breathing

12

If someone has a rapid respiratory rate, they can loose a lot of ___ ___.

insensible water

13

Homeostasis is a __ __ or __ environment in the body maintained by various __ __.  

relatively stable; constant; control mechanisms

14

Extracellular fluid

body fluid outside the cells

15

Intracellular fluid

body fluid inside the cells

16

The fluid of the body is secreted in specialized compartments like: (3)

1.) Joints
2.) Intestinal Lumen
3.) Cerebral Ventricles

17

Fxns of body fluid: (5)

1.) surrounds and permeates the cell
2.) lubricant and solvent for metabolic chemical reactions
3.) transports oxygen, nutrients, chemical messengers and waste products to destinations
4.) regulates body temperature
5.) medium for food digestion

18

The total body water in a person is __ -__% their body weight

40-60%

19

__% of an adult's body weight is water

60%

20

__% of an infant's body weight is water

70%

21

Women who generally have more adipose tissue, have a __ __ of water in their body than males

lower proportion

22

The obese and elderly have a _ __ of water in their body

lower proportion

23

In a newborn, about __% of the body fluid is in the extracellular fluid
In a toddler it is __%

50%

30%

24

The extracellular fluid accounts for __ of the body's fluids. It is responsible for __ and __ __ to and __ __ from the cells.

1/3

transporting; carrying nutrients; waste products

25

Intravascular
what does it include?

fluid within the blood vessels
electrolytes, plasma, and albumin

26

Interstitial
location of most __ __.
Little to no __,
Rich in __, __, and __.
Low in __, __, and __ __.

between cells
extracellular fluid
protein
sodium, chloride, and bicarbonate
potassium, magnesium, and phosphate ions

27

Transcellular
Examples : Brain & Spinal Cord =
Lungs =
Heart=
GI tract =

contained in specialized body cavities
cerebral spinal fluid
pleural fluid
pericardial fluid
(peritoneal fluid?) diarrhea/vomiting

28

Intracellular make up __ of total body fluids
It contains: (4)
The electrolytes that it contains include: (3)
There is low __ and __ levels.

2/3 of total body fluids ;
solutes, oxygen, electrolytes, and glucose;
K, Mg, Phosphorous ;
Na; Cl

29

Intracellular fluid provides the medium for __ __ of the __ to take place

metabolic processes
cell

30

Fluid homeostasis contains for 4 subprocesses:

intake, absorption, distribution, excretion

31

Intake: mostly through __ and __. (__L)
Other examples include: __ of liquids through __, __ __ (___L), and __.

eating; drinking; 2.2; infusion; IV; cellular metabolism (0.3L), accidental

32

Absorption: occurs through the __ __.
Abnormal absorption occurs when there is __ __ in water or through __ in __ __.

GI tract
prolonged submersion
lungs; near drowning

33

Distribution involves __ __ and __ other compartments and is a result of __ __.

transfer to ; from; concentration gradients

34

Excretion: lost through __ and __ . Also __ __ __ through __ and __.
Excretion occurs through __, __, and __.

urine/ feces
insensible water loss; sweat; breathing
bowels, lungs, skin

35

The __ __ is the primary barrier for movement of solutes through the body

cell membrane

36

__ allow water and small water soluble substances to pass

Pores

37

Active tranport is the movement of molecules through the cell membrane from an area of __ to __ concentration

low to high

38

Active transport is usually associated with accumulating high amounts of substances that the cell needs such as __, __ and __ __.

Active transport uses __.

Examples of active transport:

ions, glucose, amino acids

ATP

uptake of glucose in the intestines

uptake of mineral ions in the hair root in plants

39

Passive transport is the movement of substances across the __ __
Does it require energy?

The rate depends on the ___ of the cell membrane

cell membrane

NO

permeability

40

4 main examples of passive transport include:

Diffusion
Facilitated Diffusion
Filtration
Osmosis

41

Facilitated Diffusion uses ___ ___ embedded within the cell membrane

transport proteins

42

During filtration, fluid moves from __ __ __ to __ __ __.

high hydrostatic pressure ; lower hydrostatic pressure

43

Hydrostatic pressure is the pressure created by the __ __ __.
Examples include:

weight of fluids

increased pressure of arteries forces fluid into capillary walls and into interstitial spaces

44

Osmosis is the water movement across the cell membrane from __ solute concentration to __ concentration

low; higher

45

If RBC is placed in a dilute hypotonic solution what kind of osmotic pressure is this?
Water may __ the cell causing it to __ and __.

low osmotic pressure

enter; swell; malfunction

46

Osmolarity =

osmolar concentration in 1 Liter of solution when describing fluids outside the body

Moles of some particle/ 1 L of solution

47

Osmolality =

osmolar concentration in 1 KG of solvent for describing fluids inside the body

48

1 L of water weighs __ KG

1

49

Think of osmolality and osmolarity as meaning ___

CONCENTRATION

50

Hydrostatic pressure is the __ force and osmotic pressure is the __ force in fluid movement

push ;

pull

51

At the arterial end of the capillary the blood hydrostatic pressure __ the interstitial hydrostatic pressure and the __ __ __ of the blood. Therefore fluid is __ __ of the capillary into the interstitial compartment

exceeds; plasma colloid pressure

pushed out

52

At the venous end of the capillary the blood hydrostatic pressure is __ and the __ __ is higher therefore fluid is pulled back in to the capillary.

decreased

osmotic pressure

53

Lymphatic capillaries __ __ __

return excess fluid

54

Regulation of water balance: Internal control mechanisms include:
1.)
2.)
3.)
4.)
are responsible for __ and __ of fluid balance

1.) thirst
2.) RAAS system
3.) ADH
4.) diuretics

distribution; maintenance

55

The __ , __, and __ __ are responsible for regulating water balance

hypothalamus
pituitary
adrenal cortex

56

Hypothalamus is responsible for __.

This arises from __ __ or increase in __ like __. There are also ___ in the hypothalamus that regulate fluid so if water volume falls below certain threshold or __ become too high, the brain signals thirst.

thirst

lower fluids; osmolites; salt
osmoreceptors ; osmolites

57

Posterior pituitary release __, which regulates __ __ by the __.

ADH ; water retention; kidneys

58

Adrenal cortex: responsible for releasing __ and __ to regulate both __ and __.

glucocorticoids
mineralocorticoids
water; electrolytes

59

ADH is also referred to as __

vasopressin

60

ADH is synthesized in the __ and stored in the __ __. When there's a fluid volume deficit or increased __ __, the __ sense this and stimulates __ and ___. __ acts on the renal and __ __ ___ in the kidneys and makes them __ __ to water, so water is ___ instead of __ in the urine. The reverse is also true. When fluid is in excess (hypervolemia) and there is a decrease in plasma osmolality , ___ sense this and __ is suppressed allowing for urinary excretion of water.

hypothalamus; posterior pituitary
plasma osmolality; osmo-receptors; third; ADH;
ADH; distal collecting tubules; more permeable; reabsorbed; excreted; osmoreceptors; ADH

61

ADH only affects __ __.

water reabsorption

62

__ and __ secreted by adrenal cortex help regulate __ and __.

Glucocorticoids; minerlaocorticoids; water; electrolytes

63

Glucocorticoids like __ primarily have an __-______ effect and increase __ __ levels

cortisol; anti-inflammatory; serum glucose

64

Mineralcorticoids like __ enhance __ __ and __ __.

aldosterone; sodium retention and potassium excretion

65

The adrenal cortex regulation is also known as the:

Renin Angiotensin Aldosterone System (RAAS)

66

When decreased renal perfusion such as with ___ or __, the release of __ from the kidneys causes the conversion of ___ (from the __) to ____ _.

hypotension; hypovolemia; renin; angiotensinogen; liver; angiotensin 1

67

Angiotensin 1 is converted to __ _ by way of the enzymes called __ __ __ (___) which is found in the __.

Angiotensin II

Angiotensin converting enzyme (ACE)

Lungs

68

Angiotensin II is a ____, which results in __ __ __.

vasoconstrictor; increased blood pressure

69

Angiotensin II stimulates the release of __ from the __ __, which causes the tubules of the kidneys to increase the reabsorption of __ and__ in the blood and excrete __. This increases the fluid volume in the body which also increases __ __.

aldosterone; adrenal cortex

sodium; water; potassium; blood pressure

70

GI regulates water balance with __, __, and __.

intake, absorption, excretion

71

Kidneys regulate water balance with __ and __.

ADH; aldosterone

72

Heart plays role with production of __ and __

ANP = atrionaturetic peptide and BNP (beta naturitic peptide)

73

ANP secreted by heart cels act as a powerful ___.

vasodilator

74

BNP is secreted by __ of the heart in response to ___ ___ of the heart muscles such as when the heart is ____ due to ___ ____ overload

ventricles
excessive stretching
enlarged ; fluid volume

75

BNP decreases __ __ __ and __ __ __.

systemic vascular resistance; central venous pressure

76

BNP and ANP antagonize the ___ and __ blood volume and __ systemic blood pressure in after load

RAAS; decrease; lower

77

Electrolytes are __ __ dissolved in __.

ionized salts; water

78

Isotonic solution is if cell placed in solution has the __ osmolality as __ __. Neither __ nor __

Example: __

same; intracellular fluid; shrink; swell

normal saline

79

Hypotonic solution: when the cell is placed in a hypotonic solution, which has a __ osmolality than the __ __ they __ as water moves __ the cell.

Example: __ __ __

lower
intracellular fluid
swell
into

half normal saline

80

Hypertonic solution: when cell in hypertonic solution, which as a __ osmolality than __ __
they __ as water is pulled __ of the cell

For example: __% ___

greater
intracellular fluid
shrink; out

3% saline

81

Intake occurs normally through __ and __ __ but also: (4)

food; fluid intake
1.) oral medications
2.) IV or blood infusions
3.) body tubes
4.) near drowning (salt water)

82

Absorption is the key to maintain __. Depends on __ , which can be electrolyte __ or __.

balance
diuretics; sparing; wasting

83

Absorption is essential for electrolyte to be used metabolically; this depends on :
(4)

1. Concentrations
2. Binding Proteins
3. pH of intestine
4. Medications (diuretics that spare or waste electrolytes)

84

Distribution is primarily influenced by __ including (5):

hormones
1. Epinephrine
2. Insulin
3. Parathyroid hormone
4. Medications
5. May be rapid

85

Excretion: can be lost through __, ___ and __ (__)
Patient with high K can be given medications to __ __ __ in feces
Abnormal losses include patient having a __ with a lot of __.

urine; feces, sweat (sodium)

increase K excretion

drain; output

86

Why are infants at high risk for fluid and electrolyte imbalances? (3)

1. immature kidneys
2. rapid respiration (insensible water loss)
3. more surface area than adults so they loose fluid very rapidly

87

What are elderly at high risk for fluid and electrolyte imbalance?
Elderly population have __ and __ changes to the __.
Structural changes lead to __ __ __ and __ in __ ( __ __ _ __)

hormonal; structural; kidney

decreased renal flow; decrease; GFR (filtering rate of kidneys)

88

The elderly have a decrease in __ ___. They also lose their ability to __ their urine and __ water.

creatinine clearance; concentrate; conserve

89

The elderly have a decrease in __ and __. They also have an increase in __, loss of __ tissue and __ of the skin, which causes more water __ through the skin

renin; aldosterone; ADH; subcutaneous; thinning; loss

90

Female bodies contain more __ tissue
More __ = __ fluid

fatty
fat; fluid

91

__ and __ also have low proportion of water, so they are more likely to be adversely affected by fluid and electrolyte imbalance

elderly; obese

92

Hypovolemia =

extracellular fluid volume deficit

93

Hypovolemia loss is a/an ___ loss. This means that the __ fluid and the __ within the cell are the same thus there is no change in __.

isotonic; extracellular; concentration; osmolality

94

With hypovolemia, it is characterized by __ depletion and thus differs from dehydration, which is defined as excessive loss of __ __.

Na; body water

95

Causes of hypovolemia: (Big Picture) (2)

1. Decreased Intake
2. Increased Loss

96

Causes of Hypovolemia -> Decreased Intake
-> (2)

1. Someone who is nauseous/anorexic might not drink enough fluids
2. Someone who has the inability to drink (lethargy/coma) will also have decreased intake

97

Causes of Hypovolemia -> Increased loss -> (7)

1. Trauma that involves hemorrhage
2. Blood Donations
3. Burns- loss of plasma that can lead to hypovolemia
4. High urine output (polyuria, diuretics to treat HTN, dialysis d/t chronic kidney disease)
5. High GI output - someone with diarrhea, vomiting
6. Nasal Gastric Tube for suctioning (for someone with bowel obstruction)
7. Fluid Shift (third spacing, shock, diaphoresis)

98

Diuretics not only promote fluid loss, but also __ __ or __. These meds are used for: (2)

electrolyte reabsorption; loss
1. Treating patients for HTN
2. Treating patients for Heart Failure

99

Loop diuretics such as __ diurese (or __ __) by inhibiting __ and __ reabsorption from the __ of __ in the kidneys. The also inhibit __ and __ reabsorption

Lasix; remove fluid; Na; Cl; Loop; Henle; magnesium; calcium

100

Thiazine diuretics like __ diurese by inhibiting __ and __ reabsorption from the __ __ __ in the kidneys; they also increase __ __ at the distal tubule.

HCTZ ; Na; Cl; distal convoluted tubules ; calcium reabsorption

101

Potassium-sparing diuretics like __ are competitive antagonists for __. Stimulation of the __/__ exchange in the __ __ of the kidneys does not occur. Because of this, patients on aldactone lose a lot of fluid but retain or reabsorb __ as well as prevents reabsorption of __.

Aldactone; aldosterone

Na/K; collection tubules

K; Na

102

Clinical manifestations of hypovolemia might not be present until ~ __ to __% of volume is lost

10-20%

103

Hypovolemia can be recognized by ___. This is b/c when the body loses a lot of fluid, the heart is trying to compensate for the decreased cardiac output by __ __.

tachycardia

working harder

104

Someone who has lost a lot of blood or fluid could also have a __ __ __.

lower blood pressure

105

The absence of perfusion can be assessed by skin signs such as __ __ __. If it's the case of a lot of blood loss, this person will also be __. Other sx that you might see in someone who is hypovolemic could be:
1.)
2.)

poor skin turgor
pale
1.) lightheadedness
2.) dizziness/feeling faint

106

B/c a person who is hypovolemic have low blood volume, the kidneys are not adequately perfused so they have a __ __ __ which is called __.

low urine output; oliguria

107

If someone is hypovolemic b/c of blood loss, we can look at labs which show that there is a low __ consisting of a __ __ and __ ___. The patient may also feel __ and __ __.

RBC; low hemoglobin; low hematocrit; nauseated; very thirsty

108

Another clinical manifestation of hypovolemia is __ __ __
One liter of fluid weighs __ __. So if a person loses __ __ or __ __ in a 24-hour period, that means they have excreted one liter of fluid or lost it through another abnormal route such as __ or __ from a __.

substantial weight loss

one kg
2.2 lbs
suctioning; drains; wound

109

Third spacing = fluid shifting from the __ __ to the __ __ . This occurs patients with __ __ , __ or __ __ in the __ __.

intravascular space; interstitial space
liver failure; ascites; increased fluid; peritoneal space

110

We treat hypovolemia by correcting the __ __
If it's decreased intake in __ __, we can replace both water and electrolytes with __ fluid such as:
(2)

underlying cause
PO fluid; isotonic ;
Normal Saline
Lactated Ringer's

111

If the hypovolemia is a result of hemorrhage, we can give __ __ like __ __.

blood products; packed RBCs

112

The important thing for us to remember is to monitor our patient's __ and __ as we measure their __ __

intake; output; daily weight

113

Patients with hypovolemia are known to have ___, or decreased urine output. As we are replacing fluids, we want to make sure they have an adequate urine output. We also want to make sure that they are not __ __. It is important to __ __ __.

oliguria; retaining fluids; weigh them daily

114

Maintain safety. Someone who is hypovolemic may be __ or __ so we have to put them on __ __ if they have a change in __ __.

lightheaded; confused; fall precautions; neural status

115

Someone who is hypovolemic will have a __ __ __ and __ __ __.

decreased skin turgor; dry mucous membranes

116

Dehydration is the

insufficient body fluid resulting from inadequate intake, excessive loss of fluids, a combination of both, or fluid shift between compartments

117

In dehydration, loss is more common and affects the __ compartment first

extracellular

118

Water can shift ___ the extracellular compartments. For example: If fluid is lost from the __ __ b/c of vomiting, water shifts from the __ ___ in to the __ __ to replace the loss of __. If the deficit continues, eventually fluid is lost from the __ impairing __ __.

within; digestive tract; vascular compartment ; digestive tract ; secretions; cells; cell functions

119

Dehydration: Mild deficit:

a decrease of 2% in body weight

120

Dehydration: Moderate deficit:

5% weight loss

121

Dehydration: Severe deficit:

8% of > weight loss

122

Clinical Manifestations: Initially, dehydration involves a decrease in __ and __ __. These losses may produce direct effects such as:
(9)

interstitial; intravascular fluids

1. Dry mucous membranes in the mouth
2. decreased skin turgor or elasticity
3. Low BP
4. Weak Pulse
5. Feeling Fatigue
6. Increased HCT (hematocrit) indicating a higher proportion of RBCs compared to the amount of water in the blood
7. prolonged capillary refill time
8. decreased or absent tears
9. depressed fontanel for neonates/infants

123

As brain cells continuously lose water and friction, what occurs? (3)

1. Decreased mental function
2. confusion
3. Loss of consciousness

124

In dehydration, he body attempts to compensate for fluid loss by:

1. increasing thirst
2. increasing HR
3. constricting the cutaneous blood vessels which leads to pale and cool skin
4. the body produces less urine, less concentrated urine increasing the specific gravity as a result of renal vasoconstriction
5. increase secretions of ADH and aldosterone

125

Alcohol consumption is important to ask when asking questions about PO intake b/c alcohol causes __ __ __.

increased fluid loss

126

On physical examination, we will see __ __ __ in the mouth and decreased __ __. Looking at the lab analysis for someone who is dehydrated, we want to check their __ as well as their __ ( __ __ __) and __. The __ and __ really gives us a view into how their kidneys are working. We can also look at __ __ __ , which will be elevated as urine is concentrated and has low water.

dry mucous membranes; skin turgor; electrolytes; BUN; blood urea nitrogen; creatinine;

BUN; creatinine; urine specific gravity

127

BUN : the __ produces urea as a waste product of the digestion of protein. BUN is an indication of renal health.
Normal ranges:

liver;

1.8-7.1 mmol/L

128

The main causes of an increase in BUN are: (7)

1. High protein diet
2. Decrease in Glomerular Filtration Rate (GFR) suggestive of renal failure
3. Decrease in blood volume (hypovolemia)
4. Congestive heart failure (CHF)
5. Gastrointestinal hemorrhage
6. Fever
7. Increased catabolism

129

Creatinine: Serum creatinine is an important indicator of renal health b/c it is an easily measured byproduct of __ __ that is excreted unchanged by the __.

muscle metabolism; kidneys

130

The body excretes waste molecules via urination and the role of the kidney is to concentrate the urine, such that waste molecules can be excreted with __ __ of __ and __. The concentration of the excreted molecules determines the urine's __ __.

minimal loss; water; nutrients

specific gravity

131

Adults generally have a specific gravity in the range of ___ to ___.

1.000 to 1.030

132

Increases in specific gravity (increased __ of solutes in the __) may be associated with: (7)

concentration; urine

1. Dehydration
2. Diarrhea
3. Emesis
4. Excessive sweating
5. Urinary tract/ bladder infection
6. Decreased blood flow to the kidney (especially as a result of heart failure)
7. Excess of antidiuretic hormone caused by Syndrome of Inappropriate Antidiuretic Hormone

133

Specific Gravity > ___ is consistent with frank dehydration. Hypovolemic patient usually have a specific gravity > ___.

1.035

1.015

134

Dehydration is a more serious problem for __ and __.
For infants, they experience greater insensible water loss through rapid respirations and have an increase need for water owing to their __ __ __. The __ __ is rapidly depleted in an infant affecting not only the __ and __, but also the __. This is indicated by:
1.)
2.)
3.)

infants/elderly

high metabolic rate

vascular compartment

heart/brain

kidneys

1. decreased urine output
2. increased lethargy
3. dry mucous membranes

135

Electrolyte losses can influence water balance significantly b/c electrolyte changes lead to __ __ change between compartments We can do this via __ __ such as having them drink water or things like __ if we are looking at a child who is sick and who is __ excessively. We can also treat dehydration with __ __ such as __ __ or __ __ and give electrolytes such as __ or __ which we can __

osmotic pressure

oral rehydration; Pedialyte ; vomiting

intravenous fluids; normal saline; lactated ringer's; K ; Mg ; intravenously

136

Isotonic dehydration

refers to a proportionate loss of fluid and electrolytes

137

Hypotonic dehydration

Loss of more electrolytes than water

138

Hypertonic dehydration

Loss of more water than electrolytes

139

B/c isotonic dehydration refers to a proportionate loss of fluid and electrolytes, serum electrolytes stay in a __ __.

normal range

140

Causes of isotonic dehydration include: (5)

1. Fasting
2. Diarrhea
3. Vomiting
4. Burns
5. Hemorrhage

141

Clinical manifestations of isotonic dehydration: (5)

1. dry mucous membranes
2. oliguria
3. dry skin
4. impaired skin integrity
5. other sx of hypovolemia (tachycardia, hypotension)

142

Ways we can treat isotonic dehydration: (3)

1. Administer normal saline
2. Administer lactated Ringer's
3. Administer oral hydration

143

Hypertonic Dehydration: refers to a loss of more __ than __. Therefore, serum electrolytes will be __.

fluid; electrolytes
elevated

144

Causes of hypertonic dehydration:

1. Having extended fever
2. Diabetes insipidus - lose a lot of fluid via urination
3. diabetes mellitus
4. reduced fluid intake

145

Clinical manifestations of hypertonic dehydration: signs of ______ including:
(5)

Signs of hypernatremia including:
1. thirst
2. lethargy
3. agitation
4. seizures
5. coma

146

Treatment for hypertonic dehydration:
GIVING __ __ such as (3).

HYPOTONIC solutions
1. .45 normal saline
2. .25 normal saline
3. D5W (Dextrose in water)

147

With diabetes insipidus (DI), there is a reduction in the release or action of __. __ is responsible for the _ of water.

ADH; ADH; reabsorption

148

Causes of DI include:

1. CNS disorders (e.g., brain tumors, head injury, infection)
2. Kidney Damage
3. Medications (Lithium)

149

In DI, the __ __ and the __ __ do not appropriately reabsorb water. This leads to: (4)

renal tubules; collecting ducts;
1. decreased water reabsorption
2. increased urine output
3. increased serum osmolality
4. sx of dehydration and hypernatremia

150

What can cause hypotonic dehydration? (3)

1. Addison's disease
2. Overuse of diuretics
3. Marathons & other long strenuous activities where H20 is the only intake (no electrolyte intake)

151

Clinical manifestations of hypotonic dehydration: (3)

1. confusion
2. Possible sz/ coma
3. N/V

152

Treatments of hypotonic dehydration:

1. Giving hypertonic fluids such as 3% NaCl
2. Administering Hypertonic fluids

153

Hypervolemia, or extracellular fluid excess, has no change in __. It's an __ fluid gain with an excess of __ and __

osmolality
isotonic
water/ sodium

154

Causes of hypervolemia: (5)

1. Chronic renal failure, acute glomerulonephritis (the kidneys are not functioning the way they normally should. B/c of this, they're not excreting enough urine and water is retained)
2. CHF (the heart fails to pump blood throughout the body the way it should therefore fluid is retained)
3. Liver failure, Cirrhosis
4. Hormone imbalances ( Cushing's disease, hyperaldosteronism, corticosteroid therapy) As previously discussed, steroids cause water reabsorption.
5. In addition, if someone has excess fluid intake either PO or increased IV infusions of isotonic solutions such as normal saline, they are also at risk for hypervolemia

155

Clinical manifestations of hypervolemia:
1.)
2.)

1. Edema
2. Circulatory Overload

156

Clinical manifestations of hypervolemia: Edema:
This can be seen in the __ or as manifested by __ __ or __ __ which we see in pts with __

extremities; pulmonary edema; pulmonary congestion; CHF

157

Circulatory Overload can be manifested by __ __, __ __ __ (__) and elevated __

bounding pulses; jugular vein distention (JVD),
BP

158

Treatment for a pt with hypervolemia: treat the __ __! For example, a pt with chronic renal failure would be under __ to remove the excess fluid
If we have a pt with CHF, we can give __ such as __ in order to increase __ __ of __.
We can also implement __ __. Typically in CHF pts they have a _ L __ __ a day.

underlying cause; dialysis

diuretics; Lasix; urinary excretion; water

fluid restriction; 1 L fluid restriction

159

Nursing interventions of hypervolemia: (3)

1. monitor intake/output - weigh patients daily
2. monitor respiratory status (pt with hypervolemia/pulmonary edema will have dyspnea/SOB)
3. monitor skin and mucous membrane

160

we can look at overhydation as being:
(3)

1. isoosomostic
2. hyperosomotic
3. hypotonic

161

Isoosmotic Overhydation:

Over hydration either orally or via IV with isotonic solution; can lead to edema

162

Hyperosmotic Overhydration:

Over-administration of IV or oral hypertonic solution; leads to fluid shifts in the vasculature;
Causes increased plasma volume; decreased intracellular fluid
This can cause increase in BP causing hypertensive crisis

163

Hypotonic Overhydration:

Caused by Syndrome of Inappropriate ADH (SIAHD) or ingestion of a large volume of water which causes hyponatremia
This can lead to death due to hyponatremia and CNS disturbance

164

With SIADH, there is an __ of __.

overproduction; ADH

165

SIADH is caused by:

1. CNS disorders (brain tumors, head injury, stroke)
2. Malignancies (small cell lung cancer)
3. Medications (thiazides, TCA, Opioids

166

SIADH leads to: (4)

1. Dilutional hyponatremia and decreased serum osmolality
2. there is a decrease in plasma osmolality below the normal volume and increase in urine
3. this leads to water retention and decreased urine output
4. sx of fluid overload and hyponatremia

167

Edema is the excessive amount of fluid in the __ __ which causes __ of the tissues

interstitial compartment

swelling

168

What are the 4 main causes of edema?

1. Increased capillary hydrostatic pressure
2. loss of plasma proteins
3. obstruction of lymphatic circulation
4. increased capillary permeability

169

Edema d/t increased capillary hydrostatic pressure:
Prevents the turn of blood from the __ __ to the __ __ of the capillary OR
forces an excessive amount of fluid __ of the capillary __ the tissues

interstitial compartment; venous end

out; into

170

An example of increased capillary hydrostatic pressure d/t forcing an excessive amount of fluid out of the capillary into the tissues

pulmonary edema

171

Specific causes of edema related to increased hydrostatic pressure include:

increased blood volume associated with:
1. kidney failure
2. pregnancy
3. CHF
4. Administration of excessive fluids

172

Edema d/t loss of plasma proteins:
Particularly __ which results in the decrease in plasma __ pressure.
The presence of fewer plasma proteins allows more fluid to __ the capillary and less fluid to __ to the __ end of the capillary. This can occur in pts with __ __ or __ __.
__ levels may drop acutely in __ patients who may have large areas of __ __

albumin; osmotic

leave; return ; venous

kidney disease; liver disease

Protein; burn; burned skin

173

Edema d/t obstruction of lymphatic circulation: such an obstruction usually causes a __ edema b/c excessive fluid and proteins are not returned to the __ __. This situation may develop if a __ or __ damages a __ __

localized; general circulation;
tumor; infection; lymph node

174

Edema d/t increased capillary permeability: this causes __ edema and may result from an __ __ or __;
__ and other chemical mediators like __ are released from cells following tissue injury causing increased capillary permeability and increased __ __ into the __ area. __ also leaks into the __ compartment, increasing the __ pressure in the interstitial fluid thus holding more fluid in the interstitial area

localized; inflammatory response; infection
Histamine; bradykinin
fluid movement;
interstitial;
Proteins;
interstitial;
osmotic

175

With edema, there can be functional impairment such as (3) :

1. restriction of joint movement
2. reduced vital capacity
3. impaired diastole

176

Reasons for pain associated with edema (3)

1. edma exerts pressure on nerves locally
2. headache with cerebral edema
3. stretching of capsule in organs (kidney, liver)

177

Edema causes impaired __ __. __ leads to tissue breakdown

arterial circulation
ischemia

178

If someone who has __ edema, for example b/c of trauma or dental work, dentures may not fit well or it may be difficult to __ __ __.

oral

take accurate impressions

179

Edema on skin: the swollen area is very susceptible to __ __ b/c of the __ __.

tissue breakdown
increased pressure

180

Third-spacing is when fluid shifts __ of the blood and __ the body cavity/tissue. Examples: (4)

The fluid is __ __ __ as circulating fluid volume

Simply __ the patient will not reflect this shift and fluid distribution (vascular compartment -> interstitial space)

out; into
1. pt with liver failure who has ascites
2. increased fluid in abdominal cavity
3. Peritonitis: inflammation/infection of the peritoneal membrane
4. burns

no longer available

weighing

181

Most clinically important electrolytes include:

Na+, K+, Ca+ Mg+ PO4-, Cl-

182

Extracellular fluid comprises __ of total body fluid. It can be broken down into: (3)

1/3

1. Intravascular fluid such as blood
2. Transcellular fluid such as CSF
3. Interstitial fluid such as those surrounding the cells

183

Primary electrolytes found in ECF include: (3)

Na, Cl, Ca

184

Intracellular fluid = __ body fluids in adults and contains:
(4)

2/3

O2, K, Mg, Glucose

185

Sodium is the primary extracellular fluid cation (over__). Diffusion of Na occurs between the vascular and interstitial fluids. Na transport across the cell membrane are controlled by the Na/K pump or __ ___ resulting in Na levels high outside the cell and low inside the cell.

90%

active transport

186

Na is actively secreted into __ and other body secretions. It exists in the body primarily in the form of __ and ___.

mucus

salt (NaCl) and sodium bicarbonate

187

Na is lost from:

perspiration/ urine/ feces

188

Levels of sodium are controlled primarily by kidneys through the action of ____

aldosterone

189

Sodium levels are essential in the (5):

1. acid-base balance (sodium bicarbonate & sodium phosphate)
2. osmotic forces
3. conduction of nerve impulses
4. muscle contractions
5. cellular chemical reactions and membrane transport

190

Alterations in Na result in __ __.

CNS manifestations

191

Hyponatremia causes: (3)

1. Direct loss of Na from the body (vomiting/ diarrhea)
2. Diuretic Use
3. Excess of water in the extracellular compartment such as with inappropriate administration of hypotonic IV fluids and SIADH which leads to dilution of Na

192

Clinical Manifestations of Hyponatremia: (4)


If it is due to sodium loss: sx/signs include: (3)

If it is due to dilutional hyponatremia, what for s/s of __.

REMEMBER NEUROLOGIC
1. lethargy
2. confusion
3. sz
4. coma

1. lightheadedness
2. increased thirst
3. decreased urine output

OVERLOAD

193

Treatment for hyponatremia: (2)

1. give them salt tabs or hypertonic solution like 3& NS
2. Restric water

194

Causes of Hypernatremia: (4)

1. Water deficiency
2. A deficiency in the synthesis or release of ADH such as diabetes insipidus or excess Na intake and inadequate water intake
3. Inappropriate administration of hypertonic IVFs
4. Cushing Disease/Syndrome: Increased secretion of ACTH (adenocorticotropic hormone) from the anterior pituitary (secondary hypercortisolism). This is most often as a result of a pituitary adenoma (specifically pituitary basophilism) or due to excess production of hypothalamus CRH (Corticotropin releasing hormone) that stimulates the synthesis of cortisol by the adrenal glands

195

Clinical Manifestations of hypernatremia:

1. neurologic sx - decreased LOC, confusion, sz, and coma
2. if due to sodium gain, think of fluid overload
3. if due to net water loss, think of hypovolemia - such as thirst, lethargy agitation and impaired level of consciousness

196

Treatment of hypernatremia: (2)

1. Restrict Na
2. Replete volume so we can give hypotonic solutions to treat the hypovolemia and draw more Na to the cell

197

K is ingested in foods and excreted out of urine under the influence of ___

Aldosterone

198

Foods high in K:

bananas, citrus fruits, tomatoes, lentils

199

The hormone __ promotes movements of __ into the cells

insulin; K

200

K is important in __ __ and __ of all muscle types especially __ __

nerve conduction/ contractions; cardiac muscles

201

Abnormal K levels both high and low have a significant and serious effect on the contractions of __ __ causing changes in __ .

cardiac muscles; EKGs

202

Acidosis shifts _ ions __ of the cells and into the __ fluid where it doesn't belong

K; out; extracellular

203

Alkalosis tends to move more _ ions _ the cells

K; into

204

With acidosis, many H ions diffuse from the blood into the interstitial fluid b/c of the high hydrogen ion concentration in the blood. When these H ions move into the cell, they __ __ out of the cell to maintain electrochemical __. Then the excess K ions in the interstitial fluid diffuse into the blood leading to __. The reverse occurs with alkalosis.

displace K ions

neutrality

hyperkalemia

205

Acidosis also promotes H ion __ by the kidneys and __ of K to the body

excretion; retention

206

Essential fxns of K (3)

1. transmission and conduction of nerve impulses
2. normal cardiac rhythms
3. skeletal and smooth muscle contractions

207

Changes in pH affect K+ balance: H ions accumulate in the ___ during state of acidosis.
K+ shifts __ to maintain a balance of cations across the membrane

ICF

out

208

Causes of hypokalemia: (10)

1. Reduced intake of K
2. Low K Diet
3. Abnormal loss via the kidneys/GI tract especially from v/d
4. Magnesium deficiency
5. Treatment of DKA
6. Cushing Syndrome
7. Alcoholism
8. Malnutrition
9. Diuretics use
10. Metabolic alkalosis

209

Hypokalemia cause: Treatment of DKA: __ plays a role in K going into and out of the cell; DKA is treated with insulin b/c of __ __ in the blood; Not only does glucose goes into the cell, __ also goes into the cell, creating less __ or __ in the extracellular space.

insulin

high glucose; K

K; hypokalemia

210

Hypokalemia - Clinical Manifestations (7)

1. Bradycardia
2. Skeletal muscle weakness
3. Weakness of respiratory muscles
4. Decreased GI motility
5. Impaired regulation of arterial blood flow
Severe Manifestations
6. Shallow respirations from the weakness of the respiratory muscles
7. Polyuria

211

Treatment - Hypokalemia (3)

1. We can give IV or oral K
2. KCL supplements orally or IV have a great impact on absorption
3. We can also use K sparing diuretics such as Aldactone or increase the dietary K

212

Hyperkalemia - caused by: (12)

1. increase intake of K such as with IV supplementation, herbal supplementation, or increase in the diet high in K
2. shift of K from the intracellular space to the extracellular space
3. metabolic acidosis
4. Decreased renal excretion and you see this in pts with renal failure
5. Insulin deficiency
6. Cell trauma
7. Multiple transfusions
8. Pt on medications such as digoxin, ACE inhibitors, potassium sparing diuretics such as Aldactone
9. Traumatic injuries, burns
10. Renal failure
11. Hyperglycemia
12. Aldosterone deficit (Addison’s disease)

213

Hyperkalemia: caused by aldosterone deficit: ADDISON'S DISEASE ->

rare, chronic endocrine system disorder in which the adrenal glands do not produce sufficient steroid hormones (glucocorticoids and mineralocorticoids)

214

Clinical manifestations of hyperkalemia: (10)

1. Tingling of lips and fingers
2. Restlessness
3. Intestinal cramping
4. Diarrhea
5. Increased neuromuscular irritability
o With severe attacks you can have
6. Muscle weakness
7. Loss of muscle tone
8. Flaccid paralysis
9. Cardiac dysrhythmias
10. Respiratory arrest

215

Treatment of hyperkalemia: (5)

1. D50 plus insulin to bring more K to the cell (transient (short) therapy for urgent hyperkalemia)
2. IV calcium with bring more K to the cell
3. Kaexalate- promote K to be excreted in the stool, but it causes diarrhea
4. Sodium Bicarbonate- potassium moves into the cells (transient therapy for urgent hyperkalemia)
5. Diuretics

216

Calcium balance: controlled by: __ ___ and __ but also influenced by Vitamin __ and __ ion levels

parathyroid hormone; calcitonin; D; phosphate

217

__ blood calcium levels stimulate the secretion of parathyroid hormone which increases calcium absorption from the __ ___, ___ and promotes reabsorption from ___

low

digestive tract, kidneys, bone

218

Vitamin D may be __ or __ in the skin in the presence of __ __ such as the sun; then must be activated by the __.

ingested; synthesized; UV rays; kidneys

219

Vitamin D promotes __ __ from the __ and __ in the blood

calcium movement; bone; intestines

220

Calcium and phosphate ions in the ECF have a ___ relationship
Ex: If calcium is high, phosphate is __.
The product of calcium and phosphate concentration should be a ___ ___

reciprocal; low
constant volume

221

Calcium is essential for: (4)

1. Structures of bones and teeth
2. Blood clotting
3. Hormone secretion
4. Cell receptor function

222

99% of calcium is located in the bone as ___ with balance controlled by parathyroid hormone and calcitonin

hydroxyapatite

223

Clinical Manifestations- Hypocalcemia (7)

1. Muscle cramps
2. Hyperactive reflexes
3. Hyperactive bowel sounds
4. Paresthesias
5. Positive Chvostek and Trousseau sign
6. Delayed heart conduction
7. Remember increased neuromuscular excitability

224

The effects of hypocalcemia on cardiac and skeletal muscle differs-

Skeletal muscle spasm:

Weaker Contraction of Cardiac muscle spasm:

results from the increased irritability of the nerves associated with muscle fibers


directly related to the calcium deficit

225

Adequate calcium is __ __ skeletal muscle cells to provide for contractions;
contractions of cardiac muscle relies on available __ __ __passing through the calcium channels. This is the basis for the action of cardiac drugs known as __ __ __.

stored in

extracellular calcium ions

calcium channel blockers

226

Treatment for hypocalcemia:

1. Give oral or IV calcium
2. Important to treat the underlying cause

227

Hypercalcemia is a warning sing of __

cancer

228

Causes of hypercalcemia:

o Hyperparathyroidism which occurs in 2/3 of cases
o Increased intake of calcium such as with calcium supplements or diets high in calcium
o Vitamin D overdose
o Prolonged demobilization
o Thiazide Diuretics like HCTZ
♣ Malignancy
♣ Hypophosphatemia
♣ Thyrotoxicosis
♣ Pheochromocytoma

229

clinical manifestations of hypercalcemia

o Muscle weakness
o Hypoactive reflexes
o Tingling (around the mouth)
o Intestinal cramping
o Hypoactive bowel sounds
Constipation
6. cardiac arrest
7. lethargy

230

In hypercalcemia there is __ neuromuscular excitability

DECREASED

231

Treatment of hypercalcemia

o Hydrate to reduce instance of developing calcium stones
o Calcitonin and biphosphanates to bring down the calcium levels
o Excretion of calcium with loop diuretics and giving isotonic saline and infusions

232

__ % of total body magnesium is stored in the bone

50%

233

Magnesium serum levels are leaked to both _ and __ levels

K ; calcium

234

Magnesium is found in (6) and is important in many __ __, __ __ and __ __.

green vegetables, nuts, bananas, oranges, peanut butter, chocolate ;
enzyme reactions
protein synthesis
DNA synthesis

235

Hypomagnesemia is caused by:

o results from malabsorption or malnutrition often associated with chronic alcoholism
o low serum levels may occur with loop diuretics
o diabetic ketoacidosis
o hyperparathyroidism
o hyperaldosteronism
o Renal dysfunction
o Hyperthyroidism

236

Clinical manifestations hypomagnesemia:

o Neuromuscular hyperirritability
♣ Tremors
♣ Involuntary repetitive movements
♣ Insomnia
♣ Personality changes
♣ Increased heart rate with arrhythmias

237

Treatment of hypomagnesemia

o IV Magnesium replacement

238

People with __ __ __ should not take magnesium containing drugs and should check for all over the counter drug labels for magnesium content

chronic kidney disease

239

Hypermagnesemia occurs with:

o Occurs with renal failure
o Occurs with excess ingestion of magnesium containing antacids such as milk or magnesia or maalox

240

Hypermagnesemia- clinical manifestations

o Depresses neuromuscular function
♣ Decreased reflexes
♣ Lethargy
♣ Muscle weakness
♣ Respiratory depression
♣ Cardiac arrhythmias

241

Hypermagnesemia treatment:

1. stop intake
2. pt may need dialysis

242

Phosphate is located primarily in the __, but also circulate in the __ and __. It is important in ___ (__).
Seen in __ and __ __

bone; ICF; ECF

metabolism (ATP)

bone; tooth mineralization

243

__ __ __ = acid-base balance

phosphate buffer system

244

Phosphate has a __ relationship with calcium
__ calcium __ phosphate; vice versa

reciprocal
high; low

245

Hypophosphatemia may result from:

o Malabsorption syndromes
o Diarrhea
o excessive use of antacids
o alkalosis
o hyperparathyroidism
o neurologic function
♣ tremors
♣ hyporeflexia
♣ paresthesia
♣ confusion
♣ anorexia
♣ difficulty in swallowing

246

Hyperphosphatemia is caused by:

renal failure

247

Chloride ions tend to follow __ b/c of the attraction of the __ __ on the ions

sodium

electrical charge

248

High Na levels = __ Cl levels

High

249

Chloride and __ ions which are both negatively charged can exchange places as the blood circulates through the body in order to maintain and assist in acid-base balance

bicarbonate

250

As bicarbonate ions are used up in binding up with metabolic acids, __ ions diffuse __ of RBCs into the serum to maintain the __ __ ions in the blood.
The reverse can occur when serum levels of Cl decrease and bicarb ions:

Cl; out
same negative

leave their RBCs to maintain electrical neutrality`

251

Low serum chloride leads to high serum bicarbonate or __ = __ shift

alkalosis; chloride

252

Low serum chloride is usually associated with alkalosis in the early stages of:

vomiting when hydrochloric acid is lost from the stomach

253

causes of hyperchloremia:

1. Excess chloride ions may develop with the excessive intake of sodium chloride orally or IV
2. Hypernatremia due to other causes leading to edema and weight gain