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What is HYPOVOLEMIA

FVD or HYPOVOLEMIA occurs when loss of ECF volume exceeds the intake of fluid.

1

What is a lab test useful in determining a persons fluid volume status

BUN and its relation to serum creatine concentration.

A volume depleted person has a BUN elevated out of proportion to serum creatine. Ratio 20:1

The HCT level is also greater than normal because there is a decreased plasma volume.
Urine specific gravity is increased in relation to the kidneys attempt to conserve water

2

Why can a BUN be elevated

It can be elevated because of dehydration or decreased renal perfusion and function

3

When does hypokalemia occur

HYPOKALEMIA occurs with GI & renal losses

4

Hyperkalemia results from what

Adrenal insufficiency

5

When does hyponatremia occur

It occurs with increased thirst and ADH release.

6

What does hypernatremia result from

Hypernatremia results from increased insensible losses and diabetes insipidus

7

When is urine specific gravity decreased

With diabetes insipidus

8

What is secreted when fluid volume is low

Aldosterone is secreted when fluid volume is low causing reabsorption of sodium and chloride.
Urine osmolality can be greater than 450 because the kidneys try to compensate by conserving water.

9

For a person with fluid volume deficit,what type of fluids will be administered

Isotonic electrolyte solutions ( lactate ringers, 0.9% sodium chloride)
Are 1st line of choice to treat the hypotensive person with FVD because they expand plasma volume.
As soon as the person becomes normotensive, a hypotonic solution ( 0.45% sodium chloride) is often used to provide both electrolytes and water for renal excretion of metabolic wastes.

10

What assessments should be done to determine when therapy should be slowed to avoid fluid volume overload.

Accurate and frequent assessments of I&O, weight, vital signs, central venous pressure,LOC,breath sounds and skin color

11

What are contributing factors to fluid volume deficit

Loss of water and electrolytes from vomiting, diarrhea, fistulas, excessive sweating,burns, blood loss, GI suction, 3rd space fluid shifts, decreased intake

Uncontrolled Diabetes and diabetes insipidus both contribute to depletion of extra cellular fluid volume.

12

What are signs symptoms and of a person with FVD

Acute weight loss, decreased skin turgor, oliguria, concentrated urine, capillary filling prolonged, low CVP, low BP, flattened neck veins, dizziness, weakness, thirst and confusion. Increased pulse, muscle cramps,sunken eyes, nausea, increased temp,cool clammy pale skin.

13

What lab values are indicative of FVD

Increased HGB, HCT
increased serum and osmolality and specific gravity
Increased BUN and creatine

Decreased urine sodium

14

What are contributing factors of fluid volume excess

Compromised regulatory mechanisms such as renal failure heart failure and cirrhosis
Overzealous administration of sodium containing fluids
Fluid shifts in other words treatment of burns
Prolonged corticosteroid therapy severe stress and hyper aldosteronism augment fluid volume excess

15

What are signs and symptoms of hypervolemia

Acute weight gain peripheral Edema and ascites
Distended jugular vein crackles elevated CVP shortness of breath and increased blood pressure bounding pulses and cough increased respiratory rate increase urine output

16

What lab values are in the indicative of hypervolemia

Decreased hemoglobin and hematocrit
Decreased serum and urine osmolality
Decreased urine sodium and specific gravity

17

What are contributing factors of sodium deficit
(Hyponatremia levels less than 135)

Loss of sodium as the use of the Diuretics,loss of G I fluids renal disease adrenal insufficiency gain of water as an excess of the ministration of D5W and water supplements for patients receiving hypotonic tube feedings
Disease states associated with SIADH such as head trauma and oat cell lung tumor.
Meds associated with water retention such as oxytocin and certain tranquilizers and psychogenic polydipsia
Hyperglycemia and heart failure can cause a loss of sodium

18

What are signs and symptoms of hyponatremia

Anorexia,nausea,and vomiting,headache lethargy,dizziness,confusion muscle cramps,weakness,muscular twitching,seizures,papilledema Dry skin, increased pulse,decreased blood pressure, weight gain,edema

19

What labs are indicative of hyponatremia

Decreased serum and urine sodium,
decreased urine specific gravity and osmolality

20

What are contributing factors to hypernatremia

Water deprivation inpatients unable to drink
Hypertonic two feedings without adequate water supplements
diabetes insipidus,heatstroke,hyperventilation,watery diarrhea,burns and diaphoresis
Excess corticosteroids sodium by carbonate and sodium chloride administration saltwater in near drowning victims

21

What are signs and symptoms of hypernatremia
Levels greater than 145

Thirst elevated body temperature swollen dry tongue sticky mucous membranes hallucinations lethargy restlessness irritability simple partial or tonic clonic seizures pulmonary edema hyperreflexia twitching nausea vomiting and anorexia increased pulse and blood pressure

22

What are contributing factors of hypokalemia
Levels less than 3.5

Diarrhea,vomiting,gastric suctioning,corticosteroid administration hyperaldosteronism,carbenicillin,amphotericin B, bulimia,osmotic diuresis,alkalosis,starvation,diuretics and digoxin and toxicity

23

What are contributing factors of hyperkalemia

Pseudo hyperkalemia,oliguric renal failure,use of potassium sparing diuretics,metabolic acidosis,Addison's disease,crush injury, burns,stored bank blood transfusions,rapid the administration of potassium,medications such as ACE INHIBITORS, NSAIDS, CYCLOSPORINE

24

What are signs and symptoms of hyperkalemia

Muscle weakness, tachycardia, bradycardia, dysrhythmias, flaccid paralysis, paresthesia, intestinal colic, cramps, abdominal distention,irritability, anxiety prolonged PR interval and QRS duration absent P waves, ST depression

25

What are calcium levels

8.5-10.5

26

What are contributing factors of hypocalcemia levels less than 8.5

Hi both parathyroidism (May follow thyroid surgery or radical neck dissection) malabsorption, pancreatitis, alkalosis, vitamin D deficiency, massivesubcutaneous infection, generalized Peritonitis, massive transfusion of citrated blood, chronic diarrhea, diuretic phase of renal failure, fistula, Burns and alcoholism

27

What are contributing factors of hypercalcemia

Hyper parathyroidism, malignant neoplastic disease, prolonged immobilization, overuse of calcium supplements, vitamin D excess,oliguric phase of renal failure, acidosis, corticosteroid therapy, fire is not diuretic use, digoxin toxicity

28

What are signs and symptoms of hypercalcemia

Muscular weakness,constipation, anorexia, nausea and vomiting, polyuria and polydipsia, dehydration, hypoactive deep tendon reflexes,Lethargy, deep bone pain, pathologic fractures, flank pain, calcium stones, hypertension

29

What are signs and symptoms of hypocalcemia

Numbness,tingling in the fingers and toes, positive Trousseau's sign and chvostek's signs,seizures, carpopedal spasms, hyper active deep tendon reflexes irritability, bronchospasm, anxiety,impair clotting time, decreased prothrombin, diarrhea, decreased BP

30

What will a ECG show for a person with hypocalcemia

Prolonged QT interval are in length and ST

31

What labs indicate hypocalcemia

Decrease magnesium

32

What are safe ranges of magnesium

1.8- 2.7

33

What are contributing factors to magnesium deficit

Chronic alcoholism, hyperparathyroidism, hyperaldosteronism, diuretic phase of renal failure, malabsorption since disorders, diabetic ketoacidosis, Refeeding after starvation, parenteral nutrition, chronic laxative use, diarrhea, acute myocardial infarction, heart failure, decreased potassium and calcium

34

What are signs and symptoms of a magnesium deficit

Neuromuscular irritability,positive Trousseau's sign, and chvostek's sign,insomnia, mood changes, anorexia, vomiting, increased tendon reflexes, and increased blood pressure

35

What will a ECG show of a person with a magnesium deficit

PCVs, flat or innervated T waves, depressed QT SEGMENT, PROLONGED PR IMTERVAL, AMD WIDENED QRS

36

What are contributing factors of hypermagnesemia

Oliguric phase of renal failure particularly when magnesium containing meds are Administered
Adrenal insufficiency
Excess magnesium administration, diabetic ketoacidosis, and hypo thyroidism.

37

What are signs and symptoms of excess magnesium

Flushing, hypotension, muscle weakness, drowsiness, hypo active reflexes, depressed respirations, cardiac arrest and coma, diaphoresis
Prolonged PR IMTERVAL and QRS, peaked T WAVES

38

What are phosphorus levels

2.5-4.5

39

What are contributing factors of hypophosphatemia

Re feeding after starvation
Alcohol withdrawal, diabetic ketoacidosis, respiratory and metabolic alkalosis, Decreased magnesium and potassium, hyper parathyroidism, vomiting,diarrhea, hyperventilation,vitamin D deficiency assoc with malabsorption disorders,mourns, acid base disorders,parenteral nutrition,and diuretic and antacid use.

40

What are signs and symptoms of hyperphophatemia

Tetany, tachycardia, anorexia, nausea and vomiting,muscle weakness, signs of symptoms of hypocalcemia, hyperactive reflexes,soft tissue calcifications In lungs,heart, kidneys and cornea.

41

What are signs and symptoms of hypophosphatemia

Paresthesias, muscle weakness, bone pain, tenderness, chest pain, confusion, cardiomyopathy, respiratory failure,seizures, tissue hypoxia, increased susceptibility to infection, nystagmus.

42

What are contributing factors of phosphorus excess

Acute and chronic renal failure
Excess intake of phosphorus, vitamin D Excess
Respiratory and metabolic acidosis
Loop, osmotic or thiazide diuretic use.
Overuse of bicarbonate
Rapid removal of ascetic fluid with a high sodium content
IV fluids that lack chloride ( dextrose and water)
Draining fistulas and ostomies,HF, cystic fibrosis

43

What are chloride levels

96-108

44

What are contributing factors of excess chloride

Excessive chloride infusions with water loss, head injury ( sodium retention), hypernatremia, renal failure, corticosteroid use, dehydration, sever diarrhea ( loss of bicarbonate) respiratory alkalosis,diuretics, overuse of salicylates, kayexalate, acetazolamide,phenylbutazone, and ammonium chloride use, hyper parathyroidism, and metabolic acidosis.

45

What are signs and symptoms of excess chloride

Tachypnea, lethargy, weakness, deep rapid respirations, decline in cognitive status, decreased cardiac output, dyspnea, tachycardia,pitting edema, dysrhythmias, coma

46

What lab values are indicative of excess chloride

Increased serum chloride,potassium and sodium
Decreased pH
Decreased serum bicarbonate, normal anion gap, increased urinary chloride level.

47

What is treatment of HYPOVOLEMIA

Isotonic fluids such as normal saline.
Give salt if they do not have HF, in which salt would be contraindicated.

48

For fluid depletion what fluids will you give

Isotonic

49

For cellular dehydration what will u give

Hypotonic solutions
Lactated ringers, normal saline
There is no change in osmolality, it increases circulating volume

50

Aldosterone

Increases thirst sensation and retains fluids

51

ADH hormone

As they name states ( ANTIDIURETIC) it retains fluid, urine output will be low and concentrated.

52

For cellular dehydration which occurs secondary to dehydration, what type,of fluids will be ordered

Hypotonic solutions it draws fluids back into the cells.

53

What do hypertonic solutions do

Draws fluids back out of the cell.

54

What is a hypertonic solution

Mannitol

55

For a person experiencing fluid loss what fluids will they be given

Start with NS or Lactated ringers
Do not use d5 1/2 which will push fluid into the cells.

56

What does D5 1/2 do

Push fluid in the cell.

57

What vital signs indicate FVD

Decreased BP, increased HR
The Herat is pumping more to circulate blood thru the body.

58

What happens in Addison's disease

Looses salt, the person must seek salt replenishment

59

What organ can contribute to fluid volume excess

The kidney
Renal impairment can contribute to fluid volume excess due inability to excrete fluids

60

Dialysis

Removes fluids when diuretics are no longer working ( CHF)

61

What normal potassium levels

3.5-5
Above 7 can cause dysrhythmias
Above 8 can cause cardiac arrest

62

When would you not replace a persons potassium

If the person is in end stage renal disease, it will accumulate leading to hyperkalemia

63

What 2 electrolytes go together

Phosphorus bonds with calcium

64

What is therapy for HYPERCALCEMIA

Calcitonin spray ( test for allergies because it is derived from a fish
Alternate nostril each day.

65

For hypocalcemia, what would be a supplement

Vit D Supplementation

66

Increased phosphate levels coincides with what other electrolyte

Calcium
Increased phosphate means decreased calcium
Increased calcium means decreased phosphate