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1

hypervolemia is

fluid volume excess

2

hypovolemia is

fluid volume deficit

3

fluid volume excess: definition

too much fluid in the vascular space

4

how does heart failure lead to fluid volume excess?

heart is WEAK
cardiac output DECREASES
kidney perfusion DECREASES
urine output DECREASES
volume stays in VASCULAR SPACE

5

3 meds that can lead to fluid volume excess and why

alka-seltzer
fleet's enema
IVF with Na

all 3 have a lot of Na

6

hormones that regulate fluid volume

aldosterone
atrial natriuretic peptide
anti-diuretic hormone

7

aldosterone: what and where

steroid (mineralocorticoid) made by the adrenal glands

8

aldosterone: normal action

in response to LOW blood volume (d/t vomiting, hemorrhage, etc) -->aldosterone secretion increases
--> Na + H2O retained
--> blood volume goes up

9

diseases with too much aldosterone x2

Cushing's Syndrome (too much of all electrolytes)
hyperaldosteronism aka Conn's Syndrome

10

disease with too little aldosterone

Addison's Syndrome
( lose Na + H2O = fluid volume deficit )

11

atrial natriuretic peptide: where & action

secreted by atria (in response to stretch due to increased volume)
causes excretion of Na and H2O

12

opposite action from aldosterone

atrial natriuretic peptide -->

13

anti-diuretic hormone: where and action

secreted by pituitary gland
causes retention of H2O (and therefore Na)

14

too much ADH / not enough ADH: diseases x2

too much ADH: SIADH
not enough ADH: diabetes insipidus

15

siadh

syndrome of inappropriate anti-diuretic hormone
TOO MANY LETTERS TOO MUCH H2O

retain H2O --> fluid volume excess
blood: dilute
urine: concentrated

16

diabetes insipidus

DI = DIuresis

lose (diurese) H2O --> fluid volume deficit
blood: concentrated
urine: dilute

THINK: SHOCK

17

see diabetes insipidus, think...

DIuresis
shock!

18

key words to make you think potential ADH problem

craniotomy, head injury, sinus injury, transphenoidal hypophysectomy, any condition leading to ICP

19

other names for ADH

vasopressin
DDAVP

- may be utilized as ADH replacement in DI -

20

hypervolemia s/s: vessels full therefore...

distended neck and peripheral veins

leak --> peripheral edema, third spacing

21

hypervolemia s/s: CVP...

increased

MORE VOLUME MORE PRESSURE

22

hypervolemia s/s: lung sounds

wet
- down low, listen posteriorly at bases

23

hypervolemia s/s: polyuria

kidneys trying to help you diurese

24

hypervolemia s/s: pulse

full and bounding

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hypervolemia s/s: BP

increases

MORE VOLUME MORE PRESSURE

26

hypervolemia s/s: weight

increases

fluid not fat

27

fluid retention think...

heart problems first!

28

hypervolemia: treatments x5

- low Na diet
- restrict fluids
- daily i/o and weights
- diuretics
- bed rest

29

with all diuretics watch...

lab work - potential dehydration and electrolyte problems

30

how does bedrest induce diuresis?

through the release of ANP and decreased production of ADH
- fluid returns to core, heart stretches, ANP produced and pituitary signaled to decrease ADH production

31

why give IVF slowly to the elderly?

this age group goes into fluid volume excess easier

32

why are IVF given during bedrest?

prevent DVT, PE, pneumonia

33

major fluid deficit results in

shock

34

hypovolemia: causes + why

loss of fluids
- thoracentesis, paracentesis, vomiting, diarrhea, hemorrhage

third spacing
- burns, ascites

diseases with polyuria
- polyuria becomes oliguria becomes anuria

35

hypovolemia s/s: weight

decreases

36

hypovolemia s/s: skin turgor

decreased

37

hypovolemia s/s: mucus membranes

dry

38

hypovolemia s/s: urine output + why

decreased
- kidneys aren't being perfused or are trying to retain fluid to compensate

39

hypovolemia s/s: BP

decreased

LESS VOLUME, LESS PRESSURE

40

hypovolemia s/s: pulse

increased and weak and thready - heart is trying to pump what little fluid is left

41

hypovolemia s/s: respirations + why

increased because body perceives decrease in circulating blood volume as hypoxia

42

hypovolemia s/s: CVP

decreased

LESS VOLUME, LESS PRESSURE

43

hypovolemia s/s: peripheral/neck veins

vasoconstrict, very tiny!

44

hypovolemia s/s: extremities + why

cool d/t peripheral vasoconstriction in an effort to shunt blood to vital organs

45

hypovolemia s/s: urine specific gravity

increased - very concentrated

46

hypovolemia treatment x3

prevent further losses
replace volume
safety precautions

47

how do you replace volume with mild hypovolemia?

PO

48

how do you replace volume with severe hypovolemia?

IVF

49

what safety precautions should be taken for hypovolemic patient? x2

fall risk: r/t changes in vitals and mental staus
monitor for fluid overload

50

isotonic solutions: action

goes into vascular space and stays there

51

isotonic solutions: examples

NS, LR, D5W, D5 1/4 NS

52

isotonic solutions: uses x2

for client that needs blood volume
- fluids lost via n/v, burns, sweating, trauma

also, NS is basic solution when administering blood

53

isotonic solutions: in excess can cause x3

fluid volume excess, hypertension, hypernatremia

54

never give isotonic solutions to x3

patients with hypertension, renal disease, cardiac disease

55

hypernatremia is an alert only when administering isotonic solutions...

that contain sodium

56

hypotonic solutions: action

go into vascular space, hang out, shift out into the cells to replace cellular fluids

rehydrate but do not cause hypertension

57

hypotonic solutions: examples

D 2.5 W, 1/2 NS (0.45%), 0.33% NS

58

hypotonic solutions: uses x3

for client who has hypertension, renal, or cardiac disease and needs fluid replacement because of nausea, vomiting, burns, hemorrhage, etc.

also used for dilution when client has hypernatremia and for cellular dehydration

59

hypotonic solutions: alert

watch for cellular edema because this fluid is moving out to the cells which could lead to fluid volume deficit and decrease blood pressure (when used to the extreme)

60

hypertonic solutions: action

packed with particles! volume expanders that draw fluid into the vascular space from the cell

61

hypertonic solutions: examples

D10W, 3% NS, 5% NS, D5LR, D5 1/2NS, D5 NS, TPN, albumin

62

hypertonic solutions: uses

client with hyponatremia or
who has shifted large amounts of vascular volume due to a third space, severe edema, burns, ascites

63

hypertonic solutions: alert

watch for fluid volume excess

monitor in an ICU setting: hourly BP, HR, CVP -- ESPECIALLY for 3% or 5% NS (Na = worry about rapid shifts of fluid)

64

magnesium is excreted by

the kidneys, but can be lost other ways (such as via GI tract)

65

Mg and Ca act like

sedatives

66

see Mg and Ca think...

muscles first!

67

hypermagnesemia: causes x2

renal failures
antacids (in ESRD)

68

hypermagnesemia: s/s

flushing
warmth
vasodilation (decreased BP)

69

hypermagnesemia, hypercalcemia: s/s in common

decreased: DTR, LOC, HR, RR
arrhythmias
weak, flaccid muscle tone

70

hyper Mg or Ca s/s: DTR

decreased

71

hyper Mg or Ca s/s: LOC

decreased

72

hyper Mg or Ca s/s: HR

decreased

73

hyper Mg or Ca s/s: RR

decreased

74

hyper Mg or Ca s/s: heart & muscle

arrhythmias
weak, flaccid muscle tone

75

hypermagnesemia: treatment & why x4

ventilator
- Mg toxic, RR less than 12

dialysis
- kidney excretion

calcium gluconate
- reverses decreased RR and potential arrhythmias

safety precautions

76

Ca, phosphate relationship

inverse!

77

hypercalcemia: causes x3

hyperparathyroidism
thiazides
immobilization

78

PTH and calcium relationship

serum Ca low
PTH secreted and moves Ca from bones into the blood
serum Ca increases

79

how do thiazides cause hypercalcemia?

retention of Ca+

80

how does immobilization cause hypercalcemia?

weight-bearing necessary to keep Ca in bones

81

hypercalcemia: s/s x2

brittle bones, kidney stones

82

hypercalcemia: treatment

-BOOM BOOM
-fluids
-sodium phosphate enema
-steroids
-add phosphorus to diet
-vitamin D
-calcitonin

83

hypercalcemia treatment: fluids purpose

prevent kidney stones

84

hypercalcemia treatment: sodium phosphate enema purpose

Ca and P have an inverse relationship

increase P, Ca goes down!

85

hypercalcemia treatment: steroids purpose

decrease serum Ca

86

hypercalcemia treatment: calcitonin purpose

decreases serum Ca by returning it to the bones
- typically given for osteoporosis

87

hypercalcemia treatment: why safety precautions?

think: SEDATION!

88

hypomagnesemia: causes

diarrhea (lots of Mg in intestines)
alcoholism
- alcohol suppresses ADH & it's hypertonic

89

hypomagnesemia and hypocalcemia s/s

-rigid, tight muscle tone
-seizures
-stridor/laryngospasm
-positive chvostek's
-positive trousseau's
-arrhythmias
-increased DTRs
-AMS (anything)
-dysphagia

90

hypomagnesemia and hypocalcemia s/s: muscle tone

rigid, tight

91

hypomagnesemia and hypocalcemia s/s: stridor and laryngospasms why

smooth muscle

not enough sedative!

92

hypomagnesemia and hypocalcemia s/s: arrhythmias why

heart muscle - not enough sedative

93

hypomagnesemia and hypocalcemia s/s: dysphagia why

smooth muscle

not enough sedative!

94

chvostek's sign

tap cheek = twitch
sign of hypomagnesemia or hypocalcemia

95

trousseau's sign

inflate BP cuff = arm jerks
sign of hypomagnesemia or hypocalcemia

96

hypomagnesemia: treatment

- give Mg
- check kidney function before and after IV Mg (excretion of Mg!)
- seizure precautions
- diet

97

what do you do if client reports flushing and sweating when IV Mag started?

STOP INFUSION!!

98

magnesium effect on vessels

vasodilation

99

hypocalcemia: causes

hypoparathyroidism
radial neck
thyroidectomy

100

not enough PTH =

reduced serum Ca

101

hypocalcemia: treatment

-vitamin D
-phosphate binders
-IV Ca

102

nursing considerations for administration of IV Ca

-give slowly
-telemetry

103

hypocalcemia treatment: why Vitamin D

needed to utilize Ca

104

hypocalcemia treatment: why phosphate binders

because of inverse relationship between Ca and P
- bind PO4 = increase in Ca

105

sodium think...

neurological changes

106

Na level in blood is totally dependent on

how much water you have in your body.

107

hypernatremia

= dehydration; too much Na, not enough H2O

108

hypernatremia: causes x4

hyperventilation
heat stroke
diabetes insipidus
vomiting, diarrhea, etc

109

hypernatremia: s/s x3

dry mouth
thirst
swollen tongue

110

significance of thirst and hypernatremia

you are already dehydrated by the time you are thirsty

111

swollen tongue

sign that is very specific to hypernatremia

112

hypernatremia: treatment

-restrict Na
-dilute client with fluids (DILUTION MAKES #s GO DOWN)
-daily weight
-i/o
-lab work

113

if you've got an Na problem...

you've got a fluid volume problem

114

feeding tube clients to get ? + how to fix?

dehydrated; offset with free water

115

hyponatremia

dilution; too much H2O, not enough Na

116

hyponatremia: causes x4

-drinking H2O for fluid replacement
-psychogenic polydipsia
-D5W
-SIADH

117

hyponatremia: s/s x3

-headache
-seizure
-coma

118

hyponatremia: treatment

CLIENT NEEDS Na CLIENT DOESN'T NEED H2O

neuro problems? need hypertonic saline
- 3% or 5% NS

119

note about saline infusion for hyponatremia

pulling water in vascular space rapidly = beware fluid volume excess
- ICU to monitor HR, BP, CVP

brain cannot handle rapid shifts of volume quickly

120

potassium is excreted by

kidneys
therefore if kidneys are not working well, serum K goes up

121

hyperkalemia: causes

kidney issues
spironolactone

122

hyperkalemia: s/s

in this order:
muscle twitching
weakness
flaccid paralysis

also, life-threatening arrhythmias

123

hyperkalemia: treatment

-dialysis
-calcium gluconate
-glucose and insulin
-Kayexalate

124

hyperkalemia treatment: why dialysis

kidneys aren't functioning

125

hyperkalemia treatment: why calcium gluconate

decreases arrhythmias

126

hyperkalemia treatment: why glucose and insulin

insulin carries GLUCOSE and POTASSIUM into the cell

127

any time you give IV insulin, worry about...

hypoglycemia and hypokalemia

128

Kayexalate

sodium poylystyrene sulfonate
- given for hyperkalemia
- exchanges Na for K in GI tract = VOLUMINOUS DIARRHEA!

129

hypokalemia: causes

-vomiting
-ng suction
-diuretics
-not eating

130

why does ng suction contribute to hypokalemia?

we have a lot of K in our stomachs

131

hypokalemia: s/s

-muscle cramps
-weakness
-life threatening arrhythmias

132

hypokalemia: treatment

-give potassium (CHECK KIDNEY FUNCTION!)
-spironolactone
-diet

133

if you give potassium for hypokalemia...

check kidney function!

134

sodium and potassium relationship

INVERSE!

135

major problem with PO K+?

GI upset, so give with food

136

assess what before/during IV K+

UOP

137

never give IV K+...

BOLUS. always administer ON A PUMP

138

hyperkalemia EKG changes

bradycardia
tall and peaked T waves
prolonged PR intervals
flat or absent P waves
widened QRS
conduction blocks
v fib

139

hypokalemia EKG changes

U waves
PVC
v tach