fluid and electrolyte imbalance, GI bleeds, blood components

Question 1

who is likely to develop fluid volume defect?

Answer 1

older adults b/c decreased muscle mass, increased fat stores, and a reduction in the percentage of body fluids

Question 2

Intracelllular compartment and how fluid gets drawn into the cells

Answer 2

fluid is “inside the cells”

negatively charged ions within the cells attract positiviely charged ions like Na and K which draws fluid into the cells

Question 3

sodium–potassium pump

Answer 3

located in cell membrane
requires ATP for energy to actively move Na from the cell into the ECF and move K into the cell.
water is attracted to Na so if follows Na into the ECF which equals ICF balance

Question 4

what happens hen sodium-pottassium pump fails

Answer 4

Na accumulates inside the cell which causes retention of water inside the cell and accumulation of K outside the cell

Question 5

extracellular compartment

Answer 5

fluid outside the cells
divided into the intravascular fluid (plasma within blood vessels) and transcellular fluid (CSF, peritoneal fluid, synovial fluid)

Question 6

osmosis

Answer 6

diffusion or movement of water across the cell membrane
from area of lesser concentration to an area of greater concentration of solutes
its a passive process (requires no energy)
it maintains fluid equilibrium between fluid compartments

Question 7

startling forces

Answer 7

there are 4 forces to control movement of fluid between interstitial and intravascular compartments
they are: capillary hydrostatic pressure, capillary oncotic pressure, interstitial hydrostatic pressure, and interstitial oncotic pressure

Question 8

what are the two main mechanisms regulate and maintain body fluid homeostasis

Answer 8

thirst via hypothalamus regulation

excretion of body water through kidneys via the endocrine system regulation

Question 9

what are osmoreceptors

Answer 9

they are stimulated when: there is decreased blood volume, increased serum osmolality, and mouth dryness
They stimulate the pituitary to release ASH which increases water resorption into the plasma

Question 10

what are arterial baroreceptors

Answer 10

they detect pressure changes
when they sense a decrease in pressure they send a signal to the ANS
which causes vasoconstriction of renal arteries which reduces urine output to increase circulating blood volume
They also detect increased pressure and cause vasodilation

Question 11

what are the 3 endocrine regulation responses

Answer 11

there are three: adrenocorticotropic hormone (ACTH), antidiuretic hormone (ADH), and the renin-angiotensin-aldosterone system (RAAS).

Question 12

adrenocorticotropic hormone (ACTH)

Answer 12

stress response- hypothalamus sends signal to pituitary gland and releases ACTH which stimulates the release of aldosterone
(aldosterone = salt regulating hormone which regulates water balance)
causing sodium resorption and potassium is excreted by kidneys. this increases circulating blood volume by increasing water resorption = increases blood pressure

Question 13

antidiuretic hormone (ADH)

Answer 13

hypothalamus osmoreceptors detect a change of concentration of body fluid , it sends a message to pituitary to either decrease or increase ADH (which is a vasopressin)
ex. osmolality increases which causes ADH to increase the permeability of renal tubes and ducts allowing large volume of water to be resorbed. results in expands ECF, decreases serum osmolality and improves blood pressure and perfusion

Question 14

renin-angiotensin-aldosterone system (RAAS).

Answer 14

when NA is low or K is high or blood volume/pressure is low the kidneys releases renin which then releases angiotensin 1, which is converted to angiotensin 2 in lungs .
Angiotensin 2 stimulates release of ADH and aldosterone which causes retention of sodium and water by the kidneys = rapid increase in BP = improves perfusion

Question 15

what includes assessment of fluid balance (history)

Answer 15

injury or disease process that can alter fluid balance?
-surgery, NG tube, hyperventilation, N/V
medications?
-diuretics, laxatives, NSAIDs, glucocorticoids
dietary restrictions?
-NPO, low sodium diet, N/V, tube feeds, anorexia
intake and outputs?
-imbalance?

Question 16

assessment of fluid balance: vitals

Answer 16

temperature- increase due to excess loss of water and Na
pulse- tachycardia due to decreased intravascular volume
resps- dyspnea due to K and/or Mg levels
BP- orthostatic BP can show dehydration, blood loss

Question 17

assessment of fluid balance: inspection

Answer 17

sunken eyes vs round edematous face
oral tissues/tongue moist or dry
tongue furrows = FVD
jugular venous pressure- specifically he right vein
hand veins distention
hypovolemia= venous filling takes >5sec
distention should disappear within 5 sec when hand is elevated
hypervolemia = distention that doesn’t clear within 5 sec
extremities for edema

Question 18

assessment of fluid balance: palpation

Answer 18

skin turgor (forehead, sternum, inner thigh) 
       *older adults will normally have reduced skin turgor bc of elasticity 
cap refill - hypovolemia = prolonged (many factors like smokers, cold temp, anemia can effect results)
extravascular accumulation (second or third spacing) = high risk for hypovolemia
edema - pitting or non pitting
     generalized = edema all over body (results from malnutrition)
     localized = confined areas which causative condition effects capillaries/lymph tissues (ex. HF = lower extremities, sacrum) 
ascites (accumulation of fluid in peritoneal cavity) can form into pleural effusion which can cause hemodynamic instability

Question 19

third spacing of fluids

Answer 19

is the shift of fluid from the intravascular compartment into a “third” (transcellular) space—usually a serous cavity, such as the pericardial or pleural sac
S+S: can manifest as ascites and pericardial or pleural effusions. they are difficult to assess bc it is deep structures.usually need Xray/echo

Question 20

assessment of fluid balance: body weight

Answer 20

peripheral edema develops when 5L or more fluid accumulates in interstitial spaces
Pitting edema develops with accumulation of 10L
Weight gain or loss of 1kg represents a fluid gain or loss of about 1L
DAILY WEIGHTS is valuable

Question 21

assessment of fluid balance: auscultation

Answer 21

heart- may reveal 3rd or 4th heart sound with fluid overload
Tachy and hypo = fluid volume defect
pericardial friction rub can hear = accumulation of fluid in pericardial sac around heart = pericardial effusion (complication w/ kidney failure)
lungs- valuable for presence of pulmonary edema (occurs when fluid shift from vascular space into pulmonary interstitial (can indicate HF or ARDS) can hear crackles that don’t clear with cough = fluid overload

Question 22

assessment of fluid balance: percussion

Answer 22

pain w/ percussion of flank area = UTI thats extended into kidneys
of abdomen - ascites
pt w/ Renal and/or liver failure can have ascites

Question 23

assessment of fluid balance: hemodynamic monitoring (pressure and urine)

Answer 23

CVP/AWP/CO/CI/MAP
with fluid excess, all will show high pressure
with fluid deficit all will show low pressure
urine- low urine = FVD and high urine = FVE
urine concentration measured in two ways
1) urine specific gravity = measures ability of kidneys to concentrate urine
if increased = higher concentration = FVD
if decreased = FVE bc kidneys cannot concentrate urine
2) urine osmolality (more accurate if patients have protein or glucose in urine).
is concentration of solute in urine
increased = FVD as kidneys hold onto water (urine output decreases)
decreased = FVE kidneys excrete more water (UO increases)

Question 24

assessment of fluid balance: laboratory assessment

Answer 24

BUN - by product of protein metabolism
low = over hydration, malnutrition, low protein
high = dehydration, kidney injury, high protein
creatinine - byproduct of muscle breakdown + filtered by kidneys
low = pregnant
high = kidney injury, shock, heart disease
BUN to creatinine ratio - ratio between the two
low = liver disease, excessive IV fluid intake, over hydrated
high = hypovolemia, shock, GI bleeding, kidney injury, muscle or tissue injury
osmolality- serum concentration
low= FVE
high = FVD
anion gap- measures difference between (-) and (+) charged ions
low = metabolic alkalosis, severe dehydration
high = metabolic acidosis, kidney injury
albumin - plasma protein, maintains vascular osmotic pressure
low = liver failure, malnutrition, kidney injury
high = dehydration, severe diarrhea/vomiting

Question 25

assessment of fluid balance: urinalysis

Answer 25

``` measure pH (normal is 5) alkaline urine = vegetarian or infection glucose in urine = pregnancy or DM protein = glomerular basement membrane disease heme in urine = blood present ``` creatinine clearance - provide info about kidney function to measure GFR when renal function decreases, this lab value decreases

Question 26

Electrolytes

Answer 26

electrically charged microsolutes found in body fluids. There are two types of electrolytes: cations (positively charged ions) and anions (negatively charged ions). major extracellular lytes are Na, Cl, Ca major intracellular lytes are K, Mg, Po4

Question 27

Sodium

Answer 27

responsible for water balance and is required for the normal transmission of impulses across muscle and nerve cells plays an important role in maintaining acid–base balance by combining with chloride or bicarbonate to increase or decrease serum pH High Na = fluid volume in intravascular compartment increases = kidneys increase urine excretion of sodium , inhibits ADH which prevents resorption of sodium by kidneys and aldosterone release is suppressed = enhancing excretion of sodium low Na = plasma volume decreases, which triggers the RAAS causing increased sodium resorption = increasing urine output and fluid volume

Question 28

sodium and water balance

Answer 28

sodium level changes alter water balance water is drawn to sodium = high sodium in ECF pulls water from intracellular spaces ( results in shrinking of intracellular compartment and expansion of extracellular compartment this expansion can cause HF and pulmonary deem when sodium levels are low water moves from low sodium concentration (EC) to high sodium concentration (intracellular) which causes excess volume in intracellular compartment and fluid volume defect in extracellular compartment

Question 29

Chloride

Answer 29

works with sodium, they follow closely to sodium levels because chloride follows sodium in body aldosterone regulates chloride levels (stimulates resorption of sodium in the kidneys) Cl maintains osmolality of extracellular fluid space (acid-base status) which requires balance. sodium must be balance with chloride and bicarbonate. chloride and bicarbonate compete for sodium ex. if patient is getting too much sodium bicarb, there will be less chloride = hypocholermia

Question 30

Calcium

Answer 30

enters body through diet and is absrobed in intestine excess Ca is excreted through stool and urine is required for blood coagulation, neuromuscular contraction, enzymatic activities, and bone integrity. Ca is regulated by PTH, calcitonin and calciferol Ca needs vitamin D to be activated by the kidneys in order to be absorbed when Ca is low= PTH released + stimulates conversion of calcidiol to calciferol when Ca high = PTH secretion is surpassed and calcitonin is secreted which inhibits release of calcium from bone into the blood = inhibits absorption in the intestines

Question 31

potassium

Answer 31

almost all K is located inside cells body is intolerant of abnormal serum levels we consume sufficient amounts in food excess K is eliminated in urine by kidneys maintains normal Cardiac and neuromuscular function: it affects muscle contraction influences nerve impulse conduction (abnormal levels can be lethal cardiac conduction abn = dysryhtmias and cardiac arrest) important to maintain acid base balance bc hydrogen ions in vascular space exchange with K ions in intracellular space

Question 32

Magnesium

Answer 32

needed for activation of certain enzymes required for normal protein and carbohydrate metabolism ensures Na and K transportation across celll membranes plays big role in nerve cells conduction (transmitting CNS messages and maintaining neuromuscular activity) enters body through diet and excreted in poop, smalll aount in ruine

Question 33

phosphorus/phosphate

Answer 33

combines with calcium and is essential component of bones and teeth vital in neuromuscular function and required for energy in production of ATP contributes to protein, fat, carb metabolism serum level influenced by PTH + maintains relationship to calcium kidney are essential for phosphorus regulation when GFR decreases, phosphorus increases rise versa

Question 34

assessing electrolyte balance: history

Answer 34

see disease processes/conditions that alter lytes: parathyroid tumor, diabetes mellitus, acid–base imbalances, prolonged immobility, Addison disease, malnutrition, vomiting or diarrhea

Question 35

assessment of electrolytes: physical

Answer 35

vitals + CV: BP and HR Ca, K, Mg, Po4 can alter these findings if any abnormalities- ECG taken (usually bc abnormal levels of Ca, K, Mg) Neuro- abn. levels can cause changes in LOC (disorientation, confusion, agitation, lethargy, seizures) low K and Na can cause confusion and lethargy low Po4 and Ca can cause disorientation, irritability, seizures Neuromuscular and skeletal- check reflexes, muscle strength, tone and sensation (numb, tingling, parenthesia- these 3 will show in low Ca and po4) low Mg and Ca- can produce tetany = test for positive in Chvostek sign (tap face in front of ear on facial nerve and see if spasm/twitch of cheek or lip on that side) AND/OR positive Trousseau sign (BP cuff on arm and inflate cuff to above systolic pressure, patients fingers will hyperextend with thumb flexing toward palm) GI- patient w/ severe N/V and diarrhea will have lyte abnormalities from losing and not replenishing

Question 36

assessment of electrolyte- laboratory testing

Answer 36

serum electrolytes- obtain baseline when admitted and periodic labs drawn throughout hospitalization urine electrolytes- measured by collecting a 24hr urine specimen to monitor renal function, evaluate fluid and electrolyte balance help to diagnose diseases like Addisons

Question 37

fluid volume deficit (FVD) define

Answer 37

ECF volume is abnormally low of body fluid in the intravascular and interstitial compartments from loss of sodium and fluid = hypovolemia (low circulating fluid volume specifically intravascular compartment)

Question 38

loss of extracellular fluid due to third spacing

Answer 38

fluid shifts into third space can lead to FVD if the fluid shifts into serous cavity and results in trapped fluid that is unavailable for functional use

Question 39

assessing FVD

Answer 39

neuro- altered mental status, restless, diminished alertness mucous membranes- dry, decreased tongue size, furrows integ- poor turgor, dry and pale, cool extremities urine- decreased output Cardiovascular- flat neck veins, decreased cap refill vitals- tachycardia, hypotension, hyperthermia (dehydration) labs- increased hct, high urine specific gravity, increased BUN other- thirst, weight loss, fatigue

Question 40

FVD treatment

Answer 40

control source of fluid loss and correct deficit by IV fluids or PO or enteral route depending on severity isotonic fluids- has same osmolality as body fluid (equal compartment ratio) NS or RL hypotonic fluids- fluid shifts to intracellular compartments to treat cellular dehydration. use with caution bc too much can cause ICP and mental status deterioration. (avoid its with neuromuscular problems associated w/ ICP). 0.45% NS hypertonic solutions- fluid shifts from ICF to ECF into intravascular compartment expanding blood volume. used for water intoxication (intracellular fluid excess) or overuse of hypotonic solutions, or renal failure . D10W and 3% NS Outcome- acceptable pulse, BP, CVP, PAWP, serum osmolality, increased UO, improved skin turgor, moist mucous membranes, acceptable hct, BUN. absence of dehydration symptoms

Question 41

Fluid volume excess (FVE)

Answer 41

also called fluid overload or hypervolemia that produces over hydration in intravascular compartment when water nd sodium are retained caused by heart/liver/kidney failure, over hydration from too rapidly IV fluid delivery, side effect from corticosteroids LOW urine output can indicate deficit or excess of fluid

Question 42

assessment of Fluid volume excess

Answer 42

physical- mental status changes, weight gain, distended neck veins, periorbital deem, pitting edema, adventitious lung sounds like moist crackles, SOB vitals- elevated BP/CVP, PAP, increased CO lab- decreased hct, low urine osmolality, radiology = congestion/pleural or pericardial effusion/ascites low urine specific gravity

Question 43

FVE treatment

Answer 43

correct underlying cause restrict sodium and water intake administer diuretics (inhibit sodium and water resorption and increase urine output) Monitor weight, I&O, vitals, CXR, edema

Question 44

three types of diuretics

Answer 44

loop diuretic - furosemide/Lasix SE = hypokolemia Thiazide diuretic- hydrochlorothiazide/HCTZ SE = hyperglycaemia, hypokalemia Potassium sparing diuretic - spironolactone SE = hyponatremia, hyperkalemia

Question 45

Hyponatremia

Answer 45

low sodium (below 135) critical value is below (120) excessive salt loss relative to water loss (1), excessive water gain in relation to salt gain (2)or both -1- continuous release of ADH associated with antidiuretic and/or from replacing water without replacing salt (overusing D5W IV fluid) -2- huge gain of water without gain of salt. rapid ingestion or administration of water exceeds kidneys ability to excrete it can develop hyponatremia seizures can develop with Na levels <110 most severe complication is cerebral edema

Question 46

hyponatremia S+S

Answer 46

``` hypotension confusion, headache, lethargy vomiting, diarrhea, cramps seizures, muscle cramps or spasms fluid deficit ```

Question 47

hyponatremia treatment

Answer 47

correct underlying cause may be given hypertonic solution like 3% or 5% NaCl (monitor for pulmonary edema) Conivaptan hydrochloride (Vaprisol) may be ordered. (blocks ADH in kidneys = cause excretion of water and retention of sodium fluid restriction Monitor CNS functions and mental status be careful, don't want to correct levels too quickly, can lead to neurologic problems

Question 48

hypernatremia

Answer 48

high sodium above (145) critical levels about (160) extracellular volume of water is low and sodium is high concentrated water shifts from intracellular space to extracellular, the cells shrink and shrivel causing cellular dehydration and extracellular compartment is overloaded with water cause- administration of sodium bicarbonate solutions to correct metabolic acidosis, diuretics or diuresis from hyperglycaemia, GI losses from NG suction

Question 49

hypernatremia S+S

Answer 49

``` hypertension, tackhycardia confusion, thirst, restless N/V hyper reflexes, muscle twitching, seizures fluid excess and edema ```

Question 50

hypernatremia treatment

Answer 50

water replacement - hypotonic IV fluids diuretics may be given to excrete sodium monitor neuro status especially with water replacement , and I&O

Question 51

hypocalcemia

Answer 51

``` low calcium (less then 9) critical less then (6.5) cause- vit D deficiency, hypoparathyroidism, hypo magnesium, sepsis, CKD, decreased PTH secretion also can occur from lg administration of stored blood (bc has citrate in it which binds to calcium = lowers calcium) ```

Question 52

hypocalcemia S+S

Answer 52

hypotension ECG changes - prolonged QT interval, long ST segment irritable cramps, parasthesias, positive chvostek or trousseau sign bone fractures abnormal clotting

Question 53

hypocalcemia treatment

Answer 53

IV calcium gluconate monitor magnesium levels (tend to also be low) if they have metabolic acidosis - treat hypocalemia first (acidosis decreases ionized calcium) monitor ECG changes, neurologic and muscular changes and decreased CO

Question 54

hypercalcemia

Answer 54

high calcium above (11) critical (13) when calcium enters extracellular fluid more rapidly then it can be excreted by kidneys cause- hyperparathyroidism and malignancy, vitamin D toxicity will most likely have hypophosphatemia bc calcium and phosphate shift in opposite directions

Question 55

hypercalcemia symptoms

Answer 55

lethargy, anorexia, nausea higher calcium levels - neuromuscular changes- decreases excitability because it acts as sedative at myoneural junction delayed gastric emptying and vomiting, increased gastric acid secretion polyuria, polydypsea

Question 56

hypercalcemia treatment

Answer 56

correct underlying disease treat hyperparathyroidism with parathyroidectomy, malignancies with surgery/chemo/radiation IV fluids and diuretics to promote elimination meds: biphosphonates, calcitonin nursing considerations: at risk for injury bc of frail bones, encourage oral intake, mobilization, ensure good fiber intake

Question 57

hypokalemia

Answer 57

low potassium, when body doesn't compensate for K loss causes- GI secretion losses like vomiting, diarrhea ect. , excessive excretion by kidneys, prolonged fluid administration without K supplementation, excessive potassium wasting diuretic (spironolactone) without supplements

Question 58

hypokalemia S+S

Answer 58

ECG changes- flattened or inserted T waves, depressed ST segment respiratory muscle weakness muscle weakness or cramps constipation or ileus

Question 59

hypokalemia treatment

Answer 59

measure urine for K levels by 24 hr urine collection treat with oral or IV potassium monitor for ysrythmias and ECG changes if using IV preferred site is Central venous catheter and not peripheral vein (painful and irritation occurs)

Question 60

hyperkalemia

Answer 60

high K causes: severe kidney injury (kidney cannot excrete it) and acidosis (Hydrogen ions shift into the cells and push K out into the serum), medications like Beta adrenergic blockers, ACEIs and NSAIDs

Question 61

hyperkalemia S+S

Answer 61

``` see signs once K >6.0 ECG changes- prolonged PR interval, flat or absent P waves, tall peaked T waves, ST segment depression muscle weakness or cramps N/V, diarrhea, cramping metabolic acidosis ```

Question 62

hyperkalemia treatment

Answer 62

identify meds that are increasing potassium (NSAIDS, ACEI, Beta blockers, K sparing diuretic) decrease substances that have potassium if ECG changes or dysrhythmias occur- IV calcium gluconate to stabilize cardiac membrane. then administer regular insulin 10 units and 50 grams glucose IV or inhaler albuterol helps as well to shift K into cells Kayexelate will help with excretion of K through bowel dialysis for severe hyperkalemia and when no other options help

Question 63

hyperkalemia nursing considerations

Answer 63

can result in ventricular fibrillation and cardiac arrest notify HCP if ECG changes and elevated K values if pt has abnormal kidney function- must assess BUN and creatinine since its such a big risk factor for hyeprkalemia monitor I&O

Question 64

hypomagnesemia

Answer 64

low magnesium causes- GI or renal losses, surgery, trauma, infections, sepsis, burns, transfusions, malnutrition meds that cause = diuretics, ahminoglycosides, cyclosporine hypoparathyroidism with hypocalemia can also cause low mg

Question 65

hypomagnesemia S+S

Answer 65

ECG changes- ventricular tachycardia, T wave flattening, decreased ST segment tremors, tetany, babinski response, confusion, disorientation

Question 66

hypomagnesemia treatment

Answer 66

assess for renal failure before administering magnesium bc kidneys are responsible for excreting mg IV mg fif less then 1.2 or near changes or cardiac dysrhythmias infusion time is critical nursing considerations- hypokalemia and hypocalemia can occur with low mg

Question 67

hypermagnesemia

Answer 67

low mg | causes - renal failure, excessive mg intake (magnesium antacids or laxatives)

Question 68

hypermagesemia S+S

Answer 68

hypotension ECg changes- prolonged PR intervals, wide QRS complex brady cardia depression absent deep tendon reflexes, lethargy, drowsiness

Question 69

hypermagnesemia treatment

Answer 69

hold meds that have mg dialysis administer calcium chloride for cardiac toxicity and neuromuscular toxicity nursing considerations- assess for fluid volume excess, respiratory distress , LOC

Question 70

hypophosphatemia

Answer 70

low phosphate | causes- malnutrtion, cardiac surgery, DKA, alcoholism, respiratory/metabolic alkolosis, hyperparathyroidsim

Question 71

hypophosphatemia S+S

Answer 71

HF, N/V, anorexia, disorientation, irritable, coma, weakness, numbness and tingeling, resp failure, RBC/WBC and platelet dysfunction depresses cellular function, particularly of the hematologic and cardiovascular systems

Question 72

hypophosphatemia treatment

Answer 72

asymph/ mild - oral supplementation if normal GI function symptomatic or severe- IV phosphate and potassium phosphate nursing considerations- monitor for muscle weakness, inadequate ventilations both cause breathing difficulties be alert for hypercalemia

Question 73

hyperphosphatemia

Answer 73

high phosphate | causes- CKD or excess intake

Question 74

hyperphosphatemia S+S

Answer 74

hypotension/tachycardia ECG changes- prolonged QT interval, ventricular dysrythmias diarrhea, N/V , abd cramping altered metal status, delirium , positive chvostek and trousseau signs muscle cramping, tetany, seizures

Question 75

hyperphosphatemia treatment

Answer 75

reduce any phosphate meds/sources calcum based salts IV solution with saline helps promote excretion if functional kidneys considerations- monitor ECG , avoid phosphate containing laxatives there poisonous