Fluid & Electrolytes

Question 1

Calcium and its role in the body

Answer 1

“A mineral element needed for the process of bone formation, coagulation of blood, excitation of cardiac and skeletal muscle, maintenance of muscle tone, conduction of neuromuscular impulses, and the synthesis and regulation of the endocrine and exocrine glands. The normal adult level is 8.6 to 10mg/dL.”

• • It plays a huge role in bone & teeth, muscle/nerve function, cell function & blood clotting.
• • it’s absorbed in the GI system, stored in bone & excreted in the kidneys. Vitamin D helps play a role in calcium absorption.
• • Calcium and Phosphorus play affect each other in opposite ways.

Question 2

Magnesium and its role in the body

Answer 2

“Concentrated in the bone, cartilage, and within the cell itself; required for the use of adenosine triphosphate as a source of energy. It is necessary for the action of numerous enzyme systems such as those involved in carbohydrate metabolism, protein synthesis, nucleic acid synthesis, and contraction of muscular tissue. It also regulates neuromuscular activity and the clotting mechanism. The normal adult level is 1.6 to 2.6mg/dL.”

• –It plays a role in cell function (transferring & storing energy)
• – regulates the parathyroid hormone (in turn plays a role in calcium levels; low Mag inhibits the release of low calcium)
• – metabolizes carbs, lipids & proteins
• – regulates blood pressure
• – Mag is absorbed in the small intestine (any issues with GI system causes issues with Mag levels) and excreted by the kidneys

Question 3

Phosphorus and its role in the body

Answer 3

“Needed for generation of bony tissue. It functions in the metabolism of glucose and lipids, in the maintenance of acid-base balance, and in the storage and transfer of energy from one site in the body to another. Phosphorus levels are evaluated in relation to calcium levels because of their inverse relationship; when calcium levels are decreased, phosphorus levels are increased, and when phosphorus levels are decreased, calcium levels are increased. The normal adult level is 2.7 to 4.5mg/dL.”

Question 4

Potassium and its role in the body

Answer 4

“A principal electrolyte of intracellular fluid and the primary buffer within the cell itself. It is needed for nerve conduction, muscle function, acid-base balance, and osmotic pressure. Along with calcium and magnesium, potassium controls the rate and force of contraction of the heart and thus cardiac output. The normal adult level is 3.5 to 5.0mEq/L.”

—Its responsible for nerve impulse conduction and muscle contractility

Question 5

Sodium and its role in the body

Answer 5

“An abundant electrolyte that maintains osmotic pressure and acid-base balance and transmits nerve impulses. The normal adult level is 135 to 145mEq/L.”

• –It’s role is to help regulate H2O inside and outside the cell
• – If too much H20 in the cells, especially brain cells, can cause confusion*** caused osmosis during hyponatremia

Question 6

Metabolic Acidosis

Answer 6

“A total concentration of buffer base that is lower than normal, with a relative increase in the hydrogen ion concentration. This results from loss of buffer bases or retention of too many acids without sufficient bases, and occurs in conditions such as kidney failure and diabetic ketoacidosis, from the production of lactic acid, and from the ingestion of toxins, such as acetylsalicylic acid (aspirin).
”

Question 7

Metabolic Alkalosis

Answer 7

“A deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism.”

Question 8

Respiratory Acidosis

Answer 8

“A total concentration of buffer base that is lower than normal, with a relative increase in hydrogen ion concentration; thus a greater number of hydrogen ions is circulating in the blood than the buffer system can absorb. This is caused by primary defects in the function of the lungs or by changes in normal respiratory patterns as a result of secondary problems. Any condition that causes an obstruction of the airway or depresses respiratory status can cause respiratory acidosis.

Question 9

Respiratory Alkalosis

Answer 9

“A deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system.”

Question 10

Phlebitis

Answer 10

“An inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection.”

Question 11

Infiltration

Answer 11

“Seepage of IV fluid out of the vein and into the surrounding interstitial spaces.”

Question 12

Fresh-Frozen Plasma

Answer 12

“A blood product administered to increase the level of clotting factors in clients with such a deficiency.”

Question 13

Packed Red Blood Cells

Answer 13

“A blood product used to replace erythrocytes lost as a result of trauma or surgical interventions or in clients with bone marrow suppression.”

Question 14

Plasma

Answer 14

“The watery, straw-colored, fluid part of lymph and the blood in which the formed elements (blood cells) are suspended. Plasma is made up of water, electrolytes, protein, glucose, fats, bilirubin, and gases and is essential for carrying the cellular elements of the blood through the circulation.”

Question 15

Platelet Transfusion

Answer 15

“A blood product administered to clients with low platelet counts and to thrombocytopenic clients who are bleeding actively or are scheduled for an invasive procedure.”

Question 16

Isotonic solutions -
Ex: 0.9% sodium chloride (normal saline); (0.9% NS) & 5% dextrose in water (D5W) Isotonic (physiologically hypotonic) & 5% dextrose in 0.225% saline (D5W/¼ NS) & Lactated Ringer’s (LR)

Answer 16

1. Have the same osmolality as body fluids
2. Increase extracellular fluid volume
3. Do not enter the cells because no osmotic force exists to shift the fluids

A.When the solutions on both sides of a selectively permeable membrane have established equilibrium or are equal in concentration, they are isotonic.
B.Isotonic solutions are isotonic to human cells, and thus very little osmosis occurs; isotonic solutions have the same osmolality as body fluids.

Question 17

Hypotonic solutions -
Ex: 0.45% sodium chloride (normal saline); (½ NS) & 0.225% sodium chloride (normal saline); (¼ NS) & 0.33% sodium chloride (normal saline); (⅓ NS)

Answer 17

1. Are more dilute solutions and have a lower osmolality than body fluids
2. Cause the movement of water into cells by osmosis
3. Should be administered slowly to prevent cellular edema

A. When a solution contains a lower concentration of salt or solute than another, more concentrated solution, it is considered hypotonic.
B.A hypotonic solution has less salt or more water than an isotonic solution; these solutions have lower osmolality than body fluids.
C.Hypotonic solutions are hypotonic to the cells; therefore osmosis would continue in an attempt to bring about balance or equality.

Question 18

Hypertonic solutions -
Ex: 3% sodium chloride (normal saline); (3% NS) & 5% sodium chloride (normal saline); (5% NS) & 10% dextrose in water (D10W) & 5% dextrose in 0.9% sodium chloride (normal saline); D5W/NS & 5% dextrose in 0.45% sodium chloride (normal saline); (D5W/½ NS) & 5% dextrose in lactated Ringer’s (D5LR)

Answer 18

1. Are more concentrated solutions and have a higher osmolality than body fluids
2. Cause movement of water from cells into the extracellular fluid by osmosis

A. A solution that has a higher concentration of solutes than another, less concentrated solution is hypertonic; these solutions have a higher osmolality than body fluids.

Question 19

Colloids solution-

Ex: Dextran & Albumin

Answer 19

1. Also called plasma expanders

2. Pull fluid from the interstitial compartment into the vascular compartment

Question 20

Isotonic dehydration (fluid volume deficit)

Answer 20

a. Water and dissolved electrolytes are lost in equal proportions.
b. Known as HYPOVOLEMIA, isotonic dehydration is the most common type of dehydration.
c. Isotonic dehydration results in decreased circulating blood volume and inadequate tissue perfusion.”

Cause -

a. Inadequate intake of fluids and solutes
b. Fluid shifts between compartments
c. Excessive losses of isotonic body fluids

Treatment - Use isotonic solutions

Question 21

Hypertonic dehydration (fluid volume deficit)

Answer 21

a. Water loss exceeds electrolyte loss.
b. The clinical problems that occur result from alterations in the concentrations of specific plasma electrolytes.
c. Fluid moves from the intracellular compartment into the plasma and interstitial fluid spaces, causing cellular dehydration and shrinkage.”

Cause - “conditions that increase fluid loss, such as excessive perspiration, hyperventilation, ketoacidosis, prolonged fevers, diarrhea, early-stage kidney disease, and diabetes insipidus”

Treatment - Us hypertonic solution

Question 22

Hypotonic dehydration (fluid volume deficit)

Answer 22

a. Electrolyte loss exceeds water loss.
b. The clinical problems that occur result from fluid shifts between compartments, causing a decrease in plasma volume.
c. Fluid moves from the plasma and interstitial fluid spaces into the cells, causing a plasma volume deficit and causing the cells to swell.”

Cause -

a. Chronic illness
b. Excessive fluid replacement (hypotonic)
c. Kidney disease
d. Chronic malnutrition

Treatment - Use Hypotonic solutions

Question 23

Isotonic overhydration (fluid volume overload)

Answer 23

“1.Isotonic overhydration

a. Known as HYPERVOLEMIA, isotonic overhydration results from excessive fluid in the extracellular fluid compartment.
b. Only the extracellular fluid compartment is expanded, and fluid does not shift between the extracellular and intracellular compartments.
c. Isotonic overhydration causes circulatory overload and interstitial edema; when severe or when it occurs in a client with poor cardiac function, heart failure and pulmonary edema can result. ”

CAUSES-

a. Inadequately controlled IV therapy
b. Kidney disease
c. Long-term corticosteroid therapy

Question 24

Hypertonic overhydration (fluid volume overload)

Answer 24

a. The occurrence of hypertonic overhydration is RARE and is caused by an excessive sodium intake.
b. Fluid is drawn from the intracellular fluid compartment; the extracellular fluid volume expands, and the intracellular fluid volume contracts.

CAUSES-

a. Excessive sodium ingestion
b. Rapid infusion of hypertonic saline
c. Excessive sodium bicarbonate therapy

Question 25

Hypotonic overhydration (fluid volume overload)

Answer 25

a.  Hypotonic overhydration is known as WATER INTOXICATION. b.  The excessive fluid moves into the intracellular space, and all body fluid compartments expand. c.  Electrolyte imbalances occur as a result of dilution. ” CAUSES- a.  Early kidney disease b.  Heart failure c.  Syndrome of inappropriate antidiuretic hormone secretion d.  Inadequately controlled IV therapy e.  Replacement of isotonic fluid loss with hypotonic fluids f.  Irrigation of wounds and body cavities with hypotonic fluids”

Question 26

Fluid Volume Deficit interventions:

Answer 26

1.  Monitor cardiovascular, respiratory, neuromuscular, renal, integumentary, and gastrointestinal status. 2.  Prevent further fluid losses and increase fluid compartment volumes to normal ranges. 3.  PROVIDE oral rehydration therapy if possible and IV fluid replacement if the dehydration is severe; monitor intake and output. 4.  In general, isotonic dehydration is treated with isotonic fluid solutions, hypertonic dehydration with hypotonic fluid solutions, and hypotonic dehydration with hypertonic fluid solutions. 5.  ADMINISTER medications as prescribed, such as antidiarrheal, antimicrobial, antiemetic, and antipyretic medications, to correct the cause and treat any symptoms. 6.  ADMINISTER oxygen as prescribed.” 7.  MONITOR electrolyte values and prepare to ADMINISTER medication to treat an imbalance, if present.

Question 27

Fluid Volume Excess (overload) interventions:

Answer 27

1.  Monitor cardiovascular, respiratory, neuromuscular, renal, integumentary, and gastrointestinal status. 2.  Prevent further fluid overload and restore normal fluid balance. 3.  ADMINISTER diuretics; osmotic diuretics typically are prescribed first to prevent severe electrolyte imbalances. 4.  RESTRICT fluid and sodium intake as prescribed. 5.  MONITOR intake and output; monitor WEIGHT. 6.  MONITOR electrolyte values, and prepare to ADMINISTER medication to treat an imbalance if present. * **A client with acute kidney injury or chronic kidney disease is at high risk for fluid volume excess.

Question 28

Hyponatremia (sodium below 135 mEq/L) | Causes: Sodium imbalances usually are associated with fluid volume imbalances.

Answer 28

1.  Increased sodium excretion a.  Excessive diaphoresis b.  Diuretics c.  Vomiting d.  Diarrhea e.  Wound drainage, especially gastrointestinal f.  Kidney disease g.  Decreased secretion of aldosterone 2.  Inadequate sodium intake a.  Fasting; nothing by mouth status b.  Low-salt diet 3.  Dilution of serum sodium a.  Excessive ingestion of hypotonic fluids or irrigation with hypotonic fluids b.  Kidney disease c.  Freshwater drowning d.  Syndrome of inappropriate antidiuretic hormone secretion e.  Hyperglycemia f.  Heart failure

Question 29

Hyponatremia interventions:

Answer 29

1.  Monitor cardiovascular, respiratory, neuromuscular, cerebral, renal, and gastrointestinal status. 2.  If hyponatremia is accompanied by a fluid volume deficit (hypovolemia), IV sodium chloride infusions (3% NS-Hypertonic solution) are administered to restore sodium content and fluid volume 3.  If hyponatremia is accompanied by fluid volume excess (hypervolemia), osmotic diuretics are administered to promote the excretion of water rather than sodium. 4.  If caused by inappropriate or excessive secretion of antidiuretic hormone (SIADH), medications that antagonize antidiuretic hormone may be administered. 5.  Instruct the client to increase oral sodium intake and inform the client about the foods to include in the diet 6.  If the client is taking lithium (Lithobid), monitor the lithium level, because hyponatremia can cause diminished lithium excretion, resulting in toxicity. ****Hyponatremia precipitates lithium toxicity in a client taking lithium (Lithobid).”

Question 30

Hypernatremia (sodium above 145 mEq/L) Causes: Sodium imbalances usually are associated with fluid volume imbalances.

Answer 30

1.  Decreased sodium excretion a.  Corticosteroids b.  Cushing’s syndrome (Aldosterone problem) c.  Kidney disease d.  Hyperaldosteronism (Aldosterone retains sodium) 2.  Increased sodium intake: Excessive oral sodium ingestion or excessive administration of sodium-containing IV fluids 3.  Decreased water intake: Fasting; nothing by mouth status 4.  Increased water loss: Increased rate of metabolism, fever, hyperventilation, infection, excessive diaphoresis, watery diarrhea, diabetes insipidus

Question 31

Hypernatremia (sodium above 145 mEq/L) Interventions:

Answer 31

1.  Monitor cardiovascular, respiratory, neuromuscular, cerebral, renal, and integumentary status. 2.  If the cause is fluid loss (dehydration), prepare to administer IV infusions. MD may order isotonic or hypotonic solutions (0.45%NS) to rehydrate the cells that have lost NA+ to ECF. 3.  If the cause is inadequate renal excretion of sodium, prepare to administer diuretics that promote sodium loss 4.  Restrict sodium and fluid intake as prescribed ****Monitor the client closely for signs of a potassium imbalance. A potassium imbalance can cause cardiac dysrhythmias that can be life-threatening!

Question 32

Hyponatremia (Cardiovascular assessment)

Answer 32

■ Symptoms vary with changes in vascular volume ■ Normovolemic: Rapid pulse rate; normal blood pressure ■ Hypovolemic: Thready, weak, rapid pulse rate; hypotension; flat neck veins; normal or low central venous pressure ■ Hypervolemic: Rapid, bounding pulse; blood pressure normal or elevated; normal or elevated central venous pressure

Question 33

Hypernatremia (Cardiovascular assessment)

Answer 33

■ Heart rate and blood pressure respond to vascular volume status

Question 34

Hyponatremia (Respiratory assessment)

Answer 34

■ Shallow, ineffective respiratory movement is a late manifestation related to skeletal muscle weakness***

Question 35

Hypernatremia (Respiratory assessment)

Answer 35

■ Pulmonary edema if hypervolemia is present

Question 36

Hyponatremia (Neuromuscular assessment)

Answer 36

■ Generalized skeletal muscle weakness that is worse in the extremities ■ Diminished deep tendon reflexes ■ Lethargy

Question 37

Hypernatremia (Neuromuscular assessment)

Answer 37

■ Early: Spontaneous muscle twitches; irregular muscle contractions ■ Late: Skeletal muscle weakness; deep tendon reflexes diminished or absent

Question 38

Hyponatremia (Central Nervous System assessment)

Answer 38

``` ■ Headache ■ Personality changes ■ Confusion*** ■ Seizures*** ■ Coma ```

Question 39

Hypernatremia (Central Nervous System assessment)

Answer 39

■ Altered cerebral function is the most common manifestation of hypernatremia*** ■ Normovolemia or hypovolemia: Agitation, confusion, seizures*** ■ Hypervolemia: Lethargy, stupor, coma

Question 40

Hyponatremia (Gastrointestinal assessment)

Answer 40

■ Increased motility and hyperactive bowel sounds ■ Nausea ■ Abdominal cramping and diarrhea

Question 41

Hypernatremia (Gastrointestinal assessment)

Answer 41

■ Extreme thirst

Question 42

Hyponatremia (Renal assessment)

Answer 42

■ Increased urinary output

Question 43

Hypernatremia (Renal assessment)

Answer 43

■ Decreased urinary output

Question 44

Hyponatremia (Integumentary assessment)

Answer 44

■ Dry mucous membrane

Question 45

Hypernatremia (Integumentary assessment)

Answer 45

■ Dry and flushed skin ■ Dry and sticky tongue and mucous membranes ■ Presence or absence of edema, depending on fluid volume changes

Question 46

Fluid Volume Overload (Cardiovascular assessment)

Answer 46

``` ■ Bounding, increased pulse rate ■ Elevated blood pressure ■ Distended neck and hand veins ■ Elevated central venous pressure ■ Dysrhythmias ```

Question 47

Fluid Volume Deficit (Cardiovascular assessment)

Answer 47

■ Thready, increased pulse rate ■ Decreased blood pressure and orthostatic (postural) hypotension ■ Flat neck and hand veins in dependent positions ■ Diminished peripheral pulses ■ Decreased central venous pressure ■ Dysrhythmias

Question 48

Fluid Volume Overload (Respiratory assessment)

Answer 48

■ Increased respiratory rate (shallow respirations) ■ Dyspnea ■ Moist crackles on auscultation”

Question 49

Fluid Volume Deficit (Respiratory assessment)

Answer 49

■ Increased rate and depth of respirations | ■ Dyspnea

Question 50

Fluid Volume Overload (Neuromuscular assessment)

Answer 50

``` ■ Altered level of consciousness ■ Headache ■ Visual disturbances ■ Skeletal muscle weakness ■ Paresthesias ```

Question 51

Fluid Volume Deficit (Neuromuscular assessment)

Answer 51

■ Decreased central nervous system activity, from lethargy to coma ■ Fever, depending on the amount of fluid loss ■ Skeletal muscle weakness

Question 52

Fluid Volume Overload (Renal assessment)

Answer 52

■ Increased urine output if kidneys can compensate; decreased urine output if kidney damage is the cause

Question 53

Fluid Volume Deficit (Renal assessment)

Answer 53

■ Decreased urine output

Question 54

Fluid Volume Overload (Integumentary assessment)

Answer 54

■ Pitting edema in dependent areas | ■ Pale, cool skin

Question 55

Fluid Volume Deficit (Integumentary assessment)

Answer 55

■ Dry skin ■ Poor turgor, tenting ■ Dry mouth

Question 56

Fluid Volume Overload (Gastrointestinal assessment)

Answer 56

``` ■ Increased motility in the gastrointestinal tract ■ Diarrhea ■ Increased body weight ■ Liver enlargement ■ Ascites ```

Question 57

Fluid Volume Deficit (Gastrointestinal assessment)

Answer 57

■ Decreased motility and diminished bowel sounds ■ Constipation ■ Thirst ■ Decreased body weight

Question 58

Fluid Volume Overload (Laboratory Findings)

Answer 58

``` ■ Decreased serum osmolality ■ Decreased hematocrit ■ Decreased BUN level ■ Decreased serum sodium level ■ Decreased urine specific gravity ```

Question 59

Fluid Volume Deficit (Laboratory Findings)

Answer 59

``` ■ Increased serum osmolality ■ Increased hematocrit ■ Increased blood urea nitrogen (BUN) level ■ Increased serum sodium level Increased urinary specific gravity ```

Question 60

Osmosis (Body fluid transport)

Answer 60

a. Osmotic pressure is the force that draws the solvent (water) from a less concentrated solute through a selectively permeable membrane into a more concentrated solute, thus tending to equalize the concentration of the solvent. b.  If a membrane is permeable to water but not to all the solutes present, the membrane is a selective or semipermeable membrane. c.  Osmosis is the movement of solvent molecules (H2O) across a membrane in response to a concentration gradient, usually from a solution of lower to one of higher solute concentration. d.  When a more concentrated solution is on one side of a selectively permeable membrane and a less concentrated solution is on the other side, a pull called osmotic pressure draws the water through the membrane to the more concentrated side, or the side with more solute.

Question 61

Diffusion (Body fluid transport)

Answer 61

a.  Diffusion is the process whereby a solute (substance that is dissolved) may spread through a solution or solvent (solution in which the solute is dissolved). b.  Diffusion of a solute spreads the molecules from an area of higher concentration to an area of lower concentration. c.  A permeable membrane allows substances to pass through it without restriction. d.  A selectively permeable membrane allows some solutes to pass through without restriction but prevents other solutes from passing freely. e.  Diffusion occurs within fluid compartments and from one compartment to another if the barrier between the compartments is permeable to the diffusing substances.”

Question 62

Filtration (Body fluid transport)

Answer 62

a.  Filtration is the movement of solutes and solvents by hydrostatic pressure. b.  The movement is from an area of higher pressure to an area of lower pressure.

Question 63

Hydrostatic pressure (Body fluid transport)

Answer 63

a. Hydrostatic pressure is the force exerted by the weight of a solution. b.  When a difference exists in the hydrostatic pressure on two sides of a membrane, water and diffusible solutes move out of the solution that has the higher hydrostatic pressure by the process of filtration. c.  At the arterial end of the capillary, the hydrostatic pressure is higher than the osmotic pressure; therefore fluids and diffusible solutes move out of the capillary. d.  At the venous end, the osmotic pressure, or pull, is higher than the hydrostatic pressure, and fluids and some solutes move into the capillary. e.  The excess fluid and solutes remaining in the interstitial spaces are returned to the intravascular compartment by the lymph channels.”

Question 64

Osmolality (Body fluid transportation)

Answer 64

a.  Osmolality refers to the number of osmotically active particles per kilogram of water; it is the concentration of a solution. b.  In the body, osmotic pressure is measured in milliosmoles (mOsm). c.  The normal osmolality of plasma is 270 to 300 milliosmoles/kilogram (mOsm/kg) water.

Question 65

Hypokalemia (Potassium below 3.5 mEq/L) - “Potassium deficit is potentially life-threatening because every body system is affected.” Causes:

Answer 65

1.  Actual total body potassium loss a.  Excessive use of medications such as diuretics or corticosteroids b.  Increased secretion of aldosterone, such as in Cushing’s syndrome c.  Vomiting, diarrhea, anorexia d.  Wound drainage, particularly gastrointestinal e.  Prolonged nasogastric suction f.  Excessive diaphoresis g.  Kidney disease impairing reabsorption of potassium 2. Inadequate potassium intake: Fasting; nothing by mouth status 3.  Movement of potassium from the extracellular fluid to the intracellular fluid a.  Alkalosis b.  Hyperinsulinism (too much insulin in the blood, in turn, causing hypoglycemia. 4.  Dilution of serum potassium a.  Water intoxication b.  IV therapy with potassium-deficient solutions

Question 66

Hypokalemia (Cardiovascular assessment)

Answer 66

■ Thready, weak, irregular pulse ■ Weak peripheral pulses ■ Orthostatic hypotension

Question 67

Hypokalemia (Respiratory assessment)

Answer 67

■ Shallow, ineffective respirations that result from profound weakness of the skeletal muscles of respiration ■ Diminished breath sounds

Question 68

Hypokalemia (Neuromuscular assessment)

Answer 68

``` ■ Anxiety, lethargy, confusion, coma ■ Skeletal muscle weakness, eventual flaccid paralysis ■ Loss of tactile discrimination ■ Paresthesias ■ Deep tendon hyporeflexia ```

Question 69

Hypokalemia (Gastrointestinal assessment)

Answer 69

■ Decreased motility, hypoactive to absent bowel sounds ■ Nausea, vomiting, constipation, abdominal distention ■ Paralytic ileus

Question 70

Hypokalemia (Laboratory assessment)

Answer 70

■ Serum potassium level lower than 3.5 mEq/L | ■ Electrocardiogram changes: ST depression; shallow, flat, or inverted T wave; and prominent U wave

Question 71

Hypokalemia - Interventions:

Answer 71

1.  Monitor cardiovascular, respiratory, neuromuscular, gastrointestinal, and renal status, and place the client on a cardiac monitor. 2.  Monitor electrolyte values. 3.  Administer potassium supplements orally or intravenously, as prescribed. 4.  Oral potassium supplements a.  Oral potassium supplements may cause nausea and vomiting and they should not be taken on an empty stomach; if the client complains of abdominal pain, distention, nausea, vomiting, diarrhea, or gastrointestinal bleeding, the supplement may need to be discontinued. b.  Liquid potassium chloride has an unpleasant taste and should be taken with juice or another liquid. 5.  Intravenously administered potassium 6.  Institute safety measures for the client experiencing muscle weakness. 7.  If the client is taking a potassium-depleting diuretic, it may be discontinued; a potassium-retaining diuretic may be prescribed (Spironolactone, Aldactone, Dyazide, Maxide, Triamterene). 8.  Instruct the client about foods that are high in potassium content ****Potassium is never administered by IV push, intramuscular, or subcutaneous routes. IV potassium is always diluted and administered using an infusion device!

Question 72

Precautions with Intravenously Administered Potassium”

Answer 72

■ Potassium is never given by intravenous (IV) push or by the intramuscular or subcutaneous route. ■ A dilution of no more than 1 mEq/10 mL of solution is recommended. ■ Many healthcare agencies supply prepared IV solutions containing potassium; before administering and frequently during infusion of the IV solution, rotate and invert the bag to ensure that the potassium is distributed evenly throughout the IV solution. ■ Ensure that the IV bag containing potassium is properly labeled. ■ The maximum recommended infusion rate is 5 to 10 mEq/hour, never to exceed 20 mEq/hour under any circumstances. ■ A client receiving more than 10 mEq/hour should be placed on a cardiac monitor and monitored for cardiac changes, and the infusion should be controlled by an infusion device. ■ Potassium infusion can cause phlebitis; therefore the nurse should assess the IV site frequently for signs of phlebitis or infiltration. If either occurs, the infusion should be stopped immediately. ■ The nurse should assess renal function before administering potassium, and monitor intake and output during administration.

Question 73

Hyperkalemia (Potassium above 5.0 mEq/L) - Causes:

Answer 73

1.  Excessive potassium intake a.  Overingestion of potassium-containing foods or medications, such as potassium chloride or salt substitutes b.  Rapid infusion of potassium-containing IV solutions 2.  Decreased potassium excretion a.  Potassium-retaining diuretics b.  Kidney disease c.  Adrenal insufficiency, such as in Addison’s disease 3.  Movement of potassium from the intracellular fluid to the extracellular fluid a.  Tissue damage b.  Acidosis c.  Hyperuricemia d.  Hypercatabolism

Question 74

Sodium (Common Food Sources)

Answer 74

``` Bacon Butter Canned food Cheese Frankfurters Ketchup Lunch meat Milk Mustard Processed food Snack food Soy sauce Table salt White & wheat bread ```

Question 75

Potassium (Common Food Sources)

Answer 75

``` Avocado Bananas Cantaloupe Carrots Fish Mushrooms Oranges Potatoes Pork, beef, veal Raisins Spinach Strawberries Tomatoes ```

Question 76

Hyperkalemia - Interventions:

Answer 76

1.  Monitor cardiovascular, respiratory, neuromuscular, renal, and gastrointestinal status; place the client on a cardiac monitor. 2.  Discontinue IV potassium (keep the IV catheter patent), and hold oral potassium supplements. 3.  Initiate a potassium-restricted diet. 4.  Prepare to administer potassium-excreting diuretics if renal function is not impaired. 5.  If renal function is impaired, prepare to administer sodium polystyrene sulfonate (Kayexalate), a cation-exchange resin that promotes gastrointestinal sodium absorption and potassium excretion. 6.  Prepare the client for dialysis if potassium levels are critically high. 7.  Prepare for the administration of intravenous calcium if hyperkalemia is severe to avert myocardial excitability. 8.  Prepare for the IV administration of hypertonic glucose with regular insulin to move excess potassium into the cells. 9.  Monitor renal function. 10.  When blood transfusions are prescribed for a client with a potassium imbalance, the client should receive fresh blood, if possible; transfusions of stored blood may elevate the potassium level because the breakdown of older blood cells releases potassium. 11.  Teach the client to avoid foods high in potassium 12.  Instruct the client to avoid the use of salt substitutes or other potassium-containing substances. ****Monitor the serum potassium level closely when a client is receiving a potassium-retaining diuretic!

Question 77

Hyperkalemia (Cardiovascular assessment)

Answer 77

■ Slow, weak, irregular heart rate (dysrhythmias) | ■ Decreased blood pressure

Question 78

Hyperkalemia (Respiratory assessment)

Answer 78

■ Profound weakness of the skeletal muscles leading to respiratory failure

Question 79

Hyperkalemia (Neuromuscular assessment)

Answer 79

■ Early: Muscle twitches, cramps, paresthesias (tingling and burning followed by numbness in the hands and feet and around the mouth) ■ Late: Profound weakness, ascending flaccid paralysis in the arms and legs (trunk, head, and respiratory muscles become affected when the serum potassium level reaches a lethal level)******

Question 80

Hyperkalemia (Gastrointestinal assessment)

Answer 80

■ Increased motility, hyperactive bowel sounds | ■ Diarrhea

Question 81

Hyperkalemia (Laboratory findings assessment)

Answer 81

■ Serum potassium level that exceeds 5.0 mEq/L ■ Electrocardiographic changes: Tall peaked T waves, flat P waves, widened QRS complexes, and prolonged PR intervals****s

Question 82

“Electrocardiographic Changes in Electrolyte Imbalances” Hypocalcemia

Answer 82

Prolonged ST segment   Prolonged QT interval

Question 83

“Electrocardiographic Changes in Electrolyte Imbalances” Hypercalcemia

Answer 83

Shortened ST segment   Widened T wave

Question 84

“Electrocardiographic Changes in Electrolyte Imbalances” Hypokalemia

Answer 84

``` ST depression   Shallow, flat, or inverted T wave   Prominent U wave ```

Question 85

“Electrocardiographic Changes in Electrolyte Imbalances” Hyperkalemia

Answer 85

``` Tall peaked T waves   Flat P waves   Widened QRS complex   Prolonged PR interval ```

Question 86

“Electrocardiographic Changes in Electrolyte Imbalances” Hypomagnesemia

Answer 86

Tall T waves   Depressed ST segment

Question 87

“Electrocardiographic Changes in Electrolyte Imbalances” Hypermagnesemia

Answer 87

Prolonged PR interval   Widened QRS complexes

Question 88

Hypocalcemia (Calcium lower than 9.0 mg/dL) Causes:

Answer 88

1.  Inhibition of calcium absorption from the gastrointestinal tract a.  Inadequate oral intake of calcium b.  Lactose intolerance c.  Malabsorption syndromes such as celiac sprue or Crohn’s disease d.  Inadequate intake of vitamin D (helps calcium be reabsorbed) e.  End-stage kidney disease 2.  Increased calcium excretion a.  Kidney disease, polyuric phase b.  Diarrhea c.  Steatorrhea d.  Wound drainage, especially gastrointestinal 3.  Conditions that decrease the ionized fraction of calcium a.  Hyperproteinemia b.  Alkalosis c.  Medications such as calcium chelators or binders d.  Acute pancreatitis e.  Hyperphosphatemia f.  Immobility g.  Removal or destruction of the parathyroid glands

Question 89

Calcium (Common Food Sources)

Answer 89

Young Sally Calcium Serum Continues To Randomly Mess-up! ``` Cheese Collard greens Milk and soy milk Rhubarb Sardines Spinach Tofu Yogurt ```

Question 90

Hypocalcemia (Cardiovascular assessment)

Answer 90

■ Decreased heart rate ■ Hypotension ■ Diminished peripheral pulses

Question 91

Hypocalcemia (Respiratory assessment)

Answer 91

■ Not directly affected; however, respiratory failure or arrest can result from decreased respiratory movement because of muscle tetany or seizures

Question 92

Hypocalcemia (Neuromuscular assessment)

Answer 92

■ Irritable skeletal muscles: Twitches, cramps, tetany, seizures ■ Painful muscle spasms in the calf or foot during periods of inactivity ■ Paresthesias followed by numbness that may affect the lips, nose, and ears in addition to the limbs ■ Positive Trousseau’s and Chvostek’s signs ■ Hyperactive deep tendon reflexes ■ Anxiety, irritability

Question 93

Hypocalcemia (Renal assessment)

Answer 93

■ Urinary output varies depending on the cause

Question 94

Hypocalcemia (Gastrointestinal assessment)

Answer 94

■ Increased gastric motility; hyperactive bowel sounds | ■ Cramping, diarrhea

Question 95

Hypocalcemia (Laboratory findings)

Answer 95

■ Serum calcium level less than 8.6 mg/dL | ■ Electrocardiographic changes: Prolonged ST interval, prolonged QT interval

Question 96

Hypercalcemia (Cardiovascular assessment)

Answer 96

■ Increased heart rate in the early phase; bradycardia that can lead to cardiac arrest in late phases ■ Increased blood pressure ■ Bounding, full peripheral pulses

Question 97

Hypercalcemia (Respiratory assessment)

Answer 97

■ Ineffective respiratory movement as a result of profound skeletal muscle weakness

Question 98

Hypercalcemia (Neuromuscular assessment)

Answer 98

■ Profound muscle weakness ■ Diminished or absent deep tendon reflexes ■ Disorientation, lethargy, coma

Question 99

Hypercalcemia (Renal assessment)

Answer 99

■ Urinary output varies depending on the cause | ■ Formation of renal calculi; flank pain

Question 100

Hypercalcemia (Gastrointestinal assessment)

Answer 100

■ Decreased motility and hypoactive bowel sounds | ■ Anorexia, nausea, abdominal distention, constipation

Question 101

Hypercalcemia (Laboratory findings)

Answer 101

■ Serum calcium level that exceeds 10.5 mg/dL | ■ Electrocardiographic changes: Shortened ST segment, widened T wave

Question 102

Hypocalcemia (Calcium lower than 9.0 mg/dL) Interventions:

Answer 102

1.  Monitor cardiovascular, respiratory, neuromuscular, and gastrointestinal status; place the client on a cardiac monitor. 2.  Administer calcium supplements orally or calcium intravenously. - - after a meal or at bedtime with a full glass of water 3.  When administering calcium intravenously (ex: 10% calcium gluconate), warm the injection solution to body temperature before administration and administer slowly; monitor for electrocardiographic changes, observe for infiltration and monitor for hypercalcemia. - -also, watch pt's on digoxin because calcium may increase digoxin toxicity. 4.  Administer medications that increase calcium absorption. a.  Aluminum hydroxide reduces phosphorus levels, causing the countereffect of increasing calcium levels. b.  Vitamin D aids in the absorption of calcium from the intestinal tract. 5.  Provide a quiet environment to reduce environmental stimuli. 6.  Initiate seizure precautions. 7.  Move the client carefully, and monitor for signs of a pathological fracture. 8.  Keep 10% calcium gluconate available for treatment of acute calcium deficit. 9.  Instruct the client to consume foods high in calcium

Question 103

Diagnostic Tests for Hypocalcemia

Answer 103

A, Chvostek’s sign is contraction of facial muscles in response to a light tap over the facial nerve in front of the ear. B, Trousseau’s sign is a carpal spasm induced by inflating a blood pressure cuff (C) above the systolic pressure for a few minutes.

Question 104

Hypercalcemia (Calcium above 10.5 mg/dL) Causes:

Answer 104

1.  Increased calcium absorption a.  Excessive oral intake of calcium b.  Excessive oral intake of vitamin D 2.  Decreased calcium excretion a.  Kidney disease b.  Use of thiazide diuretics (calcium excretion decreased) 3.  Increased bone resorption of calcium a.  Hyperparathyroidism (causes too much calcium to be released in the blood) b.  Hyperthyroidism c.  Malignancy (bone destruction from metastatic tumors) d.  Immobility e.  Use of glucocorticoids (suppresses calcium absorption which leaves too much in the blood) 4.  Hemoconcentration a.  Dehydration b.  Use of lithium (affects parathyroid & causes phos increase and calcium increase) c.  Adrenal insufficiency (Addison's disease)

Question 105

Hypercalcemia Interventions:

Answer 105

1.  Monitor cardiovascular, respiratory, neuromuscular, renal, and gastrointestinal status; place the client on a cardiac monitor. 2.  Discontinue IV infusions of solutions containing calcium and oral medications containing calcium or vitamin D. 3.  Discontinue thiazide diuretics and replace with diuretics that enhance the excretion of calcium. 4.  Administer medications as prescribed that inhibit calcium resorption from the bone, such as phosphorus, calcitonin (Calcimar), bisphosphonates, and prostaglandin synthesis inhibitors (aspirin, nonsteroidal anti-inflammatory drugs). 5.  Prepare the client with severe hypercalcemia for dialysis if medications fail to reduce the serum calcium level. 6.  Move the client carefully and monitor for signs of a pathological fracture. 7.  Monitor for flank or abdominal pain, and strain the urine to check for the presence of urinary stones. (Too much calcium increases stone formation) ***A client with a calcium imbalance is at risk for a pathological fracture. Move the client carefully and slowly; assist the client with ambulation.

Question 106

Hypomagnesemia (Magnesium lower than 1.3 mEq/L) Causes:

Answer 106

1.  Insufficient magnesium intake a.  Malnutrition and starvation b.  Vomiting or diarrhea c.  Malabsorption syndrome (plus, proton pump inhibitors i.e. Protonix, Prilosec, Nexium and & GI drugs ending in "Prazole") d.  Celiac disease e.  Crohn’s disease f. Hypokalemia & hypocalcemia can cause hypomagnesemia 2.  Increased magnesium secretion a.  Medications such as diuretics (loop & thiazides) b.  ***Chronic alcoholism (ETOH stimulates kidneys to waste Mag, acute pancreatitis c. Cyclosporines (stimulates kidney to waste mag) 3.  Intracellular movement of magnesium a.  Hyperglycemia b.  Insulin administration c.  Sepsis

Question 107

Hypomagnesemia (Magnesium lower than 1.3 mEq/L) Interventions:

Answer 107

1.  Monitor cardiovascular, respiratory, gastrointestinal, neuromuscular, and central nervous system status; place the client on a cardiac monitor. 2.  Because hypocalcemia frequently accompanies hypomagnesemia, interventions also aim to restore normal serum calcium levels. 3.  Oral preparations of magnesium may cause diarrhea and increase magnesium loss. 4.  Magnesium sulfate by the IV route may be prescribed in severe cases (intramuscular injections cause pain and tissue damage); initiate seizure precautions, monitor serum magnesium levels frequently, and monitor for diminished deep tendon reflexes, suggesting hypermagnesemia, during the administration of magnesium. 5.  Instruct the client to increase the intake of foods that contain magnesium

Question 108

Hypermagnesemia (Magnesium above 2.1 mEq/L) Causes:

Answer 108

1.  Increased magnesium intake a.  Magnesium-containing antacids and laxatives (Mylanta, Maalox) b.  Excessive administration of magnesium intravenously (correcting hypomagnesemia with mag sulfate) 2.  Decreased renal excretion of magnesium as a result of renal insufficiency

Question 109

Hypermagnesemia (Magnesium above 2.1 mEq/L) Interventions:

Answer 109

1.  Monitor cardiovascular, respiratory, neuromuscular, and central nervous system status; place the client on a cardiac monitor. 2.  Diuretics are prescribed to increase renal excretion of magnesium. 3.  Intravenously administered calcium chloride or calcium gluconate may be prescribed to reverse the effects of magnesium on cardiac muscle. 4.  Instruct the client to restrict dietary intake of magnesium-containing foods 5.  Instruct the client to avoid the use of laxatives and antacids containing magnesium. ****Calcium gluconate is the antidote for magnesium overdose!

Question 110

Magnesium (Common Food Sources)

Answer 110

``` Avacado Canned white tuna Green leafy vegetables, such as spinach and broccoli Milk Nuts Oatmeal, wheat bran Peanut butter, almonds Peas Pork, beef, chicken, soybeans Potatoes Raisins Yogurt ```

Question 111

Hypomagnesemia (Cardiovascular assessment)

Answer 111

■ Tachycardia ■ Hypertension ■ **Torsades de pointes (lethal abnormal rhythm seen in ETOH abuse)

Question 112

Hypermagnesemia (Cardiovascular assessment)

Answer 112

■ Bradycardia, dysrhythmias (heart blocks) | ■ Hypotension

Question 113

Hypomagnesemia (Respiratory assessment)

Answer 113

■ Shallow respirations (weak)

Question 114

Hypermagnesemia (Respiratory assessment)

Answer 114

■ Respiratory insufficiency when the skeletal muscles of respiration are involved

Question 115

Hypomagnesemia (Neuromucular assessment)

Answer 115

■ Twitches; paresthesias ■ Positive Trousseau’s and Chvostek’s signs ■ Hyperreflexia ■ Tetany (abnormal twtiching), seizures

Question 116

Hypermagnesemia (Neuromuscular assessment)

Answer 116

■ Diminished or absent deep tendon reflexes | ■ Skeletal muscle weakness

Question 117

Hypomagnesemia (Central nervous system)

Answer 117

■ Irritability | ■ Confusion

Question 118

Hypermagnesemia (Central nervous system)

Answer 118

■ Drowsiness and lethargy that progresses to coma

Question 119

Hypomagnesemia (Laboratory findings)

Answer 119

■ Serum magnesium level less than 1.6 mg/dL | ■ Electrocardiographic changes: Tall T waves, depressed ST segments***

Question 120

Hypermagnesemia (Laboratory findings)

Answer 120

■ Serum magnesium level that exceeds 2.6 mg/dL | ■ Electrocardiographic changes: Prolonged PR interval, widened QRS complexes

Question 121

Hypophosphatemia (phosphorus lower than 3.0 mg/dL) Causes:

Answer 121

1.  Insufficient phosphorus intake: Malnutrition and starvation 2.  Increased phosphorus excretion a.  Hyperparathyroidism b.  Malignancy c.  Use of magnesium-based or aluminum hydroxide–based antacids 3.  Intracellular shift a.  Hyperglycemia b.  Respiratory alkalosis

Question 122

Hypophosphatemia (phosphorus lower than 3.0 mg/dL) Assessments:

Answer 122

1.  Cardiovascular a.  Decreased contractility and cardiac output b.  Slowed peripheral pulses 2.  Respiratory: Shallow respirations 3.  Neuromuscular a.  Weakness b.  Decreased deep tendon reflexes c.  Decreased bone density that can cause fractures and alterations in bone shape d.  Rhabdomyolysis (breakdown of muscle tissue that causes the release of myoglobin that's harmful to the kidneys) 4.  Central nervous system a.  Irritability b.  Confusion c.  Seizures 5.  Hematological a.  Decreased platelet aggregation and increased bleeding b.  Immunosuppression

Question 123

Hypophosphatemia (phosphorus lower than 3.0 mg/dL) Interventions:

Answer 123

1.  Monitor cardiovascular, respiratory, neuromuscular, central nervous system, and hematological status. 2.  Discontinue medications that contribute to hypophosphatemia. 3.  Administer phosphorus orally along with a vitamin D supplement. 4.  Prepare to administer phosphorus intravenously when serum phosphorus levels fall below 1 mg/dL and when the client experiences critical clinical manifestations. 5.  Administer IV phosphorus slowly because of the risks associated with hyperphosphatemia. 6.  Assess the renal system before administering phosphorus. 7.  Move the client carefully, and monitor for signs of a pathological fracture. 8.  Instruct the client to increase the intake of the phosphorus-containing foods while decreasing the intake of any calcium-containing foods. ***A decrease in the serum phosphorus level is accompanied by an increase in the serum calcium level, and an increase in the serum phosphorus level is accompanied by a decrease in the serum calcium level.

Question 124

Hyperphosphatemia (phosphorus above 4.5 mg/dL) Causes:

Answer 124

1.  Decreased renal excretion resulting from renal insufficiency 2.  Tumor lysis syndrome 3.  Increased intake of phosphorus, including dietary intake or overuse of phosphate-containing laxatives or enemas 4.  Hypoparathyroidis

Question 125

Hyperphosphatemia (phosphorus above 4.5 mg/dL) Assessments:

Answer 125

Refer to the assessment of hypocalcemia

Question 126

Hyperphosphatemia (phosphorus above 4.5 mg/dL) Interventions:

Answer 126

1.  Interventions entail the management of hypocalcemia. 2.  Administer phosphate-binding medications that increase fecal excretion of phosphorus by binding phosphorus from food in the gastrointestinal tract. 3.  Instruct the client to avoid phosphate-containing medications, including laxatives and enemas. 4.  Instruct the client to decrease the intake of food that is high in phosphorus 5.  Instruct the client in medication administration: Take phosphate-binding medications, emphasizing that they should be taken with meals or immediately after meals.

Question 127

Phosphorus (Common Food Sources)

Answer 127

``` Dairy products Fish Nuts Pork, beef chicken, organ meats Pumpkin, squash Whole-grain breads and cereals ```