Fluid Imbalances Flashcards
(108 cards)
1
Q
Occurs when water and electrolytes are lost in the same proportion as they exist in normal body fluids
A
Hypovolemia
2
Q
Causes of hypovolemia in ABNORMAL FLUID LOSS
A
-Vomiting
-Diarrhea
-GI suctioning
-Profuse Diaphoresis
3
Q
Causes of hypovolemia in DECREASED INTAKE
A
-Nausea
-Lack of access to fluid
4
Q
Causes of hypovolemia in THIRD SPACING
A
-Edema in burn
-Ascites in liver dysfunction
5
Q
Other causes of hypovolemia are:
A
-Diabetes insipidus
- adrenal insufficiency
6
Q
Clinical Manifestations of Hypovolemia
A
FEW CHART
-Flat neck veins
-Eyes Sunken
-Weight loss
-Concentrated urine (SG> 1.025, oliguria)
-Hypotension
-Anxiety
-Rapid, weak pulse; Respirations increased
-Temperature elevated
7
Q
Medical Management of Hypovolemia
A
-Fluid Replacement Therapy
if with mild to moderate
-Increase oral fluids
-Oral rehydration salts (ex: hydrite)
If severe:
IV therapy
If with hypotension, give isotonic fluid
Once normotensive, give hypotonic fluids
Antidiarrheals, if with diarrhea
-Loperamide (Diatabs)
Antiemetics, if with nausea/vomiting
-Metoclopramide (Plasil
8
Q
Nursing Management of Hypovolemia
A
- Monitor I&O and daily weights, as ordered
-Monitor Vital Signs; Watch out for Hypotension and Tachycardia
-Monitor skin and tongue turgor
-Encourage small, frequent sips of oral fluids; Consider like and dislikes of patient
-Regulate IV fluid to a prescribed rate
-Administer medications, as prescribed
9
Q
Refers to an isotonic expansion of the ECF caused by the abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ECF
Also known as fluid overload
A
Hypervolemia
10
Q
Hypervolemia causes
A
-Heart Failure
-Kidney Injury
-Liver Cirrhosis
-Excessive salt intake
-Excessive administration of sodium- containing fluids in patients with impaired regulatory mechanisms
11
Q
Hypervolemia Clinical Manifestations
A
-Edema
-Distended neck veins
-Puffy eyelids
-Crackles
- Weight gain
- Hypertension
- Bounding pulse
-Tachypnea, dyspnea
-Increased urine output; dilute urine
12
Q
Nursing Management of Hypervolemia
A
-Monitor I&O as ordered
- Weigh daily, WOF rapid weight gain (1 kg= 1l of fluid)
-Monitor breath sounds, especially if with therapy
-Monitor for presence of edema
-Feet and ankles for ambulatory patients
- Sacral area for bed ridden patients
-Encourage bed rest- this favors diuresis
-Regulate IVF as prescribed
-Place on semi-fowlers position if with dyspnea
-Reposition at regular intervals to prevent ULCERS
-Emphasize need to read food labels
-Instruct to avoid foods high in sodium
- Encourage use of seasoning substitutes such as lemon juice, onions, and garlic
13
Q
Medical Management of Hypervolemia
A
-Low sodium diet (mild restriction to as low as 250 mg/day)
- Diuretics
-Thiazide Diuretics- mild to moderate hypervolemia
-Loop Diuretics- severe hypervolemia
-Potassium supplementation, to prevent hypokalemia while on diuretics
-Dialysis for severe renal impairment
14
Q
ECF concentration of sodium
A
135-145 mEq/L
15
Q
It controls the body water distribution and establishes the electrochemical state necessary for muscle contraction and nerve impulse transmission
A
Sodium
16
Q
If serum sodium level is <135 mEq/L it is known as
A
Hyponatremia
17
Q
Causes of Hyponatremia
A
-Vomiting
-Diarrhea
-Gastric suctioning
-Decreased aldosterone (Addison’s disease)
-Water intoxication
-CHF
Chronic Renal Failure
18
Q
Medications that can also caused Hyponatremia
A
-Diuretics
- Lithium
- Cisplastin
-Heparin
- NSAIDs
19
Q
Hyponatremia develops when:
A
-There is too much water relative to the amount of sodium
- Too little sodium relative to the amount of water
20
Q
Mostly asymptomatic but can report/present with headache, nausea, vomiting, fatigue, confusion, anorexia, muscle cramps
A
Mild Hyponatremia
21
Q
Gait disturbances, headache, vomiting, fatigue, confusion, muscle cramps, depressed deep tendon reflexes
A
Moderate Hyponatremia
22
Q
Delirium, restlessness, agitation or lethargy, seizures, brainstem herniation, respiratory arrest, coma, death
A
Severe Hyponatremia
23
Q
Serum sodium level of Mild Hyponatremia
A
130-134
24
Q
Serum sodium level of Moderate Hyponatremia
A
125-129
25
Serum sodium level of Severe Hyponatremia
<120
26
Medical Management of Hyponatremia
Sodium Replacement
- Sodium-rich diet for those who can eat and drink
- NaCI tablets
- PLR or PNSS IV infusion, for those who cannot take sodium by mouth
Water restriction
-Indicated for hyponatremic patients with normal or excess fluid volume
Hypertonic saline solution
-Indicated for severe hyponatremia
27
Drug therapy for Hyponatremia
-AVP receptor antagonists (ends with vaptans)
-Conivaptan HCI (Vaprisol) IV
- Tolvaptan (Samsca)
28
Conivaptan HCI (Vaprisol) IV indication
Hospitalized patients with moderate to severe hyponatremia
This drug is contraindicated to seizure, delirium and coma
29
Tolvaptan (Samsca) indication
Oral medication for clinically significant hypervolemic and euvolemic hyponatremia
30
Mechanism of action of AVP receptor antagonists
Act on AVP receptors in the renal tubules to promote aquaresis
31
Nursing Management of Hyponatremia
-Monitor I&O and daily weights
- Monitor laboratory values
- Monitor the progression of manifestations
-For patients who are able to consume by mouth, encourage foods and fluids with high sodium content
-Broth made with one beef cube (900 mg)
- 8 oz of tomato juice (700 mg)
-Administer IV fluids, as prescribed
-WOF signs of circulatory overload:
-Cough, dyspnea, puffy eyelids, dependent edema, excessive weight
gain in 24 hours, crackles
-Institute safety precautions:
-Keep side rails up
- Supervised ambulation
32
Serium sodium level >145 mEq/L
Hypernatremia
33
Causes of Hypernatremia (MODEL)
M-Medications, meals
O- Osmotic diuretics
D- Diabetes insipidus
E- Excessive water loss
L- Low water intake
34
Clinical Manifestations of Hypernatremia
-Extreme thirst- the first sign
-Dry, sitcky mucous membranes
-Oliguria
-Firm, rubbery turgor
-Red, dry, swollen tongue
- Restlessness, tachycardia, fatigue
- Disorientation, hallucination
35
Hypernatremia Medical Management
SAFETY ALERT!
-Serum sodium correction should be done gradually
-Too rapid reduction in sodium level renders then plasma temporarily hypo-osmotic to the brain tissue.
TREAT UNDERLYING CAUSE
-Sodium correction
- Hypotonic electrolyte solution- first line
- IV of Choice: 0.3% NaCI
-Isotonic nonsaline solution- second line
-D5W- indicated when water needs to be replaced without sodium
36
Hypernatremia Nursing Management
-Provide oral fluids at regular intervals
- Restrict sodium in diet, as prescribed
-Monitor behavioral changes
- Promote safety
- Monitor intake and output
37
It is the most abundant electrolyte in the ICF
Potassium
38
Its normal concentration is 3.5 to 5 mEq/L
Potassium
39
Has an inverse relationship with sodium; a direct relationship with magnesium
Potassium
40
Potassium functions
1. Maintains ICF volume
2. Neuromuscular excitabillity
3. Regulates contraction and rhythm of the heart
41
Serum potassium level is <3.5 mEq/L
Hypokalemia
42
Causes of Hypokalemia (SAD BITCH)
S-Starvation
A- Alkalosis (promotes the transcellular shift of K+)
D- Drugs (Furosemide, Hydrocortisone, Laxatives)
B- Bulimia nervosa
I- Inadequate intake of K+
T- Too much insulin
C- Cushing's syndrome (causes kidneys to excrete K+)
H- Heavy fluid loss
43
In hypokalemia, everything is
In hypokalemia, "everything is low and slow"
44
Clinical Manifestations of Hypokalemia 7L (LLLLLLL)
Lethargy- drowsy and fatigued (early sign)
Low, shallow respirations.... failure
Lethal cardiac dysrhythmias (ST depression, shallow T wave, prominent U wave)
Lots of urine (frequency and volume
Leg cramps
Limp muscles
Low blood pressure
45
Medical Management of Hypokalemia
-Potassium chloride
-Oral supplementation for mild to moderate hypokalemia
-S/E: small bowel lesions
-Assess for abdominal distention, pain of GI bleeding
-IV route for severe hypokalemia (K+ of 2 mEq/L)
-Incorporate in IV bottle, as ordered
- Never give by IV push or direct IV- this causes fetal dysrhythmias
and cardiac arrest
46
Characteristics of IV potassium chloride
-Potassium is excreted via the kidneys
-Should be given ONLY after adequate UO has been established
- A decrease in UO to less than 20 ml per hour for 2 consecutive hours is an indication to stop potassium infusion
-Use an infusion pump as much as possible
- Monitor patient by continuous ECG while infusion is going on
-Apply warm compress to IV site
47
Hypokalemia Nursing Management
-Monitor for early presence in at-risk patients
-Encourage them to consume potassium-rich foods
- Educate on the proper use of laxatives and/ or diuretics
- Monitor I&O- 1L of urine output = 40 mEq/L K+ loss
-Administer potassium replacement, as ordered and using the recommended method of administration
48
Hypokalemia Nursing Management
-Monitor for early presence in at-risk patients
-Encourage them to consume potassium-rich foods
- Educate on the proper use of laxatives and/ or diuretics
- Monitor I&O- 1L of urine output = 40 mEq/L K+ loss
-Administer potassium replacement, as ordered and using the recommended method of administration
49
Serum potassium level is >5 mEq/L
Hyperkalemia
50
Less common than hypokalemia and its more life-threatening because cardiac arrest is more frequently associated with its occurrence
Hyperkalemia
51
Causes of Hyperkalemia (CARED)
C-cellular movement of K+ from ICF to ECF
A- Addison's disease (hypoaldosteronism)
R- Renal failure
E- Excessive K+ intake
D- Drugs (Spironolactone, ACE inhibitors, NSAIDs)
52
In hyperkalemia, everything is
In hyperkalemia, "everything is high and fast"
53
Clinical Manifestations of Hyperkalemia "Murder"
M-Muscle weakness (Late Sign)
U- Unable to calm down (Irritability, anxiety)
R- Respiratory failure (sec. to muscle weakness)
D- Decreasing cardiac contractility (tachycardia-bradycardia)
E- Early sign: Muscle twitch/cramps
R- Rhythm abnormalities: Tall, peaked T waves and prolonged PR interval (most dangerous)
54
Hyperkalemia Medical Management
-Obtain ECG to detect changes
-Potassium restriction (diet and meds) v
-Calcium gluconate IV
-Emergency management for extremely high K+ levels
-MOA: calcium antagonizes the action of hyperkalemia on the heart
but does not lower serum K+ level
-S/E: hypotension, bradycardia
Sodium polystyrene sulfonate (Kayexelate)
-Cation exchange resin
- Administer via PO or retention enema
- MOA: Increases fecal potassium excretion through binding of
potassium in the lumen of the gastrointestinal tract
-C/I: paralytic ileus
55
Hyperkalemia protocol in the medical management of HYPERKALEMIA
-Regular insulin (IV) + D50W: causes temporary shift of potassium into the cells
-Beta- 2 agonist (Salbutamol)
-Nebulized
- MOA: moves potassium into cells
-S/E: tachycardia, chest discomfort
-Dialysis
56
Hyperkalemia Nursing Management
-Monitor I&O closely monitor signs of muscle weakness and dysrhythmias
- Monitor vital signs, use apical pulse
- Administer medications, as prescribed
- Encourage patient to strictly adhere to potassium restriction
-Avoid fruits and vegetables, legumes, whole grain breads, lean meat, milk, eggs, coffee, tea, and cocoa
-Caution patient to use salt substitutes sparingly if they are taking other supplementary forms of potassium-sparing diuretics
57
Located primarily in the bones and teeth; the rest can be found circulating in the serum
Calcium
58
Its functions are:
-Bone mineralization
- Stabilizes the resting membrane potential of neurons thereby preventing their spontaneous activation
-Regulation of muscle contraction- causes actin and myosin filaments to slide into each other
-Cardiac contractility and conduction
- Blood coagulation (Factor IV)
Calcium
59
The types of calcium
- Ionized calcium
- Protein-bound calcium
- Calcium complexed to anions
60
Normal values of ionized calcium
4.5 to 5.1 mg/dl
61
Serum calcium level <8.5 mg/dl
Hypocalcemia
62
Causes of hypocalcemia
-Primary Hypoparathyroidism
- Surgical Hypoparathyroidism
- Radical neck dissection
- Massive administration of citrated blood
- Pancreatitis
- Kidney injury
- Prolonged bed rest/ bed ridden patients
63
In hypocalcemia, everything is
"everything is high, and fast"
64
Clinical Manifestations of Hypocalcemia
-Tetany
-Late Tetany
- Numbness, tingling, and cramps in the extremities
-Stiffness of hands and feet
-Over Tetany
65
One of the clinical manifestations of hypocalcemia are general muscle hypertonia, with tremors and spasmodic or uncoordinated contractions occurring with or without efforts to make voluntary movement
Tetany
66
Clinical Manifestations of Over Tetany in Hypocalcemia
-Bronchospasm
- Laryngospasm
- (+) Trousseau's sign: carpopedal spasm resulting from occlusion of the blood flow to the arm 3 minutes
- (+) Chvostek's sign: sharp tapping over the facial nerve causes spasm or twitching of mouth, nose, eye
- Seizures
- Dysrhythmias- torsades de pointes
- Photophobia
67
A contraction of the facial muscles elicited in response to light tap over the facial nerve in front of the ear
Chvostek Sign
68
A carpopedal spam included by inflating a blood pressure cuff above systolic blood pressure
Trosseau sign
69
Another Clinical Manifestations of Hypocalcemia
-Hypotension
- ECG Changes- Prolonged QT interval and lengthened ST segment
- Labs: hypomagnesemia
70
Medical Management of Hypocalcemia
- Calcium Salts IV
-Calcium gluconate ( 4.5mEq)
- Calcium chloride (13.5 mEq)
Nursing responsibility:
-Administer via slow/ IV slow of infusion
- Asses IV site for evidence of infiltration
- Do not use PNSS as it increases renal calcium loss; use D5W instead
of dilute solution
- Do not use concurrently with solutions containing phosphates or
bicarbonate
- Vitamin D- increases calcium absorption from the GI tract
- Calcium supplements (to be taken with meals)
-High calcium diet
-Milk products
-Green, leafy vegetables
- Canned salmon
- Canned sardines
- Fresh oysters
71
Nursing Management of Hypocalcemia
- Monitor and maintain airway patency
- Institute seizure precautions
- Reduce environmental stimulation
- Identify and modify triggers
-Padded side rails
- Bed in lowest position
-Oxygen and suction readily available
-Encourage intake of calcium-rich foods
- Advise to quit smoking and consume alcohol and caffeine in moderation
-Advise to avoid overuse of laxatives and antacids that contain phosphorus
72
Serum Calcium level of > 10.5 mg/dL
Hypercalcemia
73
Causes of Hypercalcemia
-Malignancies
-Hyperparathyroidism
- Thiazide diuretics
- Vitamin A and D toxicity
-Chronic lithium use
- Theophylline toxicity
74
In hypercalcemia, everything is
In hypercalcemia, "everything is low and slow"
75
Clinical Manifestations of Hypercalcemia (BACK ME UP)
B- Bone pain
A- Arrythmias (heart blocks, shortened QT interval and ST segment)v
C- Cardiac arrest (MOST DANGEROUS), constipation
K- Kidney stones
M- Muscle weakness
E- Excessive urination
U- Uhaw (thirst)
P- Pathologic fractures
76
Medical Management of Hypercalcemia
-0.9% NaCI solution
-Furosemide (Lasix)
-Calcitonin IM
-Corticosteroids
-Pamidronate disodium (Aredia)
-Mithramycin
77
One of the medical management of Hypercalcemia that temporarily dilutes serum calcium and increases urinary calcium excretion
0.9% NaCI solution
78
The medical management of Hypercalcemia that used in conjunction with PNSS and promotes diuresis and enhances calcium excretion
Furosemide (Lasix)
79
One of the medical management of Hypercalcemia that lowers calcium level by increasing calcium and phosphorus disposition into bones and is useful for patients with heart disease or kidney injury
Calcitonin IM
80
Medical Management of Hypercalcemia
Decrease bone turnover and tubular reabsorption for patients with sarcoidosis, myelomas, lymphomas, and leukemia
Corticosteroids
81
Medical Management of Hypercalcemia
-Biphosphonate
- Inhibits osteoclastic activity
- S/E: fever, transient leukopenia
Pamidronate disodium (Aredia)
82
Medical Management of Hypercalcemia
-Cytotoxic antibiotic
- Inhibits bone resorption and thus lowers serum calcium level
-Mithramycin
83
Hypercalcemia Nursing Management
-Encourage early and frequent ambulation
- Encourage oral fluids up to 3-4 L/day
- Encourage high fiber diet
-Implement safety precautions, as necessary
-Assess for signs of digitalis toxicity (Calcium enhances effects of digoxin)
-Monitor heart rate and rhythms
84
Intracellular cation and has a direct relationship with potassium and calcium
Magnesium
85
Normal serum magnesium is
1-3. 2.3 mg/dl
86
1/3 is
Protein bound
87
2/3 are
free cations- the active components
88
It is absorbed in the small intestine
Magnesium
89
Functions of Magnesium
-Activatior of IC enzme systems
- Plays a role in CHO and CHON metabolism
- Affects neuromuscular irritability and contractility
-Has a sedative effect- inhibits release of ACh
-Vasolidator and decreases peripheral resistance
90
Serum MG level is <1.3 mg/dl
Hypomagnesemia
91
Frequently associated with hypokalemia and hypocalcemia
Hypomagnesemia
92
Hypoalbuminemia is equal to
Hypomagnesemia
93
Hypomagnesemia causes (FAT GUM)
F-fistulas
A- Alcohol withdrawal
T- Tube feedings/TPN (magnesium def)
G- Gastric suctioning prolonged
U- Uncontrolled BM (Diarrhea)
M- Malabsorption disorders (small intestine)
94
In hypomagnesemia, everything is
In hypomagnesemia, "everything is high and fast"
95
Clinical Manifestations of Hypomagnesemia
-Cramps, spasticity
- (+) Trousseau and Chvostek sign
-Insomnia
-Mood changes
-Anorexia, vomiting
-Increased tendon reflexes
- Hypertension
-Similar to hypocalcemia
ECG changes:
-Depressed ST segment
-Prolonged QRS
- Dysrhythmias
-PVCs
- SVT
-Torsades de pointes
- Ventricular fibrillation
96
Medical Management of Hypomagnesemia
- High magnesium diet for mild deficiencies
- Green leafy vegetables
-Nuts
- Seeds
- Legumes
- Whole grains
- Seafoods
-Peanut butter
-Cocoa
-Magnesium supplements
-Magnesium sulfate IV
- For patients with overt manifestations of hypomagnesemia
- Administered using an infusion pump at a controlled rate
Nursing responsibilities:
-Monitor vital signs
- Monitor urine output; refer if U/O<100 mL over 4 hours
-Calcium gluconate at bedside
97
Hypomagnesemia Nursing Management
-Monitor at risk patients for signs and symptoms
-Institute seizure precautions (severe hypomagnesemia)
- Implement safety precautions if with confusion
-Educate on major sources of magnesium-rich foods
97
Hypomagnesemia Nursing Management
-Monitor at risk patients for signs and symptoms
-Institute seizure precautions (severe hypomagnesemia)
- Implement safety precautions if with confusion
-Educate on major sources of magnesium-rich foods
98
Hypomagnesemia Nursing Management
-Monitor at risk patients for signs and symptoms
-Institute seizure precautions (severe hypomagnesemia)
- Implement safety precautions if with confusion
-Educate on major sources of magnesium-rich foods
99
Hypomagnesemia Nursing Management
-Monitor at risk patients for signs and symptoms
-Institute seizure precautions (severe hypomagnesemia)
- Implement safety precautions if with confusion
-Educate on major sources of magnesium-rich foods
100
Serum mg of >2.3 mg/dl
Hypermagnesemia
101
Rare electrolyte abnormality
Hypermagnesemia
102
Falsely elevated Mg++ may result from
-Hemolyzed blood specimen
- Blood drawn from an extremity with a tourniquet that was applied too tightly
103
Causes of Hypermagnesemia
- Kidney injury
- Excessive intake of magnesium- containing antacids
-DKA
104
Hypermagnesemia clinical manifestations
-Flushing
-Hypotension
-Muscle weakness
- Drowsiness
- Hypoactive reflexes
-Respiratory depression
- Cardiac arrest
-Coma
-Diaphoresis
105
Hypermagnesemia causes ECG to change, what are those manifestations when ECG changes
-Bradycardia
-Prolonged PR interval and QRS
-Peaked T wave
106
Hypermagnesemia Medical Management
-Avoid giving magnesium to patients with kidney injury
-Discontinue all sources of magnesium if with severe hypermagnesemia
- Calcium Gluconate IV
-Calcium antagonizes magnesium
-Ventilatory support, if with respiratory depression
-Hemodialysis
-If with adequate renal function:
-Furosemide (Lasix)
- PLR or PNSS
107
Hypermagnesemia nursing management
-Monitor vital signs, noting hypotension and shallow respirations
-Assess deep tendon reflexes
-Assess the level of consciousness
-Caution on the use of OTC medications
