MNT — Exam #1 : Part 1 Flashcards
1
Q
When did dietetics begin?
A
- First defined in 1899 by American Association of Home Economics → “Individuals with knowledge of food who provide diet therapy for the medical profession”;
- 1917 – American Dietetics Association;
- Dietitians used to be thought of simply people in the kitchen working with food all the time → Little though was given to the clinical aspect of nutrition
2
Q
How did dietetics change in the 1970s?
A
- High levels of malnutrition in hospitals lead to better nutritional delivery both enteral and parenteral ;
- Dietitians took on lead role of screening and monitoring the needs for nutritional support of the patients
3
Q
What is now the role of the Clinical Dietitian?
A
- Clinical dietetics moved into the realm of disease prevention by providing primary and secondary care relating to atherosclerosis, cancer, T2DM, etc.;
- Now, seen as experts in treating nutritional and medical support for disease
4
Q
How are Clinical Dietitians defined?
A
- Originally those who were employed in hospitals;
- Now a provision of specialized care and modification of diets to treat medical conditions
5
Q
What is Nutrition Therapy?
A
- Practice of clinical nutrition;;
- Provided by dieticians using the nutrition care process (NCP)
6
Q
What is the Nutrition Care Process? (NCP)
A
- Method utilized by dietitians and other medical staff to deliver medical nutritional care to patients;
- ADIM/E =
1. Nutritional assessment;
2. diagnosis;
3. intervention;
4. monitoring/ evaluation
7
Q
What is Health Care?
A
prevention, treatment, and/or management of illness
8
Q
What is the Scope of Practice (SOP)?
A
- Meant to serve as the defining realm that makes up all of dietetics and what dieticians are meant to treat;
- Boundary around the profession that is subject to change as nutrition care becomes more involved;
- Flexibility and growth of the SOP allows dietetics to growth and treat patients in even more ways as the understanding progresses.
9
Q
What are the goals of the dietetics Competencies?
A
The overall goal of the competencies is to find a systematic manner in which the dietician moves through a series of steps and reasoning to yield to most complete and medically appropriate care to each patient no matter the problem or resulting treatment.
10
Q
What does an individual need to achieve Competence in Practice?
A
- Utilization of the scientific method;
- Strategic problem solving;
- Making informed decisions regarding practice and care based on the issue at hand;
- Application of diagnostic reasoning.
11
Q
What is the SOP Decision Tool?
A
- Provided by AND to dietetics professionals as a way in which to self-manage and enhance their field of treatment;
- Allows dieticians to exam their own capabilities and mandated regulations;
- They determine if they are clinically sound to provide their services in specified area or certain patients.
12
Q
What are the 3 components required to become an RD?
A
- Didactic training;
- Clinical supervised practice or internship;
- Passing the Dietetic Registration Exam
13
Q
What are Practice Standards?
A
- Standards refer to the ways in which an RD or other clinician goes about critically treating patients equally and to the best of their ability in all cases;
- Forms = ethical, criteria-based, evaluation of outcomes and Standards of Professional Performance.
14
Q
What are the Practice Standards documents?
A
-AND Code of Ethics;
-AND Standards of Professional Performance;
….which coexist through outcomes research, are examples of documents that dictate dietetic standards.
15
Q
What is the CDR Development Portfolio?
A
- Personal compilation of the experiences, certifications, and overall qualifications of an RD;
- Resume for RD’s that continually needs to grow with years of clinical practice;
- Dietitians continually need to generate more certifications and acquire more knowledge to strengthen their practitioners’ portfolio.
16
Q
What are Practice Resources?
A
- Several resources, sets of information, and methods that aid dietitians in providing optimum care to patients;
- EX: EAL, Nutrition Care Process, Definition List, Nutrition Care Manual, etc.
17
Q
What are the types of Acute Care Facilities?
A
- Hospitals;
2. Clinics
18
Q
What are the classifications of Hospitals?
A
- Public not for Profit – usually owned and managed by the country or state government;
- Private not for profit – owned or managed by the community, a religious organization, district health councils, or own hospital board;
- Private for profit – investor-owned (for-profit) health care organization;
- Veterans and Military – government-run health care facilities for veterans of the US military service and active-duty men/women
19
Q
What the classifications for Clinics?
A
- Outpatient- similar categories as above – For preventative, primary-care (EX: infection) ; and secondary health care (EX: T2DM);
- Urgent care – primary care
20
Q
What are the types of Longer-Care Facilities?
A
- Skilled Nursing Facilities (SNIF), Long term Acute Care (LTAC) – custodial services for the CHRONICALLY ill and disabled;
- Residential: Assisted Living – Complete Care Nursing Facilities – custodial services for activities of DAILY LIVING (EX: bathing, getting dressed) ;
- Rehabilitation/Restorative – provide assistance with RECOVERY from acute or chronic illness and/or surgical procedures (EX: Stroke);
- Hospice – comfort care for those who are not expected to live more than SIX months
21
Q
What is an RD/RDN?
A
- Provides nutritional care for patients → nutritional screening/assessment of pts determines presence or risk of nutrition-related problem;
- Develops a nutritional diagnosis, intervention and monitors/evaluates the nutrition care plan
22
Q
What is a DTR?
A
- ASSISTS the clinical dietician → gathers data for the screening; assigns level of risk for malnutrition;
- Administers nourishments and supplements to patients and monitors tolerance; provides info to help pts select menus and gives simple diet instructions
23
Q
What are Physical Therapists?
A
- Doctorate of physical therapy;
- PT’s provide therapy with the specific focus on the patients ability of movement and use of limbs. This can include simply improving or developing functionality, regaining use after surgery or injury, to enhancing strength to ease pain to all provide better mobility.
24
Q
What are Occupational Therapists?
A
- Masters degree and passed a registration exam;
- Assists pts to improve their ability to perform tasks in living and working environments;
- Help clients perform various activities such as using a computer to caring for daily needs due to a disabling condition
25
What is an LPN?
-
26
What is an RN?
- at least an associates degree in nursing, licensed by the state, and assists pts in activities related to maintain and recovering health;
- Largest group of health care professionals
27
What is a Social Worker?
–Professional with a bachelors degree in social work who provides persons, families or vulnerable populations with psychosocial support, advises family caregivers, counsels patients, and helps plan for needs after discharge
28
What is a Psychologist?
-
29
What is the difference in a Hospital MD and a PCP?
-
30
What is a Pharmacist?
-Licensed with a doctorate in pharmacy who compounds and dispenses medications, checks lab results for therapeutic drug levels and reviews risks for drug interactions
31
What is a Physicians Assistant?
-
32
What is a Nurse Practitioner?
-
33
What are the type of health care insurance?
- Private – personally acquired;
- Group – through employer ;
- Medicare;
- Medicaid;
- VA – veterans;
- Public Health Service’s Indian Health;
- Dept. of Defense hospitals & clinics;
- State & local public health programs: WIC, LaCare, Food Stamps, etc.
34
How are RD’s reimbursed through PRIVATE insurance?
- Group contract → RD can apply to be a provider/ receive reimbursement for services
- RD’s can be directly reimburses through the company they work for → Facility recives payment, and then pay the RD;
- Private RD’s apply to the provider and then are paid directly
35
How are RD’s reimbursed through PUBLIC Insurance with MEDICARE?
- RD reimbursement for MNT counseling since 2002;
- RD must enroll in Medicare- given provider number;
- Reimbursement only for specific diagnoses =
1. Kidney Disease NOT once dialysis is required;
2. Diabetes – ALL types;
3. Behavioral treatment for wt. management
36
How are RD’s reimbursed through PUBLIC Insurance with MEDICAID?
-Varies by state mandate
37
To become an educated and trained member of the health care team….
1. Process that begins with Didactic program in dietetics → Must be approved and accredited!!;
2. Supervised practice: Apply education in clinical setting (inclusion of patient’s individual needs);
3. Become a R.D. (registered dietitian);
4. Continuing education, practice, higher level of critical thinking
38
What is Critical Thinking?
– thinking that goes beyond the processing of information, but delves deeper into the creation of individual and new ideas, varied from the norm, challenging the information given, and yielding an overall informed and personal decision;
- Ability to piece information together and look beyond the obvious → Think outside the box!;
- Contextual considerations
39
What are the components of Critical Thinking?
1. Specific knowledge base;
2. Experience;
3. Competencies of Medical Problem Solving;
4. Standards;
5. Attitudes
40
What are some sources of info used in dietetics critical thinking?
- Medical history
- Family history
- Relationships
- Socioeconomic status
- Patient interviews
- Lab values
- Physical signs and symptoms
- Nutrition Care Manual
- EAL
- MD Consults
41
What is included in Medical Problem Solving?
- Scientific method;
- Evidenced based practice;
- Decision making;
- Diagnostic reasoning
42
What are the steps of the Scientific Method?
1. Identify phenomenon;
2. Collect data about phenomenon;
3. Formulate hypothesis to explain phenomenon;
4. Test hypothesis through experimentation;
5. Evaluate hypothesis
43
What types of questions would be used in a patient interview?
- Diet response questions → Specific;
- Open-ended questions;
- NO yes/no answer → Limited info will be given;
- Ask for explanations;
- Recap things they stated for clarifications;
- Ask for emotional responses to food
44
What is Evidence Based Practice?
*Expertise + Judgement!
–practice that utilizes systematically reviewed scientific evidence is used to make food and nutrition practice decisions;
-Goes through the process of asking questions, seeking out viable evidence, and ensuring that that evidence is the most current, most appropriate and relevant pertaining to the situation and the individual client with the most probable health enhancing results.
45
What resources could be used in Evidence Based Practice?
- EAL;
- Nutrition Care Manual;
- Patient consideration – what they are willing and able to do;
- Facility restrictions;
- MD Consultations
46
What is problem solving?
-Involves looking for clues that help RD make nutrition dx and develop solutions
47
What is involved in Diagnostic Reasoning?
- Involved in the nutrition diagnosis;
| - PES Statement
48
What is involved in Decision Making?
- Once problem identified, assess all options to solve;
- Weigh options against set of criteria;
- Consider potential consequences of each option;
- Make final decision
49
What is included in the Code of Ethics standards?
RD practices based on scientific principles & current information
50
What is included in the Standards of Professional Performance standards?
RD continues to improve knowledge & skills & evaluates quality of practice
51
What is Outcome Research?
- The evaluation of care that focuses on the status of participants after receiving care; Outcome research is used to continually evaluate that dietetics standards are being upheld and optimum care if provided;
- Population driven study; Follows a specific protocol to see how well the outcome is being achieved ;
- *Needed more and more to support the evidenced-based practice
52
What are the levels of Clinical Reasoning?
1. Entry = basic practice;
2. More Experienced = able to examine alternatives independently, systematically, disconnecting from authority
3. Highest = analysis of the entire situation, accountability for decisions, and continuous quality of care
53
What are the functions of water in the body?
- Nutrient transport;
- Transport & excretion-metabolic waste;
- Support cell shape/ structure;
- Lubrication;
- Body temperature regulation
54
What are electrolytes?
- Group of solutes found in bodily fluids;
- Bear an electrical charge!;
- Sodium, Potassium , Chloride;
- Calcium and Phosphorous
55
What is Total Body Water?
- 50-60% of total body weight;
- Influenced by fat/lean mass = more fat, let water;
- Tends to change with age
56
How does total body water % change with age?
* DECREASES with age;
- 50% Female;
- 60% Male;
- 75% Infant;
- <50% elderly
57
What are the fluid compartments of the body?
- Intracellular fluid (ICF) ;
| - Extracellular fluid (ECF)
58
What is Intracellular Fluid (ICF)?
-Fluid that is found WITHIN the cells of the body
59
What is Extracellular Fluid (ECF)?
Fluid that is found OUTSDE the cells of the body
- Interstitial - in cells;
- Intravascular - in blood;
- Transcellular (secretion within ORGANS — GI secretions, cerebrospinal fluid)
60
What are Third Spaces?
- Nonfunctional spaces;
- Body cavities that found in the spaces between organs;
- Peritoneal, pericardial, and thoracic cavities along with the joints and bursar;
- These small spaces should typically hold very minimal amounts of fluid, but accumulation in these areas may be a sign of illness or injury
61
What is Ascites?
-Abnormal accumulation of fluids within the abdominal cavity
62
Where is the MOST body fluid found?
- Intracellular;
- 28L (of total 42L);
- 67% body fluid;
- 40% body wt.
63
How much fluid is found as Extracellular?
-14L;
-33% body fluid;
20% body wt.
64
What are the 2 types of pressure that effect the movement of body fluid?
1. Osmotic — force moving fluid across semipermeable membrane;
2. Hydrostatic — pressure exerted by fluid on membranes
65
What is Osmotic Pressure?
- Movement of fluid (WATER) across a semipermeable membrane;
- Depends solely on the number of solutes found in solution;
- Drives osmosis of water from the area of LOW solute to the area of HIGH solute concentration to achieve equilibrium.
66
What stimulates the movement by OSMOTIC Pressure?
- COLLOID osmotic pressure = ONCOTIC → protein molecules;
| - Colloids = do NOT form true solution but contribute to osmotic pressure
67
What is the major colloid that effects osmotic pressure?
- Serum ALBUMIN = large blood protein;
| - Most influence upon colloid osmotic pressure
68
How do colloids stimulate osmotic movement?
These proteins are much too LARGE to actually dissolve within solution and also do not have the ability to cross membranes;
-Pressure from the colloids contributes to osmotic pressure because they force the movement of WATER to maintain equilibrium
69
What is Hydrostatic Pressure?
- The pressure the fluid exerts on the membrane;
- Varying hydrostatic pressure across membranes forces movement by FILTRATION from HIGH TO LOW PRESSURE to balance the force on either side of the membrane;
- EX: Blood Pressure — intravascular hydrostatic pressure (A LOT of peripheral edema with hypertension)
70
How does Hydrostatic Pressure effect movement of body fluid?
- When the hydrostatic pressure is UNBALANCED across a membrane, filtration of solutes (except colloids which are too large) occurs.;
- Solutes will move from the side with the HIGHER pressure to the area of LOWER pressure to attempt to create a balance of pressure
71
What is Osmolarity/Osmolality?
- Interchangeable → Values represent osmotic pressure;
| - Blood used as “normal” range for body fluids = 280-320 mOsm/kg H20
72
What are ISOTONIC Fluids?
Fluids w/ osmolality EQUAL to blood
73
What are HYPERTONIC Fluids?
- Fluids w/ osmolality GREATER than blood;
- Hypertonic → MORE Solutes than blood;
- EX: elevated blood glucose would be a hypertonic soln
74
What are HYPOTONIC Fluids?
- Fluids w/ osmolality LESS than blood;
| - Hypotonic → LESS solutes than blood
75
What are the normal osmolality condition of the body fluids?
osmolality of ECF…EQUALS...osmolality of ICF
76
What is Cellular Dehydration?
- Cellular dehydration occurs when a cell comes in contact with a HYPERTONIC solution;
- Fluid is REMOVED from within the cell and into the solution;
- Hypertonic solution with more solutes than the cell, generates a concentration gradient to pull FLUID FROM THE CELL to balance the relative concentrations;
- As the cell loses its fluid to the solution, it then becomes dehydrated;
- EX: glucose or sodium that body is attempting to dilute — DM, dehydration, excessive sweating
77
What is Cellular Swelling?
- Cellular swelling occurs when the cell is surrounded by a HYPOTONIC solution with very FEW SOLUTES;
- Cell TAKES ON excess fluid to lower its solute concentration level to equate with the surrounding solution
78
What is included in assessment of fluid INTAKE?
1. Intake by mouth (PO);
2. Calorie count sheets;
3. I & O Sheets;
4. Metabolic water
79
What is Metabolic Water?
- Water from nutrient metabolism;
- Estimated by intakes of CHO, proteins, and fats;
- INSIGNIFICANT except w/organ failure
80
What is included in I & O Sheets?
-All oral intake should be recorded for estimation of fluid consumed along with a 24-hr urine output collection to determine total urine output. Total urine output is the sum of obligatory urine (waste) and facultative urine (excess water).
81
What fluids are consumed by mouth (PO) that are calculated in fluid intake?
- Fluid and any solid foods that that are liquid at room temp (fluids, ice cream, jello, broth/soup, pudding, tube feeds, etc.);
- Watery fruits are NOT included
82
What is included in the assessment of fluid OUTPUT?
1. Sensible losses;
| 2. Insensible losses
83
What are Sensible fluid losses?
Losses that are visible and measurable → Urine and feces;
- 24 hr urine collection (or approx. 1400ml/d);
- Feces (avg. daily loss about 200ml fluid);
- Extra Potential Loss (Sensible/Measurable) – diarrhea, vomiting, draining wounds, reverse NG (stomach pumping)
84
What are Insensible fluid losses?
- NOT seen or measured;
- Respiration, skin by evaporation;
- Total loss about 700-1000ml/day
85
What is Obligatory Urine?
- Needed to remove waste;
- Waste referred to as renal solute load (RSL);
- Solute concentration in urine measured by its specific gravity;
- Mostly sodium, potassium, chloride, and urea
86
What is Specific Gravity?
- The wt. of a solution in comparison to an equal amount of distilled water; used to measure the concentrating ability of the kidneys;
- Water specific gravity = 1.00
87
What is the concentrating ability of the kidneys?
~1200 mOsm;
| -Require a minimum 500mL of obligatory urine even in fasting and starvation
88
What is Facultative Urine?
-Excess water that is excreted through urination
89
What characteristics of Urine are considered in assessment?
1. Color (Clear = healthy; Dark = dehydration);
2. Urine Osmolality (High osmolality with fluid depletion);
3. Specific gravity (Normal SG - 1.01)
90
What is the method to be used to calculate fluid needs for ADULTS?
- Based on ENERGY needs;
| - 1mL per kcal consumed
91
What is the method to be used to calculate fluid needs for INFANTS and CHILDREN?
Based on WEIGHT;
— 0-10kg child = 100ml/kg;
— 11-20kg child = 1000ml + 50ml/kg over 10kg
— > 20kg child = 1500ml + 20ml/kg over 20kg
92
What is considered when assessing/monitoring HYDRATION status?
- Daily weights;
- Admit physical evaluation: what will you look at;
- Respiratory rate and lung sounds;
- Blood pressure;
- Presence of peripheral edema;
- Intake & output records;
- Abnormal labs
93
What is evaluated in an admit physical evaluation?
- Skin;
- Eyes;
- Lips and oral cavity;
- Daily weights;
- Respiratory/lung condition;
- Blood pressure;
- Any edema that might be present;
- Patients I/O sheets
94
What are Electrolytes?
- Body solutes — IONS;
| - Dissociate in fluid to form one or more charged particles
95
What are the charges of Electrolytes?
1. Cations – ions with a POSTIVE charge;
| 2. Anions – ions with a NEGATIVE charge
96
What is Electroneutrality of body solutes?
- Cations must EQUAL anions in a given compartment;
| * *ECF or ICF → law of thermodynamics
97
Where are electrolytes found?
Some ONLY in the ECF or the ICF;
- Some are in BOTH;
- Concentrations in/out of cells also differs
98
What are the electrolytes of the ECF?
1. Cations – Sodium, calcium
2. Anions – chloride, bicarbonate
* *These are only found in small concentrations in the ICF
99
What are electrolytes of the ICF?
1. Cation – potassium
2. Anions – magnesium, phosphate
* *These are only found in small concentrations in the ECF
100
What there molecules contribute to body solutes?
-Remain STABLE in solution (no dissociation) → MAJOR effect on fluid status!!!;
Ex.: Glucose, protein, urea
101
What regulated the movement of solutes?
* CELLULAR Membranes (unlike semi-membranes) BLOCK solute movement;
- Molecular size → Smaller move more easily;
- Electrical charge;
- Hydrostatic pressure;
- Method of transport → ACTIVELY transported solutes move much easier than simply/facilitated diffusion
102
What are the Electrolyte Nutritional Requirements?
1. AIs (adequate intake) for sodium, potassium, chloride;
**Typically easily met with normal dietary intake
EX: Sodium AI is 1500mg, 1 tsp. of salt is 2300mg of sodium ;
2. Maintain normal serum levels = When imbalance occurs, serum levels change to maintain neutrality → Kidneys regulate sodium, potassium and chloride
103
What are the normal serum values for Na, K, and Cl?
* *Very small ranges!
- Sodium = 136-146 mEq/L;
- Potassium = 3.5-5.0 mEq/L;
- Chloride = 98-106 mEq/L
104
What are the physiological regulators of fluid and electrolytes?
1. Osmotic and hydrostatic pressure = osmosis/filtration;
2. Thirst mechanism;
3. GI Tract = reabsorption;
4. Kidneys;
5. Hormones
105
What is the Thirst Mechanism?
- Hypothalamus responds to signals from interstitial fluid and triggers thirst;
- Mechanism decreases with age, so may not be enough to maintain fluid in elderly;
- May not be great enough in elite athletes to account for fluid needs
106
How do the kidneys help regulate fluids and electrolytes?
-As blood pressure increases, so does hydrostatic pressure in the renal tubes;
→ Fluid moves from capillaries into renal tubules;
→ Fluid is then excreted as urine
107
What major hormones affect fluid and electrolyte balance?
1. RAAS (Renin-Angiotensin-Aldosterone System) – driven by DECREASING hydrostatic pressure;
2. Vasopressin (hormone) – released by the pituitary; AKA antidiuretic hormone (ADH)
108
How does RAAS influence fluid balance?
1. Baroreceptors in blood vessels – stimulated by low hydrostatic pressure due to low blood volume ;
2. Renin (hormone) is released, converting angiotensinogen to angiotensin I;
3. Angiotensin I becomes angiotensin II → as volume increases aldosterone (hormone) from the adrenal cortex;
4. Aldosterone makes kidneys RETAIN Na+ ;
5. Na+ concentration then rises, osmotic pressure increases retaining fluid in blood;
6. Blood volume is then returned to normal levels
109
How does Vasopressin influence fluid balance?
- Stimulated by 1) high osmolality of ECF and 2) decreasing hydrostatic pressure by baroreceptors in the blood vessels ;
- Vasopressin leads retention of fluid by kidney tubules → Increases blood volume and lowers osmolality
110
What is stimulated once RAAS creates Angiotensin II?
1. Vasopressin increased = water retention;
2. Thirst mechanism activated = increase fluid intake;
3. Arteriolar vasoconstriction = increase fluid intake
111
What regulates SODIUM levels?
1. RAAS – as water balance is controlled by vasopressin and aldosterone sodium is also regulated as well → stimulated by LOW blood volume/pressure ;
2. ANP (atrial natriuretic peptide = antagonist to RAAS); OPPOSITE to RAAS – released when arterial blood pressure increases; Causes increased urinary excretion of sodium and fluid to lower blood volume and thus osmolality concentration increases
112
What happens due to increased ANP?
- Decreases sodium absorption;
- Decreases aldosterone;
- Decreases secretion of Renin ;
- Stimulates stretch receptors in the muscle cells of the heart with INCREASED blood pressure
113
What regulates POTASSIUM levels?
1. Aldosterone – HIGH potassium causes aldosterone release from adrenals; Increased excretion of K+ by the kidneys and sodium retention ;
- OPPOSITE effect on potassium as compared to sodium → Stimulates the excretion of Potassium while retaining sodium ;
2. Acid base balance – Involves H+ and HCO3- ions → exchanges K+ to balance H+
114
How do serum concentrations of CALCIUM and PHOSPHOROUS relate?
-Reciprocal relationship → One will be low, and the other high
115
What determines the serum levels of Calcium and Phosphorous?
- Intestinal absorption;
- Exchange between EC fluid and bone;
- Renal excretion;
- Controlled by hormones = PTH (parathyroid hormone) and Calcitonin
116
How does PTH regulate serum levels?
- Secreted from parathyroid gland in response to low serum Ca++;
- Raises serum calcium by REMOVING calcium from bone and DECREASING excretion of calcium in urine;
- Stimulates activation of Vit. D to increases calcium RETENTION → Vit. D causes absorption of calcium in the small intestine;
- Increased phosphorus excretion (with good kidney function)
117
How does Calcitonin regulate serum levels?
- From thyroid gland;
- Opposes PTH by INHIBITING osteoclasts and the breakdown of bone to remove calcium;
- Lowers serum calcium and remains in bones
118
How can changes in fluid balance occur?
- Changes in fluid VOLUME;
- Changes in fluid CONCETRATION or OSMOLALITY;
- Changes in fluid COMPOSITION ;
* * Changes usually not only of one type → Fluid, electrolyte and acid/base typically happen at once
119
What are the alterations in fluid VOLUME?
- Usually in ECF;
- Changes in Na+ and water generally equal in loss/gain → Very LITTLE change in ICF or ECF osmolality
1. Hypovolemia – ECF fluid LOSS
2. Hypervolemia – TOO MUCH fluid in ECF
120
What is Pathophysiology?
- Alterations from normal anatomy and physiology due to disease/injury; study of disease;
- What is DIFFERENT from normal due to disease
121
What RENAL losses cause Hypovolemia?
1. Decreased oral intake of fluid – urinary output exceeds fluid consumed;
2. Diuretics – meds that decrease blood volume and lower BP to fully decrease ECF;
3. High protein diets increase excretion because of increased Renal Solute Load (RSL);
4. Hyperosmolar hyperglycemia nonketotic syndrome
122
What is Hyperosmolar hyperglycemia nonketotic syndrome?
Uncontrolled T2DM, body attempts to achieve the proper acid/base balance and hyperosmolality with increase excretion
123
What EXTRA renal losses cause Hypovolemia?
1. GI – vomiting/diarrhea; Fistula (opening in the GI tract, an organ);
2. Skin – Increasing body temp (fever); increased environmental heat (sweat/perspiration); Burns; Draining wounds;
3. Accumulation of fluid in “third spaces” or body cavities (Ascites)
4. Secondary to diuresis (excessive urine) → seen in recovery from renal failure
* Extra renal loss can add up to 5-6 liters
124
What is Etiology?
-The CAUSE of the disorder or nutritional deficiency
125
What are the etiologies for volume DEPLETION (hypovolemia)?
1. Isotonic-related;
2. Hypotonic-related;
3. Hypertonic-related
126
ISOTONIC Volume Depletion in Hypovolemia
* *Losing fluid and electrolytes at about the SAME rate make the osmolality remain EQUAL;
- Decreased food/water intake;
- Prolonged vomiting;
- Prolonged diarrhea
127
HYPOTONIC Volume Depletion in Hypovolemia
* *Losing fluid and electrolytes and only REPLACING the electrolytes (creating a fluid excess);
- Hx edema;
- Diuretics;
- Na restricted diets;
- Na wasting syndromes;
- Malnutrition;
- Large volume intake of hypotonic liquids
128
HYPERTONIC Volume Depletion in Hypovolemia
* *DEHYDRATION = osmolality > 295) → Losing too much FLUID only!!;
- Excessive sweating; diarrhea;
- Hyperventilation;
- Ketoacidosis;
- Prolonged fever;
- Early stages renal failure
129
What are the CARDIAC effects of Hypovolemia?
1. Decreased ECF volume → Decreased BP and blood volume → Decreased cardiac output;
2. Orthostatic hypotension;
3. Tachycardia, increased pulse to help compensate;
4. Dizziness
130
What is Orthostatic Hypotension?
- Compensatory mechanisms that attempt to maintain extremely low blood pressure, especially upon changing body position;
- Drop in BP when standing up!
131
What effect does Hypovolemia have on the skin?
- Poor skin turgor;
| - Dry skin & mucous membranes
132
What effect does Hypovolemia have on body wt.?
-Any RAPID change in body weight is of concern!
133
What effect does Hypovolemia have on thirst?
- INCREASED with HYPERTONIC dehydration;
- NO change with hypotonic volume depletion;
- Not thirsty with isotonic volume depletion
134
Osmolality Lab of Hypovolemia (by type)
1. Hypertonic: >295mOsm/kgH2O
2. Volume depletion hypotonic: < 285mOsm/kgH
3. Volume depletion isotonic: WNL
135
Serum Sodium with Hypovolemia (by type)
1. Hypertonic: > 145 mEq/L
2. Vol depletion hypotonic: < 130 mEq/L
3. Vol depletion isotonic: WNL
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Other Labs with Hypovolemia (by type)
1. Albumin (serum): GREATER normal for all
2. Hgb: GREATER normal for all
3. Bun: GREATER normal for all (BUN = blood urea nitrogen)
4. Bun:crea ratio: GREATER than 25 for all
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Urine Specific Gravity and Color with Hypovolemia
1. Hypertonic: > 1.015 (mid range nl)
2. Vol depletion hypotonic: < 1.005 (low end normal)
3. Vol depletion isotonic: > 1.005 (nl)
4. Elevated specific gravity, darker color, and cloudy
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What is the treatment for Hypovolemia?
- Based on underlying cause for lack of fluids =
1. Increase intake Na & H2O (if mild deficit);
2. IV fluids to replace fluid & electrolytes
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What IV fluids are needed for Hypovolemia?
1. 5% or 10% dextrose (add fluid WITHOUT electrolytes);
2. 0.45% saline (“half normal saline)
3. 0.9% saline (“normal saline)
3. Ringer’s solution;
4. Lactated Ringer’s
5. Dextrose in Saline (variable % dextrose and % saline)
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What is Ringer’s Solution?
-Provides fluids similar to plasma concentrations;
-Does not provide free water or energy;
-Contains Sodium, Potassium, Calcium, and Chloride;
— Lactated Soln = added 29g lactate to soln
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When would you use Lactated Ringers?
* Hypovolemia = to replace bicarb along with electrolytes;
| - Sodium lactate (precursor to bicarb) → added to normal saline base
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What is the pathophysiology of HYPERVOLEMIA?
1. ECF → fluid shift into interstitial spaces (edema);
2. Overall blood volume is increased
→ increases blood pressure
→ increases how hard heart has to work
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What causes Hypervolemia?
1. Decrease in urine output (ex: acute renal failure);
2. Excess IV Infusion or fluids from surgical procedures;
3. Unusually rapid ingestion of fluid ;
4. Excessive secretion of vasopressin (SIADH);
5. CRF, heart failure, severe HTN
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What are the clinical manifestations of Hypervolemia?
1. Elevated blood volume → Elevated blood pressure (more fluid in interstitial spaces) → Increased cardiac output ;
2. Peripheral edema (possibly pitting);
3. Dyspnea (difficulty breathing/ rales due to fluid in airways);
4. Rapid weight gain;
5. Abnormally LOW serum alb, hgb, hct, BUN → HYPOTONIC SOLN due to excessive fluid
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What is Edema?
- Accumulation of fluid in interstitial spaces;
- Pitting occurs when pressing on a edematous area results in an indentation that remains once pressure removed;
- Pitting scaled from +1 to +4
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What are Rales?
-Abnormal respiratory sounds made when air flows through liquid present in the airways
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What is the fluid retention compared to weight gain?
Wt. gain of 1kg EQUALS the retention of about 1 liter of fluid
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What is the treatment for Hypervolemia?
- Related to cause;
| - May require restriction fluid & sodium
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What regulates Sodium (Na+) serum balance?
1. RAAS (renin-angiotensin-aldosterone);
2. ECF volume;
3. Renal function are key to regulating sodium balance
- Hyponatremia = LOW sodium;
- Hypernatremia = HIGH sodium
* *Serum sodium typically reflects the ratio of water to sodium
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What are the causes of Hyponatremia (low sodium)?
1. Rarely due to inadequate Na intake;
2. Excessive diuretic use (fluid loss);
3. Increased fluid intake w/out increased Na intake (IV fluids, water intoxication) ;
4. SIADH (syndrome of inappropriate antidiuretic hormone);
5. Hyperglycemia → increase in the solute of the plasma by glucose shifting water from the ICF to the ECF to create equilibrium;
6. Hypervolemia due to CHF, Cirrhosis (excessive water fluid retention)
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When can fluid intake be excessive WITHOUT also consuming electrolytes?
- Intravenous fluid are given WITHOUT electrolytes;
- Water Intoxication = uncontrolled, excessive water consumption resulting in dilutional complications; usually with psychiatric disorders
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What is SIADH (syndrome of inappropriate antidiuretic hormone)?
- Total body water increase WITHOUT an increase in sodium, diluting serum sodium levels;
- Seen with high levels of vasopressin WITHOUT normal stimuli to release vasopressin
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What are the clinical manifestations of Hyponatremia?
1. Generally don’t occur until Na < 120 mEq/L;
2. Plasma osmolality < 287mOsm/kg;
3. S/S related to fall in osmolality → H2O entering brain cells (neurological);
4. CNS effected = N/V, muscle cramps, lethargy, confusion, seizure, shock, coma
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What is the treatment for Hyponatremia?
1. Restrict water intake to DECREASE output;
2. Administer Na if severe hyponatremia;
3. Treat underlying causes (EX: insulin for hyperglycemia);
4. IV fluids with lactated ringers (doesn’t provide free water)
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What causes Hypernatremia (HIGH sodium)?
* Generally caused by change in FLUID BALANCE rather than change in Na intake;
1. Insufficient water intake;
2. Excessive water loss → Renal & nonrenal losses (draining wounds, hyperventilation, etc.);
3. Diabetes Insipidus;
4. SIADH;
5. Hyperosmolality → hyperglycemia, increased urea production (large protein intakes);
6. Rarely, IV sodium administration (absolute excess of sodium
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How does Diabetes Insipidus cause Hypernatremia?
- Chronic excretion of very large amounts of pale urine of low specific gravity;
- Little solutes being excreted and mostly water
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How does Hypernatremia effect the CNS?
- Central Nervous System → cellular dehydration leads to increasing severity of neurological symptoms ;
- Lethargy & agitation;
- Seizures & coma (cellular dehydration of brain cells)
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How does Hypernatremia effect the skin?
- Dry mucous membranes;
| - Possible elevation of body temperature/ flushed skin
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What are the lab values that indicate Hypernatremia?
- Serum Na > 145 mEq/L ;
| - Plasma osmolality> 295 mOsm/kg
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What are the treatments for Hypernatremia?
1. Increase water intake by mouth gradually!! →
If levels fall too quickly, cerebral edema could occur;
2. IV fluids (dextrose, no sodium)
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How is serum potassium regulated in the body?
- NARROW range for K+ = Normal = 3.5-5.0;
- K+ primarily found in ICF → Intracellular Anion!;
- Only small amt of K+ in ECF, → ** but this small amount plays important role in neurotransmission and muscle contraction;
* * Imbalances are often life threatening → potassium is very important to neurotransmitter function
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What causes Hypokalemia (LOW potassium)?
- Inadequate intake;
- Loss from GI tract → Hypokalemia secondary to GI Losses;
- Increased renal loss → Hypokalemia secondary to renal losses
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What GI losses cause Hypokalemia?
1. Loss of K+ directly, and;
2. Metabolic alkalosis (from loss of gastric acid) → increased bicarbonate excretion from kidney accompanied by increased K+ excretion;
3. Vomiting & Diarrhea — decrease in ECF volume → secretion of aldosterone → Na retention & K+ excretion
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What increased renal loss causes Hypokalemia?
1. Loop diuretics = Lasix/ Furosemide;
| 2. Natural licorice/ chewing tobacco contain ALDOSTERONE compound that stimulates potassium excretion
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How do Loop Diuretics medications cause Hypokalemia?
- Lasix/Furosemide;
- Cause increased urine loss along with potassium;
- Diet needs to ensure extra intakes of potassium to counter losses;
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What are the clinical manifestations of Hypokalemia (low potassium)?
* Affects muscle contraction
1. Skeletal muscle → weakness;
2. Muscles of lungs → shallow breathing;
3. Muscles of Cardiovascular system → arrythmias and possible cardiac arrest
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What is the treatment for Hypokalemia?
- Increase consumption of K+ rich foods;
- Oral K+ supplementation;
- IV administration of K+;
- Important to determine cause
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What causes Hyperkalemia (HIGH potassium)?
1. Inadequate excretion;
2. Catabolism and strenuous exercise;
3. Acidosis – hydrogen ions excreted to correct the acidosis → potassium ions retained
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What causes inadequate excretion of potassium?
- Renal failure;
- Excessive potassium sparing diuretics/ or in combo w/salt substitutes (from the treatment of HTN);
- Shifts in K+ form ICF to ECF → shift can occur during increased hemolysis of RBCs -- Leukocytosis (high WBCs) or Thrombocytosis (low platelets)
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What are the clinical manifestations of Hyperkalemia?
1. Serum K+ > 5.5mEq/L;
2. Muscle weakness, cardiac dysrhythmias, paralysis, cardiac arrest = muscle contraction problems!;
3. Gradual increase in K+ (CRF) – Better tolerated than rapid increase
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What is the SHORT term treatment for Hyperkalemia?
1. IV calcium gluconate to decrease abn of cardiac cells;
2. Glucose and insulin can shift from ECF to the ICF;
3. Correction of acid- base imbalance → moves to the ICF ;
4. Kayexalate- allows exchange of sodium for K+ in large intestine
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What is the LONG term treatment for Hyperkalemia?
1. Dialysis;
2. K+ controlled diet;
3. Adequate nutrition support to prevent malnutrition which can lead to hyperkalemia as result of catabolism
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What are the functions of calcium in the body?
- Most abundant mineral in the human body ;
- Structural component as hydroxyapatite crystals → Most calcium is found within the BONES and TEETH (99%);
- Muscle contractions – binding to Troponin C to send signals ;
- Nerve and Impulse transmission – released due to hormonal response and neurotransmitters;
- Coenzymes for blood coagulation factors;
- Intracellular second messenger for ion transport and cell signaling
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How much calcium is found within the body fluids?
- 1% of calcium in body fluids → HIGHLY regulated due to need in muscle contractions;
- Other 99% is in bones and teeth
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What is the NORMAL serum range for calcium?
- Normal serum range: 9-10.5mg/dl;
- Serum Ca2+ is either…
1. Albumin bound = 40%
2. Complexed = 13%
3. Ionized = 47%
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What is affects by serum calcium levels?
- Serum calcium does NOT reflect bone calcium status;
- Serum calcium levels affected by serum ALBUMIN levels → Total serum calcium assessed in RELATION to serum albumin;
- Decreased serum albumin by 1g/dL = decreased serum calcium by 0.8mg/dL → pt. with LOW albumin may FALSELY seem to have low Ca2+ levels
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What hormones regulate Plasma Ca2+ homeostasis?
1. PTH = increases serum Ca2+;
2. 1,25-dihydroxycholecalciferol = increases serum Ca2+
3. Calcitonin = decreases serum Ca2+
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How does PTH regulate serum calcium?
* INCREASES serum calcium =
- Increases bone resorption of Ca+;
- Decreases Ca+ excretion (increases reabsorption by kidneys);
- Increases Ca+ absorption in GI tract (via activation of D3 by kidneys)
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How does 1,25 dihydroxychlecalciferol regulate serum calcium?
* INCREASES serum calcium =
- Increases Ca+ & phosphorous absorption in GI tract;
- Promotes reabsorption by kidneys;
- Stimulates bone resorption
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How does Calcitonin regulate serum calcium?
* DECREASES serum calcium =
- Decreases bone resorption;
- Stimulates bone formation;
- Decreases reabsorption of Ca+ & Phosphorous by kidneys
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What causes Hypocalcemia (LOW calcium)?
1. Failure of liver/kidneys → deficit of PTH or active form of Vitamin D → often seen with renal failure and liver failure ;
2. Alkalosis → causes decreased ECF Ca2+ levels ;
3. Changes in serum Phosphorous levels
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So does inadequate Ca+ intake cause hypocalcemia?
- Inadequate intakes of Calcium would results in a calcium deficiency leading to rickets in children or osteomalacia in adults;
- Low serum levels are due to serum imbalances and the inability to regulate the ion concentration between the ECF and ICF
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What are the clinical manifestations of Hypocalcemia (low calcium)?
- Serum Ca2+ <4.5mg/dL = Hypocalcemia
- Due to altered nerve transmission & electrical activity of cells;
- S/S: muscle spasms, tetany, cardiac dysrhythmias
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What is the treatment for Hypocalcemia?
- Treat underlying cause;
- IV dosing of calcium is RARELY used due to side effects
- **Untreated can be life threatening due to nervous system function
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What are the imbalances of Phosphorous?
- Hypophosphatemia = LOW;
| - Hyperphosphatemia = HIGH
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What are the causes of Hypophosphatemia?
1. Vitamin D deficiency/ decreased activation of Vitamin D ;
2. Hyperparathyroidism;
3. Antacids that bind phosphorous;
4. Situations which cause shift of phosphate from ECF to ICF — Ex: Refeeding syndrome
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What are the clinical manifestations of Hypophosphatemia?
1. Respiratory insufficiency & CNS abnormalities = encephalopathy, coma;
2. Osteomalacia, rickets due to mobilization of Ca+ and phos from bone
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What is the treatment for Hypophophatemia?
- Focus on underlying cause;
| - Oral phosphate or supp. rather than IV Phosphate due to risk of precipitation of Ca+
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What are the causes of Hyperphosphatemia?
1. Primarily due to acute or chornic renal failure related to the decreased ability to excrete phosphorous;
2. Most symptoms related to concurrent hypocalcemia
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What is the treatment for Hyperphosphatemia?
1. Dietary Phos restriction — Foods HIGHEST in Phosphorus are milk, dairy, and animal proteins;
2. Phosphate binders — W/ renal failure, calcium supps are used as phosphorus binders
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What factors must be assessed for determining fluid and electrolyte balance?
1. Disease or injury
2. Medication or treatment
3. Fluid loss
4. Nutrient restriction
5. Oral intake
6. Intake vs. output
