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Fluids & Electrolytes/Acid Base Balance

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Bonnie Cooley

on 21 June 2016

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Transcript of Fluids & Electrolytes/Acid Base Balance

Fluids & Electrolytes
Fluid and Electrolyte Balance
Necessary for life--homeostasis
Your role: help prevent and treat fluid and/or eletrolyte disturbances

Fluid volume deficit:
hypovolemia: loss of extracellular fluid exceeds intake ratio of water
dehydration: loss of water along with increased serum sodium level
Fluid volume excess:
hypervolemia (isotonic most common)
abnormal retention of water and sodium in approximately the same proportions
Fluid volume deficit
Causes:
vomiting, diarrhea, GI suctioning
decreased intake
inability to gain access to fluid
diabetes insipidis
adrenal insufficiency (aldosterone)
osmotic diuresis
hemorrhage
coma
third space shift
Your answer is:
A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for deficient fluid volume?
A. A client with a colostomy
B. A client with congestive heart failure
C. A client with decreased kidney function
D. A client receiving frequent wound irrigations

Signs/Symptoms:
rapid weight loss
decreased skin turgor
oliguria
concentrated urine (SG > 1.030)
postural hypotension
anxiety, headache, confusion
decreased cap refill
rapid, weak pulse
increased core temperature
cool, clammy skin
thirst
nausea
weakness/fatigue/cramps
dry mucous membranes
decreased CVP
Management:
I & O (at least every 8 hours)
daily weight (1 kg/2.2 lb = 1 L loss)
monitor VS
monitor for symptoms: skin and tongue turgor, mucosa, U/O should be at least 30 ml/hr,
mental status
measures to minimize fluid loss
assess breath sounds
watch for FLUID OVERLOAD
Medical management: provide fluids to meet body needs: encourage oral fluids or IV solutions (with hypotension need an isotonic solution to increase BP (NS OR LR)
The client diagnosed with diabetes insipidus weighed 180 pounds when the daily weight was taken yesterday. This morning's weight is 175.6 pounds. One liter of fluid weighs approximately 2.2 pounds. How much fluid has the client lost (in milliliters)?
A.500 mL
B.1000 mL
C.2000 mL
D.4400 mL


We are composed of fluids--
Adults:
Children:
How do we lose fluids?
sensible
insensible
A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through:
A. The skin
B. Urinary output
C. Wound drainage
D. The gastrointestinal tract

Fluid Volume Excess
Hypervolemia (isotonic most common)
Abnormal retention of water and sodium in approximately the same proportions. Almost always secondary to increase in sodium, which in turn increases total body weight
Causes: heart failure, renal failure, cirrhosis of liver, excessive dietary sodium or sodium containing IV solutions
Signs/Symptoms:
Edema
distended neck veins
abnormal lung sounds (crackles)
tachycardia
increased weight
increased urinary output
shortness of breath and wheezing
bounding pulse
increased blood pressure and pulse pressure
Diagnostics:
BUN--decreased
HCT--decreased
With renal failure serum osmolality and sodium are decreased
Chest xray may reveal pulmonary congestion
Medical management directed at the cause of overload
restriction of fluids and sodium
administration of diuretics:
thiazide diuretics (distal loop HCTZ)
loop diuretics (ascending loop--furosemide [Lasix], bumetadine [Bumex])
dialysis
Nursing Management
I & O daily weights (2.2 lbs = 1 L of fluid)
assess for edema
semi-fowler's position for orthopnea
skin care, positioning, turning
assess lung sounds, edema, monitor responses to diuretics
promote adherence to medications/diuretics
avoid sources of excess sodium/patient teaching about sodium sources
*check water supply/water softeners
promote rest
Laboratory Tests
Specific gravity: measures kidneys' ability to excrete or conserve water. Normal: 1.010 to 1.025
BUN: made up of urea. Normally 10 to 20 mg/dL. Varies with urine output
Creatinine: end product of muscle metabolism. Normally 0.7 to 1.4 mg/dL
Hematocrit: volume percentage of red blood cells (erythrocytes) in whole blood. Normally 42-52% for males and 35-47% for females
A patient who has undergone an exploratory lap and subsequent removal of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 ml/hr via an IV pump. Which data should be reported to the health care provider:
a. the pump keeps sounding an alarm that the high pressure is reached
b. intake is 1800ml, NGT output is 550, Foley output is 950 ml
c. on auscultation, crackles and rales are heard in all lung fields
d. the patient has negative edema and an increasing level of consciousness
The nurse is assigned to care for a group of patients. After review of the patients' medical records, the nurse determines which of the patients is at risk for fluid volume excess:
a. the patient taking diuretics
b. the patient in renal failure
c. the patient with an ileostomy
d. the patient requiring gastrointestinal suctioning
The nurse is caring for a patient with congestive heart failure
On assessment, the nurse notes that the patient is dyspneic, and that crackles are audible on auscultation. The nurse suspects to find excess fluid volume. What other signs would the nurse expect to note in this patient if excess fluid volume is present?
a. weight loss
b. flat neck and hand veins
c. an increase in blood pressure
d. a decrease in pulse
IV FLUIDS--Make a difference
hypotonic: fluid shifts into cells
isotonic: no shifting of fluids
hypertonic: fluids shift out of cells

*tonicity refers to the abililty of the fluid to cause solute movement
The Big "K"
Potassium is the major cation
inside
the cell
normal is 3.5 to 5
balance primarily controlled by kidneys
responsible for neuromuscular function

Caused by:
vomiting, diarrhea, NG suction
diuretics, steroids
alkalosis
poor dietary intake

signs/symptoms:
cardiac dysrhythmias, flat or inverted T waves, U wave
muscle weakness/paresthesias
anorexia, nausea, vomiting
increased potential for digitalis toxicity (digoxin)
dilute urine (if hypokalemia is prolonged)
Hypokalemia < 3.5
Medical Management:
increased dietary potassium
potassium replacement
IV for severe deficit (usually 20-40 mEq/L)
Oral replacement (tablets are large, liquids diluted in juice)
salt substitutes
Nursing Management:
assessment (serum potassium levels)
Monitor ECG
ABGs for metabolic alkalosis
Encourage sources of dietary potassium
Nursing care related to IV potassium administration
Pharmacologic therapy:
Oral preparation when possible
IV required for EKG abnormalities, unable to give GI tract, or serum level < 2 mEq/L
Potassium chloride (KCL) salt substitute
K-Lyte: powder mix with 4-6 oz juice or water
potassium chloride (KCL): IV
ALWAYS dilute
burning at injection site
rate: 20 mEq/hr or less: NEVER IVP
EKG monitoring
Assess renal function
A nurse is preparing to care for a patient with a potassium deficit. The nurse reviews the patient's medical record and determines the patient was at risk for developing the potassium deficit because the patient:
a. has renal failure
b. requires nasogastric suctioning
c. has a history of Addison's disease
d. is taking a potassium-sparing diuretic
A nursing student needs to administer potassium chloride intravenously as prescribed to a patient with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium?
a. obtaining a controlled IV infusion pump
b. monitoring urine output during infusion
c. diluting in appropriate amount of normal saline
d. preparing the medication for bolus administration
A nurse instructs a patient at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the patient understands the food sources of potassium if the patient states that the food item lowest in potassium is:
a. apples
b. carrots
c. spinach
d. avocado
Hyperkalemia: serum potassium > 5.0 mEq/L
Causes:
renal failure
tissue trauma such as burns, crush injuries, use of potassium supplements, severe infection, acidosis
Signs/symptoms:
ECG changes and dysrhythmias/cardiac arrest
muscle weakness with potential respiratory impairment
paresthesias
anxiety
nausea/diarrhea
Medical management:
monitor ECG
limit dietary potassium
dialysis
pharmacologic therapy:
Kayexalate (sodium polystyrene sulfonate)
cation exhange resin; excreted in feces, used with sorbitol (laxative effect)
po or rectal
sodium bicarbonate IV
45 mEq over 5 minutes: rapid movement of K+ into cells
Calcium gluconate IV
decrease cardiotoxic effects (doesn't alter K level)
contraindicated if pt on digoxin
Insulin and glucose
Causes K+ to move into cells
Nursing management:
assessment of serum potassium levels, mix IVs containing K+ well, monitor medication affects, dietary potassium restriction/dietary teaching for patients at risk
hemolysis of blood specimen or drawing of blood above IV site may result in false laboratory results
salt substitutes, medications may contain potassium
potassium-sparing diuretics may cause elevation of potassium
Sodium:
Most abundant in ECF
normal 135-145 mEq/L
primary determinant of osmolality
controls water distribution (water follows sodium)
important for nerve impulses
regulated by ADH, thirst and RAAS (renin/angiotensin/aldosterone system)
Hyponatremia: Sodium < 135 mEq/L
mostly occurs due to an imbalance in water rather than sodium
causes: adrenal insufficiency, water intoxication, excessive administration of dexrose and water IVFs, SIADH, losses by vomiting, diarrhea, sweating, diuretics

Signs/symptoms:
nausea, muscle spasms, confusion, H/A, poor skin turgor, dry mucosa, decreased bp, neurologoic changes, seizures, even coma
Diagnostics:
H&P including focused neuro exam
evaluation of laboratory results (Na < 135 mEq/L
review patient's medications
Medical management:
sodium replacement
oral administration of sodium rich foods (beef broth, tomato juice)
IV LR or NS may be used
Water restriction (safest method if the patient has normal fluid volume or excess fluid volume)
Nursing management:
assessment and prevention
dietary sodium and fluid limitations
intake and output
daily weight
identify and monitor at-risk patients
effects of medications (diuretics
Hypernatremia: Sodium > 145 mEq/L
Causes:
excess water loss (even through insensible loss increase such as with hyperventilation)
diabetes insipidus
heat stroke
hypertonic IV solutions or even tube feedings without water supplements
OTC meds
inadequate water ingestion

*thirst may be impaired in the elderly or ill
hypernatremia:
Signs/symptoms
thirst
elevated temperature
dry/swollen tongue
sticky mucosa
confusion, restlessness
weakness
hypotension

Medical management: hypotonic solution or D5W
Nursing Management of hypernatremia:
assessment and prevention
assess for OTC sources of sodium
offer and encourage fluids to meet patient needs
provide sufficient water with tube feedings
decrease sodium in diet
daily weight
A nurse caring for a group of patients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one patient's laboratory report. The nurse understands that which patient is at highest risk for the development of a sodium at this level?
a. the patient with renal failure
b. the patient who is taking diuretics
c. the patient with hyperaldosteronism
d. the patient who is taking corticosteroids
Calcium: Normal 8.5 to 10 mq/L
Needed for skeletal muscle contraction, blood clotting and cardiac conduction
*low albumin may cause false low total calcium
controlled by PTH and calcitonin
dietary intake is primary source
excreted by kidneys and intestines
calcium and phosphorus have inverse relationship
A patient with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexylate) orally. After administering the drug, the priority nursing action is to monitor:
a. urine output
b. blood pressure
c. bowel movements
d. EKG for tall, peaked T waves
The nurse is caring for a patient who has been in good health until the present and is admitted with cellulitis of the hand. The patient's serum potassium was 4.7 mEq/L yesterday and today's level is 7.0. Which of the following is the next appropriate nursing action:
a. call the physician and report results
b. questions results and redraw specimen
c. encourage patient to increase the intake of bananas
d. initiate seizure precautions
Hypocalcemia: Calcium < 8.5 mg/dL
Must be considered in conjunction with serum albumin
Causes: hypoparathyroidism, malabsorption, pancreatitis, renal failure, inadequate vitamin D consumption, steroids and loop diuretics

Hypocalcemia:
Signs and symptoms:
tetany (most common)
spasms of extremitiies (Trousseau's sign)
spasms of the face (Chvostek's sign)
paresthesias
hyperactive DTRs
seizures
respiratory symptoms including dyspnea and laryngospasm
prolonged clotting
Medical management:
diet (dairy, green leafy, salmon/oysters)
Calcium carbonate (Os-Cal: Tums; Rolaids) or citrate: Citracal)
PO: Asymptomatic or chronic hypocalcemia
side effects: constipation, flatulence
Vitamin D
ergocalciferol (calciferol) or Calcitriol (Rocaltrol)
Nursing Management:
Caution with Digitalis (digoxin)
Assessment: airway concerns, safety concerns, weight bearing exercises to decrease bone calcium loss, patient teaching, and nursing care related to IV calcium administration
The nurse assesses a patient to be experiencing muscle cramps, numbness, tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. The nurse reports this is consistent with which of the following:
a. hypokalemia
b. hypernatremia
c. hypermagnesemia
d. hypocalcemia
HYPERCALCEMIA: calcium >10.5 mg/dL
CAUSES: most commonly malignancy and hyperparathyroidism, bone loss related to prolonged immobility
Signs/symptoms: muscle weakness, incoordination, anorexia, constipation, nausea and vomiting, dysrhthmias, decreasing LOC
MEDICAL MANAGEMENT: treat underlying cause, IV fluids (NS dilutes the calcium and increases excretion by the kidneys, monitor electrolytes at least BID
Furosemide (Lasix) increases exretion through urine, decrease fluid overload from NS administration
Calcitonin: reduces bone resorption, increases deposition of Calcium and phosphorus into bones, increase urinary excretion
bisphosphonates: administer with water (6-8 oz) before eating (at least 30 minutes) and sit upright for 30 minutes
coritcosteroids: decrease level in 5-10 days
inorganic phosphate salts (neutra phos)-inhibitis intstinal absorption of calcium and increases deposition of Ca into bone (only if phosphate level is low)
Mr. Smith, an 82 year old male was traveling with his nephew. They were using Mr. Smith's car and credit cards. They checked into a local hotel and Mr. Smith's nephew checked out, leaving Mr. Smith. When the hotel staff found him, he had been locked up in his room for 2 days without food or drink. No one had seen him leave his room. EMS was called and he was taken to the local hospital. He was confused, had poor skin turgor with cool, clammy skin. He had scant urinary output and a rapid weak pulse. His lab results are as follows:
Na: 148
Hct: 54%
BUN 25
U/A SG 1.044

What is his likely diagnosis?
What are his nursing diagnoses?
Magnesium
abundant intracellular cation (second only to K+)
Plays a role in both carbohydrate and protein metabolism
Normally 1.3 to 2.3 mg/dL Similar to calcium in that 1/3 bound protein; remaining are free cations
Important for neuro muscular function
Also affects cardiovascular system, causing vasodilation
Hypomagnesemia:
Serum level less than 1.3 mg/dL, frequently associated with hypokalemia and hypocalcemia. Evaluate in conjunction with serum albumin
Causes: alcoholism most common cause, GI losses (NG suction, diarrhea), enteral or parenteral feeding deficient in magnesium, medications, rapid administration of citrated blood
Signs/Symptoms: neuromuscular irritability, tremors, tetany, hyperactive DTRs, seizures, dysrhthmias
Medical management: diet (green veggies, peanut butter, nuts, oranges, bananas, chocolate)


Nursing management: assessment, ensure safety, patient teaching related to diet, medications and alcohol use (refer to AA). Monitor EKG and DTRs, keep respiratory rescue at bedside
Hypomagnesemia often accompanied by hypocalcemia (monitor for hypocalcemia)
dysphagia common in magnesium depleted patients (assess ability to swallow)
Hypermagnesemia
Serum level more than 2.3 mg/dL
Causes: renal failure, excessive administrationof magnesium
Signs/symptoms: flushing, lowered BP, nausea, vomiting, absent or hypoactive DTRs, drowsiness, muscle weakness, depressed respirations, decreased cardiac impulse, may even lead to paralysis

Medical management: D/C magnesium supplements, emergent respiratory rescue, IV calcium gluconate (to counteract action on the heart), loop diuretics, IV NS or RL, hemodialysis

Nursing management: assessment (monitor reflexes, monitor respiratory status, ECG monitoring, No medications containing magnesium, patient teaching regarding magnesium containing OTC medications
Mrs. Weber, a 62 year old female with a history of DM and HTN complains of cough, SOB, ankle edema and 4 lb weight gain in 6 days. She is hospitalized and diagnosed with heart failure. She is prescribed lasix (furosemide).

What is the nursing care for Mrs. Weber?
Divide into 4 groups--take one of the following electrolytes
play detective and find sources of the electrolytes (try digging deeper into hidden sources)
Sodium
Potassium
Magnesium
Calcium
The nurse evaluates which of the following patients to have hypermagnesemia:
a. a patient with alcoholism and a magnesium level of 1.3
b. a patient with hyperthyroidism and a magnesium level of 1.6
c. a patient with renal failure, takes antacids, and has a magnesium level of 3.2
d. a patient who has congestive heart disease, takes a diuretic, and has a magnesium level of 2.3
A nurse is evaluating the lab results on the following four patients. Which is the priority for the nurse to report first:
a. a patient with osteoporosis and a calcium level of 10.6
b. a patient with renal failure and a magnesium level of 2.5
c. a patient with bulimia and a potassium level of 3.6
d. a patient with dehydration and a sodium level of 149
Mrs. Samuels is a 92 year old widow who has been living in the nursing home where you work for 4 years. Today the CNA tells you her urine smells funny. Mrs. Samuels says her heart is beating faster than normal. You check her urine and find that is is dark amber and has a strong odor. Her heart rate is 98, blood pressure 126/74, respiratory rate 20, and temp 99.2.
What other data do you want to collect?
What interventions should you provide?
How will you know if she is improving?
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