exam 1

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1

Electrolyte values

  • Na: 135 - 145
  • Cl: 98 - 106
  • Mg: 1.8 -3
  • K: 3.5-5
  • P: 2.5 - 4.5
  • Ca: 8.5 - 10.5
2

Fluid volume deficit (hypovolemia)

Contributing factors

Loss of water and electrolytes

  • vomiting
  • diarrhea
  • fistulas
  • fever
  • XS sweating
  • burns
  • blood loss
  • GI suction
  • third spacing fluid shifts

decreased intake

  • anorexia
  • nausea
  • inability to gain access to fluid

diabetes insipidus

  • leads to depletion of extracellular fluid volume

uncontrolled diabetes

  • leads to depletion of extracellular fluid volume
3

Fluid volume deficit (hypovolemia)

signs and symptoms

  • acute weight loss
  • decrease skin turgor, BP
  • oliguria
  • concentrated urine
  • capillary filling time prolonged
  • low CVP
  • flattened neck veins
  • dzness
  • weakness
  • thirst and confusion
  • increase pulse, temperature
  • muscle cramps
  • sunken eyes
  • nausea
  • cool, clammy, pale skin
4

Fluid volume deficit (hypovolemia)

lab values

  • increase hemoglobin and hematocrit
  • increase serum and urine osmolality and specific gravity
  • decrease urine sodium
  • increase BUN and creatinine
  • increase urine specific gravity and osmolality
5

fluid volume excess (hypervolemia)

contributing factors

compromised regulatory mechanisms

  • kidney injury
  • heart failure
  • cirrhosis

overzealous administration of sodium-containing fluids

  • fluid shifts
  • burns pts

prolonged corticosteroid therapy

severe stress

hyperaldosteronism augment fluid volume excess

6

fluid volume excess (hypervolemia)

signs and symptoms

  • acute weight gain
  • peripheral edema and ascites
  • distended jugluar veins
  • crackles
  • elevated CVP
  • SOB
  • increase BP, RR, UO
  • bounding pulse and cough
7

fluid volume excess (hypervolemia)

lab values

  • decrease hemoglobin and hematocrit
  • decrease serum and urine osmolality
  • decrease urine sodium and specific gravity
8

hypovolemia

medical management

  • oral route preferred
    • patient's likes and dislikes
    • mouth care and nonirritating fluids
    • small volumes of oral rehydration
    • antiemetic if nausea
  • IV route if severe or acute (Isotonic soln)
  • once normotensive --> hypotonic electrolyte soln
  • weights, IO, vitals, LOC, CVP, breath sounds, and skin color monitored
9

hypovolemia

nursing management

  • IO q8hr and sometimes hourly
  • vitals (weak, rapid pulse and ortho hypo)
  • decrease body temperature
  • skin and tongue turgor (longitudinal furrows, smaller tongue)
  • specific gravity greater than 1.020
10

hypervolemia

medical management

  • decrease sodium intake
  • diuretics (provide K and Mg)
    • thiazide -> moderate/mild
    • loop -> severe
  • hemodialysis -> extreme
    • remove nitrogenous waste
    • control: potassium, acid-base, and remove Na and fluid
11

hypervolemia

nursing management

  • IO, weigh daily, breath sounds
  • edema (peripheral measured with tape measurer)
    • turn pt, more prone to skin breakdown
  • monitor hidden sodium sources
    • water supply, water softeners, Alka-seltzer
  • promote bed rest -> increase autonomic system
12

sodium deficit (hyponatremia) <135

contributing factors

loss of sodium

  • diuretics
  • loss of GI fluids
  • renal dz
  • adrenal insufficiency

gain of water

  • XS D5W and water supplements

disease states associated with SIADH

  • head trauma
  • oat-cell lung tumor

medications associated with water retention

  • oxytocin
  • tranquilizers

psychogenic polydipsia

hyperglycemia and HF

13

sodium deficit (hyponatremia) <135

signs and symptoms

  • anorexia
  • n&v
  • headache
  • lethargy
  • dzness
  • confusion
  • muscle cramps and weakness
  • muscle twitch
  • seizures
  • papilledema
  • dry skin
  • increase pulse
  • decrease blood pressure
  • weight gain
  • edema
14

sodium deficit (hyponatremia) <135

lab values

  • decrease serum and urine sodium
  • decrease urine specific gravity and osmolality
15

sodium excess (hypernatremia) >145

contributing factors

  • fluid deprivations -> cannot respond to thirst
  • hypertonic tube feedings w/o adequate water supplements
  • diabetes insipidus
  • heatstroke
  • hyperventilation
  • watery diarrhea
  • burns and diaphoresis
  • XS cortocosteroid, sodium bicarbonate, sodium chloride
16

sodium excess (hypernatremia) >145

signs and symptoms

  • thirst
  • increase body temperature, BP and pulse
  • swollen dry tongue and sticky mucous membranes
  • hallucinations
  • lethargy
  • restlessness
  • irritability
  • simple partial or tonic-clonic seizures
  • pulmonary edema
  • hyperreflexia
  • twitching
  • n&v
  • anorexia
17

sodium excess (hypernatremia) >145

lab values

  • increase serum sodium, specific gravity and osmolality
  • decrease CVP and urine sodium
18

hyponatremia

medical management

  • restrict fluids
  • sodium replacements (oral, NG, parenteral)
    • serum sodium cannot increase more than 12 mEq/L in 24 hrs -> neuro dmg and demyelination
      • decreased alertness, ataxia, paraparesis, dysarthria, horizontal gaze paralysis, pseudobulbar palsy, coma
  • SIADH pts -> lithium (lithobid) counteracts ADH
  • small volumes of hypertonic soln
  • AVP receptor antagonist
  • vaprisol -> severe
    • contra in seizure, delirium, or coma
19

hyponatremia

nursing management

  • IO, daily weight
  • monitor if pt has diminished thirst or no access to food
20

hypernatremia

medical management

  • IV therapy
    • hypotonic -> gradual reduction, decrease risk of cerebral edema
    • isotonic (D5W) ->severe hyperglycemia with hypernatremia
21

hypernatremia

nursing management

she is a bully, she's angry, I'm scared for my life,

  • oral fluid intervals
  • Diabetes insipidus -> water intake
22

potassium deficit (hypokalemia) <3.5

contributing factors

  • diarrhea
  • vomiting
  • gastric suction
  • corticosteroid administration
  • hyperaldosteronism
  • carbenicillin
  • amphotericin B
  • bulimia
  • osmotic diuresis
  • alkalosis
  • starvation
  • diuretics
  • digoxin toxicity
23

potassium deficit (hypokalemia) <3.5

signs and symptoms

  • fatigue
  • anorexia
  • n&v
  • muscle weakness
  • polyuria
  • decrease BM, BP
  • ventricular asystole or fibrillation
  • paresthesias
  • leg cramps
  • abd, ileus distention
  • hypoactive reflexes

ECG: flat T waves, prominent U waves, ST depression, prolonged PR interval

24

potassium excess (hyperkalemia) >5

contributing factors

  • pseudohyperkalemia
  • oliguric kidney injury
  • use of potassium-conserving diuretics
  • metabolic acidsosi
  • addison's dz
  • crush injury, burns
  • stored bank blood transfusion
  • rapid IV admin of K+ and medications (ACE-I, NSAIDs, cyclosporine)
25

potassium excess (hyperkalemia) >5

signs and symptoms

  • muscle weakness
  • tachycardia --> bradycardia
  • dysrhythmias
  • flaccid paralysis
  • paresthesias
  • intestinal colic
  • cramps
  • abdominal distention
  • irritability
  • anxiety

ECG: tall tented T waves, prolonged PR interval and QRS duration, absent P waves, ST depression

26

Hypokalemia

  • increase potassium intake
  • IV (KCl, KPO4, KC2H3O2)
    • continuous EKG
27

Hyperkalemia

  • EKG -> changes, verify results with serum K+
  • restrict K+
  • IV calcium gluconate
    • counteracts hyperkalemic actions on the heart
    • monitor BP, bradycardia -> stop infusion
  • monitor IO, signs of muscle weakness and dysrhythmias, vitals (apical pulse)
28

Calcium deficit (hypocalcemia) <8.5

contributing factors

  • hyperthyroidism
  • malabsorption
  • pancreatitis
  • alkalosis
  • vitamin D def.
  • massive subQ infection
  • generalized peritonitis
  • massive transfusion of citrated blood
  • chronic diarrhea
  • decreased parathyroid hormone
  • diuretic phase of kidney injury
  • increased Phosphate
  • fistulas
  • burns
  • alcoholism
29

Calcium deficit (hypocalcemia) <8.5

signs and symptoms

  • numbness
  • tingling of fingers, toes and cirumoral region
  • + Trousseau and Chvostek sign
  • seizures
  • carpopedal spasms
  • hyperactive deep tendon reflexes
  • irritability bronchospasm
  • anxiety
  • impaired clotting time
  • decrease prothrombin,BP
  • diarrhea

ECG: prolonged QT interval, lengthened ST

30

Calcium deficit (hypocalcemia) <8.5

lab values

decrease Mg

31

Calcium excess (hypercalcemia) >10.5

contributing factor

  • hyperparathyroidism
  • malignant neoplastic dz
  • prolonged immobilization
  • overuse of calcium supplements
  • vitamin D XS
  • oliguric phase of renal failure
  • acidosis
  • corticosteroid therapy
  • thiazide diuretic use
  • increased parathyroid hormone and digoxin toxicity
32

Calcium excess (hypercalcemia) >10.5

signs and symptoms

  • muscular weakness
  • constipation
  • anorexia
  • nausea and vomiting
  • polyuria and polydipsia
  • dehydration
  • hypoactive deep tendon reflexes
  • lethargy
  • deep bone pain
  • pathologic fractures
  • flank pain
  • calcium stones
  • HTN

ECG: shortened ST segment and QT interval, bradycardia, heart blocks

33

Hypocalcemia

  • severe - emergency -> calcium salt IV (Calcium gluconate or CaCl2)
    • caution in pt w/ digitalis
    • monitor IV site (CaCl2)
    • give with D5W
    • keep in bed during infusion
  • vitamin D
  • Al(OH)3, CaC2H3O2, CaCO3 antacids - decrease phosphorus levels
    • pts with chronic kidney dz
  • calcium intake, divided does
  • seizure precautions, safety precautions - confusion
  • monitor airway - larynx stridor
  • EtOH and caffeine inhibit Ca absorption, smoking increases urine
  • Phosphorus negative relationship with Ca
34

Hypercalcemia

malignancies and hyperparathyroidism

  • XS PTH secretion -> increase release of Ca in bones and increased absorption
35

hypercalcemia

management

  • tx underlying cause
  • dilution + excretion therapy
  • calcitonin (contains salmon)
  • corticosteroid, bisphosphates, IV forms
    • IV - may cause fever, transient leukopenia, eye inflammation, nephrotic syndrome, jaw osteonecrosis
    • also, calcification, hypotension, tetany and acute kidney injury
  • increase pt mobility and encourage fluids to prevent
    • ambulate pts
36

Magnesium deficit (hypomagnesemia) <1.8

contributing factors

  • chronic alcoholism
  • hyperparathyroidism
  • hyperaldosteronism
  • diuretic phase of acute kidney injury
  • malabsorptive disorders
  • diabetic ketoacidosis
  • refeeding after starvation
  • parenteral nutrition
  • chronic laxative use, diarrhea
  • acute myocardial infarction, HF
  • decreased K+ and Ca++ and pharm agents
37

Magnesium deficit (hypomagnesemia) <1.8

  • Neuro muscular irritability
  • + Trousseau and Chvostek sign
  • insomnia
  • mood changes
  • anorexia
  • vomiting
  • increased tendon reflexes, BP

ECG: PVCs, flat or inverted T waves, depressed ST segment, prolonged PR interval, and widened QRS

38

Magnesium excess (hypermagnesemia) >3

  • oliguric phase of acute kidney injury (Mg meds given)
  • adrenal insufficiency
  • XS IV Mg admin.
  • diabetic ketoacidosis
  • hypothyroidism
39

Magnesium excess (hypermagnesemia) >3

  • flushing
  • hypotension
  • muscle weakness
  • drowsiness
  • hypoactive reflexes
  • depressed respirations
  • cardiac arrest and coma
  • diaphoresis

ECG: bradycardia, prolonged PR interval and QRS, peaked T waves

40

Hypomagnesemia

frequently associated with hypokalemia and hypocalcemia

  • diet, salts
  • too rapid of bolus -> cardiac conduction, heart block, asystole
  • UO
  • seizure precautions, safety precautions of LOC lowered
41

Hypermagnesemia

depress CNS as well as peripheral neuromuscular junction

may result in platelet clumping and delayed thrombin formation

  • avoid Mg admin in kidney pts,
  • severe - calcium gluconate and ventilation support
  • hemodialysis
  • diuretics
  • vitals, hypotension, shallow respirations, decreased deep tendon reflexes, LOC
42

Phosphorus deficit (hypophosphatemia) <2.5

contributing factors

  • refeeding after starvation
  • EtOH withdrawal
  • diabetic ketacidosis
  • respiratory and metabolic alkalosis
  • decreased Mg, K
  • hyperparathyroidism
  • vomiting
  • diarrhea
  • hyperventilation
  • vitamin D deficiency assoc. w/ malabsorptive disorders
  • burns
  • acid-base disorders
  • parenteral nutrition
  • diuretic and antacid use
43

Phosphorus deficit (hypophosphatemia) <2.5

signs and symptoms

  • parestesias
  • muscle weakness
  • bone pain and tenderness
  • chest pain
  • confusion
  • cardiomyopathy
  • respiratory failure
  • seizures
  • tissue hypoxia
  • increased susceptibility to infection
  • nystagmus
44

phosphorus excess (hyperphosphatemia) >4.5

contributing factors

  • acute kidney injury and chronic kidney dz
  • XS intake of phosphorus
  • vitamin D XS
  • respiratory and metabolic acidosis
  • hypoparathyroidism
  • volume depletion
  • leukemia/lymphoma treated with cytotoxic agents
  • increased tissue breakdown
  • rhabdomyolysis
45

phosphorus excess (hyperphosphatemia) >4.5

signs and symptoms

  • tetany
  • tachycardia
  • anorexia
  • n&v
  • muscle weakness
  • s/s of hypocalcemia
  • hyperactive reflexes
  • soft tissue calcifications in lungs, heart, kidneys and cornea
46

hypophosphatemia

prevention, IV soln if acute, replacement if not severe

  • gradual introduction to calories if pt is malnourished
  • prevent infection
  • PO4 diet
47

hyperphosphatemia

  • treat underlying disorder
    • volume depletion, respiratory or metabolic acidosis, elevated PTH, bone disease
  • vitamin d preparations - calcitriol
  • low phos diet
48

chloride deficit (hypochloremia ) <96

contributing factors

  • Addison's disease
  • red. Cl intake or absorption
  • untreated diabetic ketoacidosis
  • chronic resp. acidosis
  • XS sweating
  • vomiting
  • gastric suction
  • diarrhea
  • sodium and potassium deficiency
  • metabolic alkalosis
  • diuretics
  • overuse of bicarbonate
  • IF fluids lacking Cl
  • draining fistulas and ileostomies
  • HF
  • cystic fibrosis
49

chloride deficit (hypochloremia ) <96

signs and symptoms

  • agitation
  • irritability
  • tremors
  • muscle cramps
  • hyperactive deep tendon reflexes
  • hypertonicity
  • tetany
  • slow shallow respirations
  • seizures
  • dysrhythmias
  • coma
50

chloride deficit (hypochloremia ) <96

lab values

  • decrease serum Cl, Na, urine Cl, serum K
  • increase pH, serum bicarbonate, total CO2 content
51

chloride excess (hyperchloremia) >108

contributing factors

  • XS NaCl infusion with water loss
  • head injury
  • hypernatremia
  • kidney injury
  • corticosteroid use
  • dehydration
  • sever diarrhea
  • respiratory alkalosis
  • admin of diuretics
  • overdose of salicylates
  • kayaexalate
  • acetazolamide
  • phenylbutazone and ammonium chloride use
  • hyperparathyroidism
  • metabolic acidosis
52

chloride excess (hyperchloremia) >108

signs and symptoms

  • tachypnea
  • lethargy
  • weakness
  • deep rapid respirations
  • decline in cognitive status
  • decreased CO
  • dyspnea
  • tachycardia
  • pitting edema
  • dysrhythmias
  • coma
53

chloride excess (hyperchloremia) >108

lab values

  • increase serum Cl, K, Na, urinary Cl lvl
  • decreased serum pH, bicarbonate
  • normal anion gap
54

hypochloremia

  • treat underlying cause, electrolyte or acid-base
  • NS
  • D/c diuretic
  • ammonium chloride
  • I&O, ABG, electrolytes
  • LOC, muscle strength, movement, vitals
  • diet
55

hyperchloremia

  • electrolyte and acid base
  • hypotonic soln., LR