Fundamentals of Nursing: Fluid, electrolyte and acid-base balance Flashcards


Set Details Share
created 6 weeks ago by Jenniferduvall
9 views
updated 5 weeks ago by Jenniferduvall
show moreless
Page to share:
Embed this setcancel
COPY
code changes based on your size selection
Size:
X
Show:
1

What are the functions of body fluids?

transports nutrients to cells and carrys waste from cells

transports hormones, enzymes, platelets, RBC's and WBC's

facilitates cellular metabolism

assists with digestion of food

serves as a medium for excreting waste

acts as a lubricant

2

Intracellular fluid (ICF)

fluid within cells

-responsible for cell function & metabolism

- about 70% of the total body water

3

Extracellular fluid (ECF)

fluid outside the cells

-includes intravascular and interstitial fluids

- also includes transcellular fluid, minor level of fluid

- about 30% of the total body water

4

ECF- interstitial

lies in the spaces between the body cells

5

ECF - intravascular

plasma within the blood

6

ECF -transcellular

specialized fluids such as cerebrospinal, pleural, peritoneal, pericardial, synovial & digestive juices

7

Fluid intake is regulated primarily by ...

the thirst mechanism located in the hypothalamus

8

intake is stimulated by ...

intracellular dehydration or loss of water from the body or a decrease in fluid volume

9

Body produces balance by shifting fluids and solutes between

the ECF and ICF

10

The primary site for the regulator of fluid volume is the

renal system

11

___________ is the primary solvent

water

12

solutes are ___________

electrolytes and nonelectrolytes

13

Fluid volume deficit (hypovolemia) symptoms

dry skin and mucous membranes

thirst

reduced skin turgor

weak, rapid pulse

decreased urine output (oliguria)

hypotension

fatigue

anorexia

14

Fluid volume excess (hypervolemia) symptoms

weight gain over a short period of time

elevated blood pressure, bounding pulse

pale, cool skin

edema, ascites

crackles, shortness of breath

neck vein distension

15

average I & O per day

1500 - 3500 mL

16

Urine volume concentration

a low urine volume and high specific gravity indicated fluid volume deficit; a low urine volume and a low specific gravity indicates renal disease

17

normal urine specific gravity

1.005 - 1.030

18

urine specific gravity 1.030 or greater

dehydration

19

urine specific gravity 1.005 or less

fluid overload or renal failure

20

urinary output should equal fluid intake.... true or false

true

21

normal urinary output for the average adult

1500 mL/ 24hr or about 40-80 mL/hr

22

_________ is a more accurate indicator of fluid gained or lost.

body weight

23

when third spacing occurs in a patient could they have a fluid volume deficit with out weight change?

yes

24

Isotonic solution

same osmolality as the fluid in the cells

no change in the cells

these types of fluids are given to increase ECF volume, maintain fluid volume, treat hypovolemia

given if blood volume is low from dehydration or bleeding

examples: 0.9% normal saline, lactated ringers solution

25

hypotonic solutions

lower osmolality than blood. This causes water to go into the cells, expand the intracellular compartment

can cause cells to swell

given when correcting high serum electrolyte levels

Examples: 0.33% Normal Saline, 0.45% Normal saline

26

Hypertonic solutions

higher osmolality than blood. Osmosis pulls fluid from the cells to the vascular system

can cause cells to shrink

given to treat low serum electrolyte levels, hypoglycemia or hyponatremia

Examples: Dextrose 5% in Normal Saline, 3% Normal Saline, 5% Normal Saline, Dextrose 10%, Dextrose 5% Lactated Ringers

27

Complications associated with IV infusions

infiltration, VAD-related infection, Phlebitis, Thrombus, Speed Shock, Fluid Overload, Air Embolus

28

Phlebitis Scale

0 = no symptoms

1=erythema at access site with or without pain

2= pain at access site with erythema and/or edema

3= pain at access site with erythema and/or edema

streak formation

palpable venous cord

4= pain at access site with erythema and/or edema

streak formation

palpable venous cord >1 in length

purulent drainage

29

Infiltration

the escape of fluid into subcutaneous tissue, dislodged needle or penetrated vessel wall

-swelling, pallor, coldness, or pain around the infusion site

30

VAD related infection symptoms

erythema, edema, induration, drainage at the insertion site, fever, malaise, chills, other vital sign changes

31

Phlebitis

an inflammation of the vein.

symptoms - local, acute tenderness, redness, warmth, slight edema of the vein above the insertion site.

32

Thrombosis

a blood clot

- symptoms similar to phlebitis, IV fluid flow may cease if clot obstructs needle

33

speed shock

the bodys reaction to a substance that is injected into the circulatory system too rapidly

symptoms - pounding headache, fainting, rapid pulse, apprehension, chills, back pains and dyspnea

34

fluid overload

the condition caused when too large a volume of fluid infuses into the circulatory system

- too large a volume of fluid infused into circulation

symptoms - engorged neck veins, increased bp, and difficulty breathing

35

air embolus

air in the circulatory system

symptoms - respiratory distress, increased HR, cyanosis, decreased BP, change in level of consciousness

36

acidosis

the blood has too much acid (or too little base) resulting in a decrease in blood pH

37

alkalosis

the blood has too much base (or too little acid) resulting in a increase in blood pH

38

acidosis and alkalosis are categorized depending on their primary cause as .....

metabolic

respiratory

39

to prevent or correct a patients fluid, electrolyte, or acid base imbalance nursing interventions

dietary modifications

modification of fluid intake

medication administration

iv therapy

blood and blood product replacement

administration of parenteral nutrition

patient and family teaching

40

these may reflect the patients fluid status and renal function

-below or above normal levels of sodium, potassium, calcium, magnesium, phosphate and chloride

- below normal or above normal levels of bicarbonate

- increased BUN may indicate impaired renal function, diabetic ketoacidosis, and burns

- increased creatinine may indicate impaired renal function, heart faiure, shock, dehydration

41

risk factors for fluid volume deficit (hypovolemia)

vomiting, diarrhea, suction, fistulas, hemorrhage, excessive sweating, skin trauma, burns, draining, wounds, third-space fluid shifts, excessive laxative or diuretic use, polyuria from renal disease or diuretics, hyperglycemia, change in mental status (unable to gain access to fluids, depression, confusion)

42

nursing interventions for hypovolemia

assess for presence or worsening of FVD, administer oral fluids if indicated, if patient is unable to eat and drink anticipate TPN or tube feedings to be ordered, monitor patients response to fluid intake either oral or parenteral, be alert for signs of fluid overload, provide appropriate skin care.

43

risk factors fluid volume excess (hypervolemia)

compromised regulatory mechanisms: renal failure, CHF, cirrhosis of liver, cushing syndrome, GI irrigation with hypotonic fluid, Excess IV fluids with sodium, corticosteroid therapy, excessive ingestion of sodium-containing substances in diet or sodium-containing medications

44

nursing interventions for hypervolemia

assess for presence or worsening of hypervolemia, encourage adherence to sodium-restricted and fluid-restricted diet if ordered, avoid OTC drugs or check with primary care provider or pharmacist about sodium content, encourage rest periods, monitor patients response to diuretics, teach self monitoring of weight and intake and output, attentive skin care, monitor respiratory status

45

risk factors for hyponatremia (low sodium)

Loss of sodium, as in: Loss of GI fluids, Use of diuretics, Adrenal insufficiency

Gains of water, as in: Excessive administration of D5W, Water intoxication

Disease states associated with SIADH (a form of hyponatremia)
Pharmacologic agents that may impair water excretion

46

symptoms of hyponatremia

Anorexia
Nausea and vomiting
Lethargy
Confusion
Muscle cramps
Muscular twitching
Seizures
Coma
Serum Na below 135 mEq/L
Urine specific gravity <1.010

47

nursing interventions for hyponatremia

Monitor fluid losses and gains.
Monitor for presence of GI and CNS symptoms.
Monitor serum Na levels.
Check urine specific gravity.
If able to eat, encourage foods and fluids with high sodium content.
Be aware of sodium content of common IV fluids.
Avoid giving large water supplements to patients receiving isotonic tube feedings.
Take seizure precautions when hyponatremia is severe.

48

risk factors for hypernatremia

Water deprivation
Increased sensible and insensible water loss
Ingestion of large amount of salt
Excessive parenteral administration of sodium-containing solutions
Profuse sweating
Diabetes insipidus

49

symptoms of hypernatremia

Thirst
Elevated body temperature
Tongue dry and swollen, sticky mucous membranes
Severe hypernatremia:

Disorientation

Hallucinations

Lethargy when undisturbed

Irritable and hyperactive

Focal or grand mal seizures

Coma

Serum Na above 145 mEq/L
Urine specific gravity >1.015

50

nursing interventions for hypernatremia

Monitor fluid losses and gains.
Observe for excessive intake of high sodium foods.
Monitor sodium content of prescriptions and OTC drugs.
Monitor for changes in behavior such as restlessness, lethargy, and disorientation.
Look for excessive thirst and elevated body temperature.
Monitor serum Na levels.
Check urine specific gravity.
Give sufficient water with tube feedings to keep serum Na and BUN at normal limits.

51

risk factors for hypokalemia (low potassium)

Diarrhea
Vomiting or gastric suction
Potassium-wasting diuretics
Steroid administration and certain antibiotics
Poor intake as in anorexia nervosa, alcoholism, potassium-free parenteral fluids
Polyuria

52

symptoms of hypokalemia

Fatigue
Anorexia, nausea, and vomiting
Muscle weakness
Decreased bowel motility
Cardiac arrhythmias
Increased sensitivity to digitalis
Polyuria, nocturia, dilute urine
Postural hypotension
Serum K below 3.5 mEq/L
ECG changes
Paresthesias or tender muscles

53

nursing interventions for hypokalemia

Monitor for occurrence of hypokalemia.
Assess digitalized patients at risk for hypokalemia, which potentiates the action of digitalis
Prevent hypokalemia by:

Encouraging extra K intake if possible

Educating about abuse of laxatives and diuretics

Administer oral K supplements if ordered.
Be knowledgeable about danger of IV potassium administration.

54

risk factors for hyperkalemia

Decreased potassium excretion
Oliguric renal failure
Potassium-sparing diuretics
Hypoaldosteronism
High potassium intake, especially in presence of renal insufficiency
Shift of potassium out of cells (acidosis, tissue trauma, malignant cell lysis)

55

symptoms for hyperkalemia

Vague muscle weakness
Cardiac arrhythmias
Paresthesias of face, tongue, feet, and hands
Flaccid muscle paralysis
GI symptoms such as nausea, intermittent intestinal colic, or diarrhea may occur
Serum K >5.0 mEq/L

56

nursing interventions for hyperkalemia

Monitor for hyperkalemia, which is life threatening.
Prevent hyperkalemia by:

Following rules for safe administration of K

Avoiding giving patients with renal insufficiency K-saving diuretics, K supplements, or salt substitutes

Cautioning about foods high in potassium content

57

risk factors for hypocalcemia

Surgical hypoparathyroidism
Malabsorption
Vitamin D deficiency
Acute pancreatitis
Excessive administration of citrated blood
Alkalotic states

58

symptoms of hypocalcemia

Trousseau and Chvostek signs
Numbness and tingling of fingers and toes
Mental changes
Seizures
Spasm of laryngeal muscles
ECG changes
Cramps in muscles of extremities
Total serum calcium <8.5 mg/dL

59

nursing interventions for hypocalcemia

Take seizure precautions when hypocalcemia is severe.
Monitor condition of airway.
Take safety precautions if confusion is present.
Educate people at risk for osteoporosis about the need for dietary calcium intake.
Discuss calcium-losing aspects of nicotine and alcohol use.

60

risk factors for hypercalcemia

Hyperparathyroidism
Malignant neoplastic disease
Prolonged immobilization
Large doses of vitamin D
Overuse of calcium supplements
Thiazide diuretics

61

symptoms of hypercalcemia

Muscular weakness
Tiredness, lethargy
Constipation
Anorexia, nausea, and vomiting
Decreased memory and attention span
Polyuria and polydipsia
Renal stones
Neurotic behavior
Cardiac arrest
Serum calcium >10.5 mg/dL

62

nursing interventions for hypercalcemia

Increase mobilization when feasible.
Encourage sufficient oral intake.
Discourage excessive consumption of milk products.
Encourage bulk in the diet.
Take safety precautions if confusion is present.
Be alert for signs of digitalis toxicity in hypercalcemic patients.
Force fluids to prevent formation of renal stones.

63

risk factors for hypomagnesemia

Chronic alcoholism
Intestinal malabsorption
Diarrhea
Nasogastric suction
Drugs

Thiazide diuretics

Aminoglycoside antibiotics

Excessive doses of vitamin D

Citrate preservative in blood

64

symptoms of hypomagnesemia

Neuromuscular irritability

Increased reflexes

Coarse tremors

Seizures

Cardiac manifestations

Tachyarrhythmias

Increased susceptibility to digitalis toxicity

Mental changes

Disorientation

Mood changes

Serum magnesium <1.3 mEq/L

65

nursing interventions for hypomagnesemia

Assess for magnesium deficit because it predisposes patient to digitalis toxicity.
Take seizure precautions if necessary.
Monitor condition of airway because laryngeal stridor can occur.
Educate the patient if abuse of diuretics or laxatives is a problem.
Educate about intake of foods rich in magnesium.

66

risk factors for hypermagnesemia

Renal failure
Adrenal insufficiency
Excessive magnesium administration during treatment of eclampsia
Hemodialysis with hard water or dialysate high in magnesium content

67

symptoms of hypermagnesemia

Early sign is serum magnesium level of 3–5 mEq/L
Flushing and sense of skin warmth
Hypotension
Depressed respirations
Drowsiness, hypoactive reflexes, and muscular weakness
Cardiac abnormalities

68

nursing interventions for hypermagnesemia

If hypermagnesemia is present, be alert for low BP and shallow respirations, lethargy, drowsiness, and coma.
Do not give magnesium-containing medications to patient with renal failure or compromised renal function.
Be cautious of OTC drugs.
Check deep tendon reflexes frequently.

69

risk factors for hypophosphatemia

Glucose administration
Refeeding after starvation
Parenteral nutrition
Alcohol withdrawal
Diabetic ketoacidosis
Respiratory alkalosis

70

symptoms of hypophosphatemia

Cardiomyopathy
Acute respiratory failure
Seizures
Decreased tissue oxygenation
Joint stiffness
Serum phosphate <2.5 mg/dL

71

nursing interventions for hypophosphatemia

Be aware that severely hypophosphatemic patients are at greater risk for infection.
Administer IV phosphate products cautiously.
Introduce parenteral nutrition cautiously in patients who are malnourished.
Monitor for diarrhea when taking oral supplements.
Sudden increase in serum phosphate level can cause hypocalcemia.

72

risk factors for hyperphosphatemia

Renal failure
Chemotherapy
Large intake of milk
Excessive intake of phosphate-containing laxatives (Fleet phosphosoda)
Large vitamin D intake
Hyperthyroidism

73

symptoms of hyperphosphatemia

Short-term consequences:
Symptoms of tetany, such as tingling of the fingertips and around the mouth, numbness, and muscle spasms
Long-term consequences:
Precipitation of calcium phosphate in nonosseous sites such as the kidneys, joints, arteries, skin, or cornea.
Serum phosphate >4.5 mg/dL

74

nursing interventions for hyperphosphatemia

Monitor for signs of tetany.
Be aware that soft tissue calcification can be a long-term complication of chronically elevated serum phosphate levels.
Instruct patients that use of phosphate-containing laxatives can result in hyperphosphatemia.
Avoid foods high in phosphorus content.