Test Two (GI,Fluids/electrolytes,Acid-base balance,Endocrine) Flashcards

enzyme that aids in digestion of fats

aids in digestion of proteins

phase of the digestive process that occurs when enzymes mix with ingested food and when proteins, fats, and sugars are broken down into their component molecules.

phase of the digestive process that occurs when small molecules, vitamins, and minerals pass through the walls of the small and large intestine and into the bloodstream.

food moving from stomach to small intestine

saliva, salivary amylase

hydrochloric acid, pepsin, intrinsic factor

amylase, lipase, trypsin, bile

indigestion

Abdominal pain, dyspepsia, gas, nausea and vomiting, constipation, diarrhea, fecal continence, change in bowel patterns, characteristics of stool, jaundice, history of GI surgery or problems, appetite and eating patterns, teeth, and nutritional assessment including weight patterns
Psychosocial, spiritual, and cultural factors
Assess knowledge; need for patient education

black stool

white stool

CBC and Chemistry
AST (Aspartate Aminotranferase)
ALT (Alanine Aminotransferase)
Amylase and Lipase
Bilirubin
Carcinoembryonic antigen (CEA)

Fecal occult blood tests (False-positive NSAID’s, ASA, Red Meat, within 72 hours)

false-negative with vitamin C within 72 hrs

Stool examination for ova, parasites, and bacteria

...

Inspection, auscultation, palpation, percussion

...

Purpose- to detect tissue densities and abnormalities in the abd, liver, pancreas, spleen, and biliary tract
Client Prep- with or without contrast (IV or PO contrast may be used), NPO 4 hours prior if contrast used, IV access
Follow-up Care- none specific unless sedation was needed
If IV contrast used – hold Metformin 24 hours before and 48 hours after to prevent renal failure

vit. C, NSAIDs, ASA, Red meat within 72 hours prior

parasitic infection

parasitic infection, ulcers, anemia

Purpose-detect abnormalities of the esophagus, stomach, or duodenum (hiatal hernias, ulcers)
Client Prep- NPO (6-8hrs), PO contrast, no opioids or anticholinergic meds for 24 hrs prior
Follow-up Care- drink plenty of fluids to eliminate barium. Laxative may be given. Stool may be chalky for 24-72 hrs after exam.

acute pancreatitis

Purpose- detect changes in large intestines (polyps, tumors, and other lesions)
Client Prep- clear liquids only 12-24hrs prior, NPO 8hrs prior, bowel cleansing night before exam, might have cramping and discomfort during the procedure
Follow-Up Care- same as upper GI

Purpose- visualize the mucosal lining of esophagus, stomach, and duodenum
Client Prep- NPO at least 8 hrs prior
Follow-up Care- NPO until gag reflex returns, check temp freq for first 2 hrs post-procedure, begin with clears and advance as ordered.

checking for h-pylori (ulcers)

Purpose- visualize the liver, gallbladder, bile ducts and pancreas, and determine obstructions
Client Prep- same as EGD
Follow-up Care- same as EGD, also educate on s/s of possible pancreatitis (nausea, abdominal pain, and elevated temp)

Purpose- view large bowel for things such as: obtaining bx, removing polyps, evaluate cause of chronic bowel problems, locate source of GI bleeding
Client Prep- clear liquids 12-24 hrs prior, NPO 6-8hrs prior, bowel cleansing night before
Follow-up Care- VS monitoring freq, monitor for s/s of perforation and hemorrhage
Will have lots of gas afterwards (feeling of fullness & cramping)

for hemorrhaging
and VS

patient will be gassy- bowel pumped with gas for procedure

...

True

Protrusion of a portion of the stomach thru an opening (hiatus) in the diaphragm lying next to the esophagus.

part of stomach “slides” thru the hiatal opening into the thoracic cavity when pt is supine, and goes back into abd cavity when standing upright

fundus and greater curvature of the stomach “roll” up thru the diaphragm, forming a pocket alongside the esophagus.

...

weakening of diaphragm muscles around esophagogastric opening, factors that increase intra-abdominal pressure (obesity, pregnancy, ascites, tumors, physical exertion, heavy lifting), trauma, poor nutrition, and a forced recumbent position (bedrest) are also predisposing factors.

similar to GERD, and may mimic GB disease, angina, and peptic ulcer disease. MAY BE ASYMPTOMATIC.

Barium Swallow, x-rays, fluoroscopy

Backward flow of GI contents in to the esophagus- at the lower esophageal sphincter

pyrosis (burning sensation in the esophagus), dyspepsia (indigestion), regurgitation, chronic cough especially at night, chest pain, dysphagia or odynophagia (painful swallowing)

health history, evaluate complaints r/t heartburn, note relieving factors

Endoscopy or barium swallto

True

epithelial lining that the body substitutes for the normal lining in the lower esophagus during the healing process that becomes more resistant to acid, but is considered pre-malignant and increases risk for CA in patients with prolonged GERD

results in the narrowing of lumen (stricture) that causes dysphagia

barretts epithelium, fibrosis and scarring, Esophageal ulceration, hemorrhage, aspiration pneumonia

Lifestyle changes- HOB up at least 6 in, stop alcohol and smoking b/c these cause decrease LES pressure, wt reduction for obese client, do not wear restrictive clothing
Diet therapy- avoid foods that dec LES pressure (choc, fat, mints) and foods that can delay esophageal healing (spicy, acidic i.e OJ and tomatoes) carb. bev increase intra-abdom pressure, eat 4-6 small meals/day, don’t eat for 3 hrs prior to sleep.
Drug Therapy- Antacids (Maalox, Mylanta, MOM, TUMS) for occ episodes, increase the pH of gastric contents, Histamine Antagonists (Pepcid, Zantac, Tagamet, ), PPIs (Prilosec, Prevacid, Protonix, Nexium

Squamous-cell most common, adenocarcinoma is increasing in incidence

Smoking, Excessive alcohol intake, Chronic trauma, Barrett’s esophagus, Spicy foods, Poor oral hygiene, GERD

usually don’t appear until later stages but may include: dysphagia, pain (epigastric, substernal, back) that increases with swallowing

Assess risk factors for esophageal cancer, pain, dysphagia, and nutrition status

EGD, Biopsy

Altered nutrition (may necessitate need for feeding tube), Pain, Fluid Volume Deficit, Risk for aspiration, Anxiety

through the nose to the stomach

Decompress the stomach
Lavage the stomach
Diagnose GI disorders
Administer medications and feeding
To treat an obstruction
To compress a bleeding site
To aspirate gastric contents for analysis

enteric tube...includes NG, gastric, duodenum, jejunum

Levin – Single lumen
Sump - Refer to fig. 36-1 – One way valve that allows air to enter and prevents gastric contents to reflux

True

Patient teaching and preparation
Tube insertion
Confirming placement
Securing the tube
Monitoring the patient
Maintaining tube function
Oral and nasal care
Monitoring, preventing, and managing complications
Tube removal

Safe and cost-effective
Preserve GI integrity
Preserve the normal sequence of intestinal and hepatic metabolism
Maintain fat metabolism and lipoprotein synthesis
Maintain normal insulin and glucagon ratios

long term feeding

shorter term feeding

Intermittent bolus feedings
Intermittent gravity drip
Continuous infusion
Cyclic feeding

checking for correct placement of enteral tubing

30 ml of air

can also check with ph strip for stomach acid being hit with tube

gravity

continue checking every 8 hours

continuous controlled pump

semi-fowlers...at least 30-45 degrees

Nutritional status and nutritional assessment
Factors or illnesses that increase metabolic needs
Hydration and fluid needs
Digestive tract function
Renal function and electrolyte status
Medications and other theories that effect nutrition intake and function of the GI tract
Compare the dietary prescription to the patient needs.

blood sugar, insulin

Imbalanced nutrition
Risk for diarrhea
Risk for ineffective airway clearance
Risk for deficient fluid
Risk for ineffective coping
Risk for ineffective therapeutic regimen management
Deficient knowledge

Imbalanced nutrition
Risk of infection
Risk for impaired skin integrity
Ineffective coping
Disturbed body image
Risk for ineffective therapeutic regimen management

Diarrhea
Nausea and vomiting
Gas/bloating/cramping
Dumping syndrome
Aspiration pneumonia
Tube displacement
Tube obstruction
Nasopharyngeal irritation
Hyperglycemia
Dehydration and

Wound infection
GI bleeding
Premature removal of tube
Aspiration
Constipation
Diarrhea

can be caused by enteral feeding because food moves too quickly through the intestines....causes diarrhea, nausea, etc

nutritional balance, normal bowel elimination pattern, reduced risk of aspiration, adequate hydration, individual coping, knowledge and skill in self-care, and prevention of complications.

attaining an optimal level of nutrition, absence of infection, adequate fluid volume, optimal level of activity, knowledge of self-care, and absence of complications.

check for location, administer water, feeding, and admin water again

don't mix meds with feeding...admin water, give med, admin water again

30 ml or larger

don't hang more than 4 hours of feeding in open system

even though the feeding formula is good for 24 hours

can use same bag for 24 hours...just add more formula

Administer water before and after each medication and each feeding, before and after checking residual, every 4-6 hours, and whenever the tube feeding is discontinued or interrupted.

dumping syndrome

Measure residual prior to intermittent feedings and every 4-8 hours during continuous feedings.

Selection of TF formula; consider fiber, osmolality, and fluid content
Prevent contamination of TF; maintain closed system, do not hang more than 4 hours TF in an open system
Maintain proper nutritional intake
Assess for reason for diarrhea and obtain treatment as needed
Administer TF slowly to prevent dumping syndrome
Avoid cold TF

usually 4x4 pad

and clean site every 8 hours around tube site

Elevate HOB at least 30-45 degrees during and for at least 1 hour after feedings

Monitor residual volumes

Maintain hydration by supplying additional water and assessing for signs of dehydration
Promote coping by support and encouragement, encourage self-care and activities
Patient teaching

total parental nutrition

An admixture of lipid emulsions, proteins, carbohydrates, electrolytes, vitamins, trace minerals, and water.

A method to provide nutrients to the body by an IV route.
A complex mixture containing proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals, and sterile water is administered in a single container.
The goals of parenteral nutrition are to improve nutritional status and to attain a positive nitrogen status.

pre-albumin

temperature- infection from tubing is common

Intake is insufficient to maintain anabolic state.
Ability to ingest food orally or by tube is impaired.
Patient is not interested or is unwilling to ingest adequate nutrients.
The underlying medical condition precludes oral or tube feeding.
Preoperative and postoperative nutritional needs are prolonged.

24 hours

central line

Pneumothorax
Clotted or displaced catheter
Sepsis
Hyperglycemia
Rebound hypoglycemia
Fluid overload

attaining an optimal level of nutrition, absence of infection, adequate fluid volume, optimal level of activity, knowledge of self-care, and absence of complications.

Appropriate catheter and IV site care
Strict sterile technique for dressing changes
Wear mask when changing the dressing
Assess insertion site
Assess for indicators of infection
Proper IV and tubing care

Use infusion pump. Flow rate should not be increased or decreased rapidly. If fluid runs out, hang 10% dextrose solution.
Monitor indicators of fluid balance and electrolyte levels.
I&O.
Weights.
Monitor blood glucose levels.

Goals and purpose
Components of PN
Emergency contact numbers
Demonstrate use of equipment and how to handle and hang the IV
Demonstrate dressing changes
Demonstrate how to flush or heparinize the catheter
Potential complications and actions

Pathophysiology – inflammation of the stomach and intestinal tract that causes vomiting, diarrhea or both
Etiology – most common causes are viruses (rotavirus) and bacteria (Salmonella) in food or water.
Clinical Manifestations – episodes of vomiting and diarrhea and may develop symptoms of dehydration, malaise, abdominal cramps or fever
Prevention – handwashing, principle food handling (eggs and raw meat)
Assessment – abdomen assessment and hydration assessment.
Labs – CBC – for dehydration and elevated WBC’s
Nursing Dx – Fluid volume deficit

Infect humans through fecal-oral contamination or through ingestion of food or water contaminated with cysts or spores, through host-to-host contact, or by the bite of a mosquito or other insect that has previously bitten an infected person

diarrhea, gastroenteritis, malaria

skin pentration of larvae or ingestion of helminth eggs. Trichinelloisis (caused by roundworms) is a disease caused by eating raw or undercooked meat of pigs or wild animals that contain Trichinella larvae.

Inflammation of the stomach (gastric mucosa)
A common GI problem

rapid onset of symptoms usually caused by dietary indiscretion. Other causes include medications, alcohol, bile reflux, and radiation therapy. Ingestion of strong acid or alkali may cause serious complications.

prolonged inflammation due to benign or malignant ulcers of the stomach or by Helicobacter pylori. May also be associated with some autoimmune diseases, dietary factors, medications, alcohol, smoking, or chronic reflux of pancreatic secretions or bile.

mucosal damage
cells secrete HCL or pepsinogen and intrinsic factor

abdominal discomfort, headache, lassitude, nausea, vomiting, hiccuping.

epigastric discomfort, anorexia, heartburn after eating, belching, sour taste in the mouth, nausea and vomiting, intolerance of some foods. May have vitamin deficiency due to malabsorption of B12.

achlorhydria, hypochlorhydria, or hyperchloryhydria.

duodenum

UGI X-ray or endoscopy and biopsy.

Anxiety
Imbalanced nutrition
Risk for fluid volume imbalance
Deficient knowledge
Acute pain

Erosion of a mucous membrane forms an excavation in the stomach, pylorus, duodenum, or esophagus

Associated with infection of H. pylori

Risk factors include excessive secretion of stomach acid, dietary factors, chronic use of NSAIDs, alcohol, smoking, and familial tendency.

Manifestations include a dull gnawing pain or burning in the mid-epigastrium; heartburn and vomiting may occur

LABS- monitor H/H & coagulation studies

Dietary intake and 72 hour diet diary

30 min prior to meal

smoking and alcohol

pain relieved by antacids early in the disease, dyspepsia, early satiety, weight loss, abdominal pain, loss or decrease in appetite, bloating after meals, nausea, and vomiting. Diagnosis of the disease is often late.

EGD with biopsy
Ultrasound –presence of tumors
CT

Anxiety
Imbalanced nutrition
Pain
Anticipatory grieving
Deficient knowledge

medications, chronic laxative use, weakness, immobility, fatigue, inability to increase intra-abdominal pressure, diet, ignoring urge to defecate, and lack of regular exercise.

Fewer than 3 BMs per week
Abdominal distention, Indigestion
Decreased appetite
Headache, Fatigue
A sensation of incomplete evacuation
Straining at stool
Elimination of small-volume, hard, dry stools

Hypertension
Fecal impaction
Hemorrhoids
Fissures
Megacolon

Increased frequency of bowel movements (more than 3 per day), increase amount of stool (more than 200 g per day), and altered consistency (i.e., looseness) of stool

diarrhea

a rumbling or gurgling noise made by the movement of fluid and gas in the intestines

a clinical sign, where there is a feeling of constantly needing to pass stools, despite an empty colon.

criteria of recurrent abdominal pain or discomfort for at least 3 days a month in last 3 months

women than men

age of 10-30

increased WBCs, peri-umbilical pain (McBurney’s point) eventually shifting to RLQ, rebound tenderness (Rovsing’s sign), N/V, anorexia, possible low-grade fever

abd assessment, CBC (shows elevated WBC’s), x-ray, ultrasound, CT

sigmoid colon

could rupture appendix

sac-like herniation's of the lining of the bowel that extend through a defect in the muscle layer

multiple diverticula without inflammation

infection and inflammation of diverticula

usually caused by severe constipation

age
and low fiber diet

mild or severe pain in lower left quadrant, nausea, vomiting, fever, chills, and leukocytosis.

Barium Enema, Colonoscopy, CT with contrast, CBC, ESR

Perforation, Peritonitis, Abscess formation, Bleeding, fistula (where bowel joins with another organ)

chrohn's disease

chronic, nonspecific inflammatory bowel disorder that can affect any part of GI tract but mainly terminal ileum, jejunum, and colon

more commonly associated with smoking

DIARRHEA, abdominal pain, cramping, tenderness developing into weight loss, malnutrition, dehydration, electrolyte imbalances

barium studies, colonoscopy, sigmoidoscopy, bx performed, CBC, ESR, Decreased albumin and protein

with Chrohn's because they're not digesting protein well

affects the superficial mucosa of the colon causing multiple ulcerations, diffuse inflammations and shedding of the colonic epithelium – usually in the rectum and lesions spread throughout the large intestine

breaking thru submucosa and leaving ulcerations that destroy mucosal epithelium causing bleeding and diarrhea, watery mucus

exacerbations & remissions, diarrhea, passage of watery mucus & pus, LLQ abdominal pain, rectal bleeding, pallor, anemia, and fatigue

Barium series, Sigmoidoscopy, Colonoscopy, CBC (High WBC), Low H & H

bowel is obstructed by disorders outside of the intestine or by blockages in the lumen of the intestine

result of neuromuscular disturbance resulting in decreased or absent peristalsis causing back up of intestinal contents

...

increased inta-abd pressure by coughing, straining, and heavy lifting. Obesity, pregnancy, and poor wound healing are other risk factors

weakness in the abdominal muscle wall thru which a segment of bowel or other abd structure protrudes

located in the groin where the spermatic cord in males or the round ligament in females emerges from the abd wall.

are seen most often in obese women and in children. They are caused by a failure of the umbilical orifice to close

(Ventral) usually result from a weakness in the abdominal wall following abd. surgery

...

cancer of colon and rectum predominantly adenocarcinoma.
The second cause of cancer deaths in the United States.

...

bile

for times of high energy requirements:
exercise, fight or flight, etc.

clotting

very fine capillary system...because blood has to come into contact with hepatocytes

jaundice from bilirubin, cephalopothy (confusion), trembling, bilirubin binds to brain tissue, portal hypertension (filter clogged causes backup),blood goes into stomach because of portal hypertension (Ascites)

blood in stomach from portal hypertenstion because vessels in esophagus swell and leak into stomach

cirrhosis of liver can cause bleed out and death via this route

tarry stool seen, faster bleed can cause vomitting of blood

lack of bile from liver dysfunction

Aspartate Aminotransfease - AST (also SGOT) 15 – 40 u/L
Alanine Aminotransferase – ALT 10 – 40 u/L
Leucine Aminopeptidase – 75 – 200 u/L
Gamma-Glutamyl Transpeptidase – GGTP 0 – 30 u/L
Alkaline Phosphatase – 0 – 93 u/L

Erythrocyte Sedimentation rate
Serum Total Bilirubin
Unconjugated <1.1 mg/dL Conjugated <0.3 mg/dL
Urobilinogen * <1mg/dL
Prothrombin Time – PT <2.0 (times reference)
Serologic Tests – negative

tells us there is inflammation in body

unconjugated- not water soluble and hasn't been through liver yet

conjugated- has been changed by liver

may seem change in urine color if there is a lot of conjugated bilirubin

bilirubin in urine

test for clotting time
<2.0 (times reference)-- normal time for someone not on warfarin)

varies by age and gender

shows disease process

HAV,HBV,HCV,HDV,HEV,HFV,HGV

or

H(A-G)V

concentrated in stool during incubation period (common transmission worldwide is contaminated H2O)

undercooked shellfish

cleanliness, vaccines (HAV,HBV), standard precautions

washing produce, hands, etc

blood born: sexual contact, sharing drug needles, parenteral (in utero)

prodromal stage- (1 week)- flu-like symptoms, RUQ pain

Icteric Stage- (2-6 weeks)- worsening symptoms, jaundice, rash/itching

Convalescent- (2-6 weeks)- return to normal function, lab values normal

more common in women, rare

associated with graves, type I diabetes, myethenia gravis, etc

ingestion

body fluids

fatty liver disease
sudden massive loss of liver tissue replaced by massive amounts of fat (associated w/alcohol,drug toxicitiy, but can be idiopathic)
etiology- drug toxicity,hepatitis
people on TPN, wilson's disease, IDDM

encephalopathy - confusion, coma

elevated liver enzymes, bilirubin, PT (same as hepatitis but no antibodies b/c of absence of virus)

ascites, GI discomfort, generalized edema,jaundice, eventually respiratory or renal problems

Metabolic Alkalosis
Hypokalemia
Hypoglycemia
Clotting Disturbances
Sepsis
Renal Failure
Respiratory Failure

ALT
AST
Serum Bilirubin
Urobilinogen
Biopsy
Blood Glucose
PT
Ultrasound

Chronic Alcohol Ingestion
Hepatotoxins
Hepatitis
Gallbladder Obstruction
Heart Failure

Inflammation of Liver Cells
Infiltration with Fat and WBCs
Fibrotic Scar Tissue Replaces Liver Tissue

portal hypertension, anemia, hepatic encephalopathy,hepatorenal syndrome (ammonia crystals cause itching), GI problems including clay color stool, ammenorhea (no period), testicular atrophy, low testosterone (ED and male breasts), hemorrhoids

renal failure, clotting defects, ascites, portal hypertension, encephalopathy

liver enzymes, bilirubin, urobilinogen, serum ammonia, PT, abdominal x-ray, UGI series, liver scan, EGD (esophogus- endoscopic test), liver biopsy

Excess Fluid Volume
Imbalanced Nutrition
Pain
Risk for Disturbed Thought Processes
Risk for Ineffective Breathing Pattern
Risk for Deficient Fluid Volume
Risk for Infection

liver failure, no cancer, no complications, otherwise stable

inflammation, autodigestion, elevated enzymes,fluid loss

shock,DIC (Disseminated intravascular coagulation)- microclotting through out body due to excessive bleeding, chronic pancreatitis

Alcohol
Biliary Disease
Trauma
Some Drugs
scorpion and snake bites
Unknown (idiopathic)

not encapsulated so when there is disorder the surrounding tissue is affected (surrounding fat is digested)

Abdominal Pain
Guarding
Rigid Abdomen
Hypotension or Shock
Respiratory Distress
Low Grade Fever
Nausea and Vomiting
Jaundice
grey turner (bluish color to flanks)

Cardiovascular Failure
Acute Respiratory Distrss Syndrome
Renal Failure
Hemorrhage
Infection

Serum Amylase – 30 – 110 u/L
Serum Lipase – 3 – 73 u/L
X-Ray
CT
Ultrasound

Pain
Imbalanced Nutrition
Risk for Ineffective Breathing Pattern
Risk for Injury

Cholecystitis: Inflammation

Cholelithiasis: Stones

Choledocholithiasis: Stones in Common Bile Duct (can damage liver if left untreated)

Stasis
High Cholesterol Intake
Fasting
Sedentary Lifestyle
Family History
More Common in Women
Pregnancy
Risk Increases with Age

Increased Vital Signs
Vomiting
Jaundice
Epigastric Pain
RUQ Tenderness
Nausea
Indigestion
Positive Murphy’s Sign
Biliary Colic (pain)

Cholangitis
Necrosis/Perforation of GB
Empyema
Fistulas
Adenocarcinoma of GB
Pancreatitis

female,fat,over 40,fertile

WBC
Serum Amylase
X-Ray
Nuclear Scan
Ultrasound

Acute Pain
Risk for Deficient Fluid Volume
Risk for Impaired Skin Integrity
Risk for Ineffective Breathing Pattern

loss of ECF into space that does not contribute to equilibrium

fluid in cells-- 2/3rds of body fluid

fluid outside cells- intravascular,interstitial, and transcellular

cerebrospinal, percardial,synovial

lymph

fluid in lood vessels- aka plasma

third spacing fluid

positively charged ions

major types: sodium,potassium,calcium,magnesium,hydrogen ions

negatively charged ions

chloride,bicarbonate,phosphate,sulfate, and proteinate ions

electrolyte balance

exerted on walls of blood vessels (as in ascites)

exerted by protein in plasma

fluid is shunted to area higher in protein

hydrostatic and osmotic pressures

area of low solute concentration to area of high solute concentration across membrane walls. No energy required. Water moves.

solutes move from area of higher concentration to one of lower concentration . No membrane (like adding drop of food color to water). No energy required

movement of water, solutes occurs from area of high hydrostatic pressure to area of low hydrostatic pressure (like water leaking from hose) Takes energy

physiologic pump that moves fluid from area of lower concentration of one of higher concentration. (Example : Sodium-potassium pump) Takes energy.

required for movement against concentration gradient

maintains higher concentration of extracellular sodium, intracellular potassium

has same osmolarity as blood plasma (0.9% salt)

has greater osmolarity than blood plasma -- higher concentration of salt

lower osmolarity than blood plasma (pt dehydrated but electrolytes are normal)

Potassium 3.5 – 5.0 mEq/L
Hypokalemia (jitters)
Hyperkalemia (heart failure)

Sodium 135 – 145 mEq/L
Hyponatremia (low EC salt- cells swell)
Hypernatremia (fluid moves out- cell shrinks)

Bicarbonate-regulated by kidneys

Normal Saline (0.9%NS)
Lactated Ringer’s (LR)- contains other electrolytes

½ Normal Saline (0.45%NS)

D5W has no salt

Dextrose 5% in Normal Saline (D5NS)
Dextrose 5% in ½ Normal Saline (D51/2NS)
Dextrose 5% in Lactated Ringer’s (D5LR)

Dextrose makes it hypertonic

human albumin--rarely seen but used to pull off excess fluid off tissues b/c protein pulls water

Dietary intake of fluid, food or enteral feeding
Parenteral fluids

Kidney: urine output – 1 to 2 L usual daily volume or 1ml/kg/h in all age groups (KNOW-math problem for test)

Skin loss: sensible (sweating), insensible losses (fever)
Lungs – loss is greater with increased respiratory rate or depth, or a dry climate.
GI tract – diarrhea and fistula cause larger losses.
Other – wounds
Must count all areas of fluid losses

...

renin

Aldosterone

sodium and water retention thus increasing blood volume and pressure

hypovolemia- dehydration

hypervolemia- fluid volume overload

loss of water along with increased serum sodium level

dehydration

diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage, coma, third space shifts (ie, burn pt's, liver failure (ascites) and HF)

rapid weight loss, decreased skin turgor (tenting), oliguria, concentrated urine, postural hypotension, rapid weak pulse, increased temperature, cool clammy skin due to vasoconstriction, lassitude, thirst, nausea, muscle weakness, cramps

Hypokalemia occurs with GI & renal losses
Hperkalemia occurs with adrenal insufficiency
Hyponatremia occurs with increased thirst & ADH release
Hypernatremia results form increased insensible losses and Diabetes Insipidus

heart failure, renal failure, cirrhosis of liver

excessive dietary sodium or sodium-containing IV solutions

edema, distended neck veins, abnormal lung sounds (crackles), tachycardia, increased BP, pulse pressure and CVP, increased weight, increased UO (urinary output), shortness of breath and wheezing

stays down

regular edema returns

jugular vein distention measured at 45 degree angle
should be 3 mm or less

Serum sodium less than 135 mEq/L

adrenal insufficiency, water intoxication, Syndrome of Inappropriate Antidiuretic Hormone (SIADH) or losses by vomiting, diarrhea, sweating, diuretics

poor skin turgor, dry mucosa, headache, decreased salivation, decreased BP, tachycardia, nausea, abdominal cramping, neurologic changes (confusion)

dietary sodium and fluid intake, identify and monitor at-risk patients, effects of medications (diuretics, lithium), water intoxication (mental illness), monitor labs

Risk for Hyponatremia r/t unreplaced loss or limited oral intake
Disturbed thought process r/t electrolyte imbalance
Risk for fluid volume excess r/t excessive intake of hypotonic fluids
Risk for injury r/t seizure, confusion (due to electrolyte imbalance

Decreased serum and urine sodium
Decreased urine specific gravity & osmolarity

Consult physician if vomiting or diarrhea >48 hr or weakness, dizziness, palpitations, cough or dyspnea, or CNS changes develop

Anyone with chronic disease should consult physician if manifestations last longer than 24 hours

serum sodium greater than 145 mEq/L

excess water loss, excess sodium administration, diabetes insipidus, heat stroke, hypertonic IV solutions , hyperventilation

thirst; elevated temperature; dry, swollen tongue; sticky mucosa; neurologic symptoms; restlessness; weakness; increased pulse and BP

OTC sources of sodium, intake of fluids to meet patient needs, sufficient water with tube feedings; Neurologic symptoms – hallucinations, lethargy, restlessness, irritability, focal or grand mal seizures, monitor labs

Primary intracellular cation
Vital role in cell metabolism

Balances Na in extracellular fluids (ECF) to maintain the electroneutrality of body fluids.

Promotes transmission & conduction of nerve impulses and contraction of skeletal, cardiac & smooth muscles

Below-normal serum potassium (<3.5 mEq/L), may occur with normal potassium levels with alkalosis due to shift of serum potassium into cells

GI losses (bulimia, starvation), medications, alterations of acid-base balance(alkalosis), hyperaldosterism, poor dietary intake

fatigue, anorexia, nausea, vomiting, dysrhythmias, muscle weakness and cramps, paresthesias, glucose intolerance, decreased muscle strength, DTRs (deep tendon reflexes)

severe hypokalemia is life-threatening, monitor ECG and ABGs, dietary potassium, IV potassium administration, monitor labs

Diagnosis
Risk for Injury r/t muscle weakness, hypotension, or seizures
Activity Intolerance r/t muscle weakness
Decreased cardiac output r/t dysrhythmia
Outcome
Client will not sustain injury

Diagnosis
Imbalanced Nutrition: Less Than Body Requirements related to insufficient intake of potassium-rich foods
Outcomes
Adequate intake of potassium-rich foods
Interventions
Educate regarding potassium-rich foods and supplements

Serum potassium greater than 5.0 mEq/L

potassium

heart failure

usually treatment related, impaired renal function, hypoaldosteronism, tissue trauma, acidosis

cardiac changes and dysrhythmias, muscle weakness with potential respiratory impairment, paresthesias, anxiety, GI manifestations, death

hyperkalemia

patients with renal dysfunction

Risk for Activity Intolerance
Risk for Decrease Cardiac Output

tissues

from cells into circulatory system

it's hypertonic and would pull fluid from cell to circulatory system...albumin is often used as a diurectic

potassium and sodium

Proper function of excitable tissues, especially cardiac muscle.
Adequate blood clotting
Structural support to bones and teeth

hypoparathyroidism, malabsorption, pancreatitis, alkalosis, massive transfusion of citrated blood, renal failure, medications, open wounds

serum level less that 8.2 mg/dL

must be considered in conjunction with serum albumin level and pH

normal level is 8.2-10.2

tetany, circumoral numbness, paresthesias, hyperactive DTRs, Trousseau’s sign, Chovstek's sign, seizures, respiratory symptoms of dyspnea and laryngospasm, abnormal clotting, anxiety

severe hypocalcemia is life-threatening, weight-bearing exercises to decrease bone calcium loss, patient understanding related to diet and medications, evaluate number of transfusions, monitor for dysrhythmia, monitor breathing, and monitor labs

Activity intolerance r/t neuromuscular irritability
Imbalanced nutrition
Ineffective breathing pattern r/t laryngospasm

tense muscles from hypocalcemia

serum level above 10.2 mg/dL

malignancy of bone, hyperparathyroidism, bone loss related to immobility, prolonged use of thiazide diuretics

muscle weakness, incoordination, anorexia, constipation, nausea and vomiting, abdominal and bone pain, polyuria, thirst, ECG changes, dysrhythmias. Complication – renal/urinary calculi (stones)

hypercalcemic crisis has high mortality, evaluate ambulation, fluids of 3 to 4 L/day containing sodium (rehydration/dilution) unless contraindicated, fiber for constipation, ensure safety (mental symptoms), monitor labs

will see increase in CO2 levels because of insufficient breathing

Decreased Cardiac Output r/t bradycardia
Impaired mobility r/t decreased muscle tone
Risk for injury r/t decreased density of bones

hypocalcemia

Most abundant intracellular cation after potassium
Involved in both carbohydrate and protein metabolism
Important in neuromuscular function
Acting peripherally to produce vasodilatation and decreased peripheral resistance
Calcium and magnesium work together – so an imbalance in magnesium will usually be accompanied by an imbalances in calcium

Serum level less than 1.6 mg/dL (normal range 1.6 – 2.6 mg/dL), evaluate in conjunction with serum albumin

alcoholism, GI losses, enteral or parenteral feeding deficient in magnesium, medications, rapid administration of citrated blood; contributing causes include diabetic ketoacidosis, sepsis, burns, hypothermia

neuromuscular irritability(Trousseau’s & Chvostek’s sign), muscle weakness, tremors, athetoid movements, ECG changes and dysrhythmias, alterations in mood (apathy & depression) and level of consciousness (delirium, confusion, hallucinations)

evaluate safety (seizure precautions and confusion), dysphasia screening, patient understanding related to diet, medications, alcohol use, monitor for dysrhythmia, and monitor labs

hypocalcemia

hypomagnesemia

Risk for injury r/t disturb though processes, confusion
Risk for aspiration
Risk for decreased cardiac output r/t possible dysrhythmia

Serum level more than 2.6 mg/dL

renal failure, diabetic ketoacidosis, excessive administration of magnesium, Addison’s disease

flushing, lowered BP & shallow respirations, nausea, vomiting, hypoactive reflexes, drowsiness, muscle weakness, depressed respirations, ECG changes, dysrhythmias

evaluate for medications containing magnesium especially pt with renal failure, patient understanding regarding magnesium containing OTC medications, monitor labs, monitor LOC, monitor for dysrhythmia & respiratory rate

Disturbed though processes r/t electrolyte imbalance
Activity intolerance r/t neuromuscular hypoactivity
Ineffective breathing pattern
Decreased cardiac output r/t dysrhythmia

Essential to the function of muscle and RBC’s and the formation of ATP
Facilitates the release of O2 from hemoglobin
Structural support to bones and teeth

Serum level below 2.5 mg/dL (normal 2.5 – 4.5 mg/dL)

alcoholism, anorexia nervosa, refeeding of patients after starvation, pain, heat stroke, respiratory alkalosis, hyperventilation, diabetic ketoacidosis, hepatic encephalopathy, major burns, hyperparathyroidism, low magnesium, low potassium, diarrhea, vitamin D deficiency, use of diuretic and antacids

neurologic symptoms (irritability, dysphagia, diplopia, seizures), confusion, muscle weakness, tissue hypoxia, muscle and bone pain (osteomalacia), increased susceptibility to infection

hypophosphatemia

evaluate intake of foods high in phosphorus, monitor labs, monitor LOC

similar to other electrolytes

Serum level above 4.5 mg/DL

renal failure, excess phosphorus, excess vitamin D, acidosis, hypoparathyroidism, chemotherapy

few symptoms; soft-tissue calcifications, symptoms occur due to associated hypocalcemia

Serum phos & Ca+, BUN & Creatitine (renal failure)

evaluate avoiding high-phosphorus foods; patient understanding related to diet, phosphate-containing substances, signs of hypocalcemia

phosphorous

if one goes up the other goes down

...

7.0

7.35-7.45

hydrogen ions (H+)

pH decreases

substance that releases Hydrogen ion

binds hydrogen

Chemical buffering in blood plasma and cells
Excretion of acids (CO2) by lungs
Excretion of acid or regeneration of base (HCO3) by kidney

bicarbonate (carbonic acid buffering system)

lungs-- rapid compensation

the kidneys- slow to compensate

ECF: inorganic phosphates, plasma proteins

ICF: proteins, organic, inorganic phosphates

Hemoglobin

acidic

CO2 produced by cells as by-product of energy production
CO2 diffuses into blood and mixes with H2O to produce H2CO3 (carbonic acid) which then separates into H+ and HCO3 (bicarbonate)
Carbonic acid releases CO2 thru aveoli recirculating H2O
Depending on need lungs either expel or retain CO2

kidneys

by secreting H+ into urine or by regenerating HCO3 for reabsorption into the blood

alkalize the body -- get rid of hydrogen ions

CO2 is biggest portion of acid in blood stream

pH is <4.5

partial pressure of oxygen in arterial blood

is the partial pressure of carbon dioxide and is a reflection of the pulmonary ventilation (35-45 mm Hg)

kidneys

is a common base in the body and a major renal component of acid-base (22-26 mEq/L)

pH 7.35 - (7.4) - 7.45
PaCO2 35 - (40) - 45 mm Hg
HCO3ˉ 22 - (24) - 26 mEq/L
PaO2 80 to 100 mm Hg
Oxygen saturation >94%

Bicarbonate-carbonic acid

Determines type of imbalance
Evaluates degree of compensation

analysis of ABGs

an artery

pH <7.35

pH >7.45

evaluate symptoms, med dx, tx's

blood pH
assess PaCO2
assess HCO3 (healthy kidneys get rid of uric acid--if poor renal function will see uric acid combine with HCO3 and increase acidity)

...

with ng suctioning or vomitting

renal failure (uric acid problem) and diabetes (lactic acid problem)

will have low pH and low bicarbonate on ABG

Lactic acidosis, diabetic ketoacidosis, azotemic, diarrhea

headache, confusion, drowsiness, increased respiratory rate and depth, decreased blood pressure, decreased cardiac output, dysrhythmias, shock; if decrease is slow, patient may be asymptomatic until bicarbonate is 15 mEq/L or less

hyperkalemia

potassium levels

acidosis

metabolic alkalosis

symptoms related to decreased calcium, respiratory depression, tachycardia, symptoms of hypokalemia

to cell exchanging potassium for hydrogen ion (H+) to balance pH

respiratory problem with inadequate excretion of CO2 (hypoventilatory states)

COPD, infections, cardiac diseases, Guillain-Barré syndrome, Drug overdose with a resp depressant, Paralysis of resp muscles, obesity, inadequate mechanical ventilation

Symptoms may be suddenly increased pulse, respiratory rate and BP, mental changes, feeling of fullness in head
Potential increased intracranial pressure

hyperventilation (CO2 eliminated)

Pulmonary disorders (pneumonia, embolism)
Acute anxiety
Stimulant drugs (epinephrine)
Neural disorders (stroke, intracranial lesions)

lightheadedness, inability to concentrate, numbness and tingling, hand feel like fingers are contracting, sometimes loss of consciousness

Activity intolerance
Disturbed thought processes
Impaired gaseous exchange
Risk for decreased cardiac output (as acidosis increases)
Risk for injury

...

sodium high due to dehydration
potassium high--mvmt from dead cells to circulation

inside cell

on cell surface

TSH
T3 and T4

PTH
Calcium
Phosphorus

nervous system and immune system

GH
ADH
Urine Specific Gravity
ACTH(adrenocorticotropic hormone)

Cortisol
24-Hour Urine for VMA( pheochromocytoma)

Fasting Plasma Glucose
Oral Glucose Tolerance Test
Glycosylated Hemoglobin

Is a disorder of the posterior lobe of pituitary gland

Insufficient ADH (vasopressin) or renal resistance to the hormone
Kidneys Do Not Reabsorb Water
Diurese 3-15 L per Day –large volumes of dilute urine.

Pituitary Tumor or Trauma
Infection of CNS –meningitis, encephalitis, tuberculosis
Drugs –lithium and declomycin
Psychogenic (extremely large fluid intake)
Nephrogenic (enough ADH but kidneys do not respond to it)

Polyuria
Polydipsia (extreme thirst)
Nocturia
Dilute Urine (colorless)
Dehydration
Hypovolemic Shock
Decreased LOC
Death

<1.005

hypernatremia

Risk for Deficient Fluid Volume
Risk for Electrolyte Imbalance
Risk for Ineffective Health Maintenance
Knowledge Deficit
Risk for Disturbed Thought Processes
Acute confusion
Disturbed Sleep Pattern
Impaired Comfort

Warm/flushed skin, dizzy upon standing, B/P 108/54, T 99.4, “sticky” eyelids

organ/gland isn't functioning properly

something else is causing malfunction of organ/gland

syndrome of inappropriate ADH (antidiuretic hormone)

Too Much ADH
Water Retention
Hyponatremia
Decreased Serum Omolality

Cancers
Bronchogenic Lung Cancer
Drugs – oncovin, tricyclic antidepressants, thiazide diurestics, phenothiazines
Head Trauma
Brain Tumor

Weight Gain Without Edema
Dilutional Hyponatremia
Serum Osmolality <275 mOsm/kg
Concentrated Urine
Muscle Cramps and Weakness
Brain Swelling, Seizures, Death

Serum/Urine Sodium
Serum/Urine Osmolality
Water Load Test

Excess Fluid Volume
Risk for Ineffective Health Maintenance

daily weight

Weakness
Hypoglycemia
Sexual Dysfunction
Risk for Cardiovascular Disease
Risk for Cerebrovascular Disease

GH Level
GH Response to Induced Hypoglycemia
CT/MRI for Tumor