Med surg exam 2 study guide Chap 11 Fluid compartments Intracellular 60% Contained within the cell body About 25L Veins, arteries, capillaries, heart, etc Extracellular 33%
Most important area of homeostasis, area outside of cells Divided into intravascular space and interstitial space Extracellular fluid volume is about 15L In-between the cells Fluid Balance Closely linked to/affected by electrolyte concentrations Fluid intake
2.3-3L a day Fluid loss Minimum urine amount needed to excrete toxic waste products= 400-600 mL/day Insensible water loss-through skin, lungs, stool. Usually 500 to 1L a day This increases during a fever, tachypnea and extreme stress Facts to remember Any fluid imbalances that occur=continuous assessment of UOP Urine output
Dehydrated pts, CHF, RF, Fluid volume deficient, and fluid volume overload IV fluids, diuretics Daily weights
1L of water weighs 2.2lb, equal to 1kg Weight change of 1lb= fluid volume change of about 500 mL Fluid volume deficit: Dehydration Fluid intake/retention does not meet bodys fluid needs; results in fluid volume deficit Assessment Thread and increased pulse rate; decreased BP; lethargy; decreased UOP; dry mucous membranes; constipation; thirst
Increased H&H (hemoconcentration), BUN, sodium, and urine specific gravity Causes-vomiting, diarrhea, ileostomy, laxatives, burns, fever, diuretics, GI suctioning, and NPO
Interview/risk factors Inquire about recent dietary habits Use of OTC diuretics Outdoor activities Weight gain and weight loss Who at risk: hemorrhage, vomiting, diaherra, excessive sweating, NPO, sustained burn wounds, GI suction, Diuretics, uncontrolled diabetes, Poor intake Flat neck and hand veins, increased RR, skin tenting, tongue wrinkles, dehydration, fever,
UOP concentrated, Urine specific gravity concentrated (the higher the dryer) BUN and Creatinine BUN and Creatinine are kidney markers and are sensitive to decreased blood flow BUN (10-20) and Creatinine (06-1.2) rise when nitrogenous wastes are found in the blood indicating kidney impairment
GFR (>65) typically has an inverse relationship (increased BUN and Creatinine with a decreased GFR)- chronic renal failure Elevations can be caused by dehydration Fluid volume overload Assessment Bounding and increase pulse; elevated BP; dyspnea, crackles on lung auscultation; edema; decreased Hematocrit (hemodilution), decreased serum sodium and urine
specific gravity (dilute urine). Weight gain is the best indicator Causes- ESRD, CHF, water intoxication, SIADH, corticosteroid therapy, and rapid fluid replacement Drug therapy Diuretics (loop diuretics) Nutrition therapy Fluid restriction ( 1200 ml/day) Salt restriction Monitoring of intake and output Daily Weight!!!!
ESRD= End stage renal disease SIADH= syndrome of inappropriate ADH Edema- while standing ankles, feet, while laying down sacrum, back Extreme cases it will be everywhere Electrolyte imbalances: etiology Hyponatremia
Due to sodium loss, water gain, or inadequate intake Sodium loss: drugs; diuretics, anticonvulsants, SSRIs, antipsychotics, cancer meds Hypernatremia
Dehydration, excessive Na intake (sodium polystyrene, sodium bicarb, renal issue)
Hypokalemia Not enough in too much out, depleting drugs, medical conditions Not enough in: inadequate K intake Too much out: GI fluid losses
Depleting drugs: diuretics, corticosteroids, insulin, excessive laxative use, albuterol
Black licorice-acts like aldosterone Hyperkalemia Too much intake, blood products, drugs, not enough excreted, crush injury Too much intake: increased dietary intake,, salt substitutes, potassium supplements Donated blood Drugs: K sparing diuretics, ACE inhibitors, ARBs, NSAIDs
Not enough excreted: renal failure ( low Na, K, protein diet) Crush injury: intracellular K released Hypocalcemia
Inadequate intake, malabsorption, calcium loss, others Inadequate intake: calcium and vitamin D (sunlight) Malabsorption: post menopausal women, diseases that affect the small bowel, drugs (anticonvulsants) Calcium loss: loop diuretics Others: renal failure, hypoparathyroidism, low magnesium, multiple blood transfusions, alkalosis, low albumin levels Hypercalcemia
Increased resorption from the bone Hyperparathyroidism Cancer
Thiazide diuretics Hypomagnesemia Poor intake, poor GIT absorption, excessive GIT loss, excessive urinary losses Poor intake; alcoholics, patients on TPN or enteral feeding Poor absorption: IBD, celiac disease GIT loss: diarrhea, laxative use, NGT drainage Urinary loss: diuretics (loop and thiazide)
Hypermagnesemia
Excessive intake, impaired excretion Excessive intake: magnesium containing antacids/laxatives Impaired excretion: renal dysfunction Rare Sodium imbalances: affect CNS
Hyponatremia Common: headache, irritability, disorientation/confusion, tired, abdominal cramping, muscle twitching/weakness, crave salt
Worst case scenario (critical low): psychosis, seizures, ataxia, airway issues Treatment
Mild: fluid restriction (safest), oral sodium supplements Critical: hypertonic 3% saline-----SLOWLY!!! Nursing implications:
Monitor neurologic status, seizure/fall precautions, strict I/Os, implement
fluid restriction, monitor labs Hypernatremia Common: restlessness or agitation, anorexia, N/V, weakness, lethargy, confusion, crave water
Worst case scenario: decreased LOC< seizures, coma Treatment: fluids PO/IV, what type (initially isotonic fluid, increase BP , switch then to hypotonic fluid (D5W) (less salt more water!!!) Nursing implications
Frequent v/s, monitor neurologic status, seizure/fall precautions, strict i/os, assess skin/mm, oral care, monitor labs Give fluids if dehydration present Potassium imbalances: affect heart/muscles/GI tract Hypokalemia Common Cardiac arrhythmias, leg cramps (hallmark), muscle weakness, decreased GI motility (decreased BS, constipation, n/v), decreased DTRs, muscle weakness, alkalosis Worst case scenario Life threatening cardiac arrhythmias/cardiac arrest
Hypokalemia may potentiate dig toxicity***
Treatment Increase dietary intake of potassium, k supplementation, Give IV potassium slowly!!!! 20mEq/hr Nursing implications Frequent V/s, cardiac monitoring, patent IV, monitor labs (recheck after supplementation), NEVER GIVE POTASSIUM IVP OR BOLUS!!!!! Very dangerous Remember suction S= skeletal muscle weakness, U= U WAVE, C= constipation, T= toxic effect of dig, I= irregular pulse, o= orthostatic hypotension, N=numbness Hyperkalemia Common
Cardiac arrhythmias, muscle weakness (which may lead to flaccid paralysis), increased GI motility, decreased DTR’s, acidosis Worst case scenario
Life threatening cardiac arrhythmias/ cardiac arrest Treatment Potassium restricted diet, if critical/symptomatic will require drug therapy
(CBIGKD) which stand for: C= calcium, B= bicarb, I= Insulin (regular, IV push), G= glucose, K= kusulate (sodium poly), D= dialysis Nursing implications Cardiac monitoring, frequent labs, VS, monitor for hypoglycemia if insulin IVP given Calcium imbalances: affect neurological/neuromuscular system (9-10.5)
