Body Fluid Composition Quiz
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Body Fluid Composition Quiz

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@IndulgentSakura

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Questions and Answers

What is the normal range for osmolality?

  • 7.35-7.45
  • 136-145
  • 23-30
  • 285-295 (correct)

    • What are cations?

    Positively charged ions

    Hyperkalemia refers to low levels of potassium in the blood.

    False

    Which fluid has the same tonicity as blood?

    <p>Isotonic</p> Signup and view all the answers

    The hormone responsible for regulating the osmolality of body fluid is called ______.

    <p>Antidiuretic Hormone (ADH)</p> Signup and view all the answers

    What are the main compartments of body fluid?

    <p>Extracellular Fluid (ECF) and Intracellular Fluid (ICF)</p> Signup and view all the answers

    Which of the following is a condition where fluid remains in the interstitial space?

    <p>Edema</p> Signup and view all the answers

    Osmosis is the movement of water across a membrane that separates fluids with the same concentration.

    <p>False</p> Signup and view all the answers

    The primary role of __________ is to regulate ECV by influencing sodium and water excretion.

    <p>Arterial Natriuretic Peptide (ANP)</p> Signup and view all the answers

    What fluid movement mechanism requires energy to move electrolytes against a concentration gradient?

    <p>Active Transport</p> Signup and view all the answers

    What would the body fluid composition of an adult male typically be?

    <p>60%</p> Signup and view all the answers

    What condition occurs when the body fluids have decreased volume but normal osmolality?

    <p>Extracellular Fluid Volume Deficit</p> Signup and view all the answers

    Which of the following is a sign of Extracellular Fluid Volume Deficit?

    <p>Sudden weight loss</p> Signup and view all the answers

    What is characterized by increased blood volume with normal osmolality?

    <p>Extracellular Fluid Volume Excess</p> Signup and view all the answers

    Hypernatremia is caused by a gain of relatively more salt than water.

    <p>True</p> Signup and view all the answers

    Hyponatremia results from excessive water intake when sodium loss is present.

    <p>True</p> Signup and view all the answers

    What does ECV stand for?

    <p>Extracellular Fluid Volume</p> Signup and view all the answers

    Which hormone is associated with water retention?

    <p>Antidiuretic Hormone (ADH)</p> Signup and view all the answers

    The condition called __________ occurs when body fluids are too concentrated due to water deficit.

    <p>Hypernatremia</p> Signup and view all the answers

    What happens to cells during hypernatremia?

    <p>Cells shrink</p> Signup and view all the answers

    Name one cause of ECV Excess.

    <p>Excessive administration of Na+-containing isotonic IV fluids</p> Signup and view all the answers

    Match the electrolyte with its intake source:

    <p>Potassium = Fruits and vegetables Calcium = Dairy products Magnesium = Dark green leafy vegetables Phosphate = Milk</p> Signup and view all the answers

    What can occur if electrolyte intake is greater than output?

    <p>Plasma electrolyte excess</p> Signup and view all the answers

    What is the serum potassium level classified as hypokalemia?

    <p>Below 3.5 mEq/L</p> Signup and view all the answers

    Hyperkalemia is classified as a serum potassium level above 5.0 mEq/L.

    <p>True</p> Signup and view all the answers

    What are some signs of hypocalcemia?

    <p>Numbness, tingling of fingers and toes, muscle twitching, and cramping.</p> Signup and view all the answers

    _______ is a medical sign that indicates low calcium levels.

    <p>Trousseau's sign</p> Signup and view all the answers

    What can excessive intake of calcium lead to?

    <p>Hypercalcemia</p> Signup and view all the answers

    What is the primary buffer in extracellular fluid?

    <p>Bicarbonate (HCO3)</p> Signup and view all the answers

    Metabolic acids are excreted by the kidneys.

    <p>True</p> Signup and view all the answers

    List the two types of acidosis.

    <p>Respiratory and Metabolic</p> Signup and view all the answers

    What can hypomagnesemia lead to regarding muscle function?

    <p>Cardiac arrest</p> Signup and view all the answers

    Match the following types of acid production with their sources:

    <p>Carbonic acid = Lungs Metabolic acid = Kidneys</p> Signup and view all the answers

    What causes respiratory acidosis?

    <p>Excessive carbonic acid from hypoventilation</p> Signup and view all the answers

    Diarrhea is a cause of metabolic acidosis.

    <p>True</p> Signup and view all the answers

    What are common signs and symptoms of respiratory alkalosis?

    <p>Light-headedness, numbness, tingling of fingers and toes, increased respiratory rate.</p> Signup and view all the answers

    A decrease in pH below __ indicates metabolic acidosis.

    <p>7.35</p> Signup and view all the answers

    What is a common laboratory finding in respiratory acidosis?

    <p>Decreased pH</p> Signup and view all the answers

    Match the following causes to their respective acid-base imbalance:

    <p>Hypoventilation = Respiratory Acidosis Diarrhea = Metabolic Acidosis Excessive vomiting = Metabolic Alkalosis Hypoxemia = Respiratory Alkalosis</p> Signup and view all the answers

    Respiratory alkalosis can be caused by anxiety.

    <p>True</p> Signup and view all the answers

    What is a consequence of metabolic alkalosis?

    <p>Muscle cramps, light-headedness, and possible confusion.</p> Signup and view all the answers

    A decrease in the HCO3 level below __ indicates compensation for metabolic acidosis.

    <p>21</p> Signup and view all the answers

    Which of the following is NOT a sign of metabolic acidosis?

    <p>High blood pH</p> Signup and view all the answers

    Drugs can cause alterations in acid-base balance.

    <p>True</p> Signup and view all the answers

    What are enzymes?

    <p>Enzymes are protein-like substances that act as a catalyst to speed up chemical reactions.</p> Signup and view all the answers

    What is the BMI range for overweight individuals?

    <p>BMI of 25 to 29</p> Signup and view all the answers

    Older adults have a decreased need for energy due to a slower metabolic rate.

    <p>True</p> Signup and view all the answers

    Which of the following factors can affect nutrition?

    <p>All of the above</p> Signup and view all the answers

    What is the primary fear associated with anorexia nervosa?

    <p>An intense fear of gaining weight or becoming fat.</p> Signup and view all the answers

    Which eating disorder is characterized by recurrent episodes of binge eating?

    <p>Bulimia nervosa</p> Signup and view all the answers

    Name one cause of dysphagia.

    <p>Myasthenia gravis.</p> Signup and view all the answers

    What is a sign of dysphagia?

    <p>Coughing during eating</p> Signup and view all the answers

    What is the first stage in diet progression for dysphagia?

    <p>Dysphagia puree.</p> Signup and view all the answers

    Which of the following is an indication for enteral nutrition?

    <p>All of the above</p> Signup and view all the answers

    What is parenteral nutrition?

    <p>Specialized nutrition support provided intravenously.</p> Signup and view all the answers

    Complications of parenteral nutrition can include tension pneumothorax.

    <p>True</p> Signup and view all the answers

    Which type of fluid is located outside of cells?

    <p>Both A and C</p> Signup and view all the answers

    Acidosis refers to a decrease in blood pH.

    <p>True</p> Signup and view all the answers

    What is the average body water percentage in an adult male?

    <p>60%</p> Signup and view all the answers

    Osmolality is the number of particles per kg of ______.

    <p>water</p> Signup and view all the answers

    Match these ions with their respective charge:

    <p>Sodium = Cation Chloride = Anion Potassium = Cation Bicarbonate = Anion</p> Signup and view all the answers

    What hormone regulates the osmolality of body fluid?

    <p>Antidiuretic Hormone (ADH)</p> Signup and view all the answers

    What happens in a hypertonic solution?

    <p>Cells shrink</p> Signup and view all the answers

    Filtration is the process of fluid moving into and out of capillaries.

    <p>True</p> Signup and view all the answers

    What is an example of an abnormal fluid output?

    <p>Vomiting</p> Signup and view all the answers

    What is the normal range for bicarbonate (HCO3-) levels?

    <p>21-28 mEq/L</p> Signup and view all the answers

    What is the cause of respiratory acidosis?

    <p>Excessive carbonic acid by alveolar hypoventilation</p> Signup and view all the answers

    Dysrhythmias are a common sign of metabolic acidosis.

    <p>True</p> Signup and view all the answers

    What laboratory finding indicates respiratory acidosis?

    <p>pH below 7.35 and PaCO2 above 45 mm Hg</p> Signup and view all the answers

    In metabolic alkalosis, the pH is typically _____ above 7.45.

    <p>increased</p> Signup and view all the answers

    Match the following conditions with their symptoms:

    <p>Respiratory Acidosis = Headache, confusion, lethargy Respiratory Alkalosis = Light-headedness, tingling Metabolic Acidosis = Decreased level of consciousness, dysrhythmias Metabolic Alkalosis = Muscle cramps, possible excitement</p> Signup and view all the answers

    Which of the following is a cause of respiratory alkalosis?

    <p>Hypoxemia</p> Signup and view all the answers

    What clinical condition often leads to increased metabolic acids?

    <p>Ketoacidosis</p> Signup and view all the answers

    Excessive administration of sodium bicarbonate can lead to metabolic acidosis.

    <p>False</p> Signup and view all the answers

    What happens to bicarbonate levels in metabolic acidosis?

    <p>HCO3 below 21</p> Signup and view all the answers

    Which factor does NOT affect metabolism?

    <p>Water intake</p> Signup and view all the answers

    What is an isotonic imbalance?

    <p>Water and sodium lost or gained in equal proportions</p> Signup and view all the answers

    What are the signs of extracellular fluid volume deficit?

    <p>Sudden weight loss, tachycardia, dry mucous membranes, poor skin turgor.</p> Signup and view all the answers

    What causes hypernatremia?

    <p>Loss of relatively more water than salt.</p> Signup and view all the answers

    What laboratory finding indicates hyponatremia?

    <p>Serum Na+ level below 136 mEq/L</p> Signup and view all the answers

    Clinical dehydration includes extracellular fluid volume deficit and hypernatremia.

    <p>True</p> Signup and view all the answers

    The clinical term for a deficit of water in the body is ______.

    <p>hypernatremia</p> Signup and view all the answers

    What hormone is known to influence potassium levels by shifting K+ into cells?

    <p>Insulin</p> Signup and view all the answers

    Match the following electrolytes with their associated intake or absorption sources:

    <p>Potassium = Fruits and vegetables Calcium = Dairy products Magnesium = Dark green leafy vegetables Phosphate = Milk and processed foods</p> Signup and view all the answers

    What are enzymes?

    <p>Enzymes are protein-like substances that act as a catalyst to speed up chemical reactions.</p> Signup and view all the answers

    What is the measurement for being overweight?

    <p>BMI 25 to 29</p> Signup and view all the answers

    What is the recommended action for older adults regarding grapefruit and grapefruit juice?

    <p>They should avoid it.</p> Signup and view all the answers

    Which of the following can be a cause of dysphagia?

    <p>All of the above</p> Signup and view all the answers

    In the context of a diet, 'Dysphagia' refers to ________.

    <p>difficulty swallowing</p> Signup and view all the answers

    What are the four levels of diet for dysphagia?

    <p>Dysphagia puree, Dysphagia mechanically altered, Dysphagia advanced, Regular</p> Signup and view all the answers

    Match the following diets with their characteristics:

    <p>Clear Liquid = Consists of broth, bouillon, and clear juices Full Liquid = Includes smooth textured dairy and pureed foods Soft Low Residue = Easily digested foods, moist tender meats High Fiber = Includes uncooked fruits and steamed vegetables</p> Signup and view all the answers

    Parenteral nutrition is only given through NG tube.

    <p>False</p> Signup and view all the answers

    What should be done during the feeding process to avoid signs of intolerance?

    <p>Keep the head of the bed elevated a minimum of 30 degrees.</p> Signup and view all the answers

    What is a complication of PN (Parenteral Nutrition)?

    <p>Pneumothorax</p> Signup and view all the answers

    Which of these factors can cause plasma electrolyte excess?

    <p>Both A and B</p> Signup and view all the answers

    What is hypokalemia?

    <p>Low serum potassium (K+) concentration</p> Signup and view all the answers

    What are common causes of hypokalemia?

    <p>Decreased K+ intake, shift of K+ into cells, increased K+ output (e.g., diarrhea, vomiting)</p> Signup and view all the answers

    Which condition is associated with hyperkalemia?

    <p>Massive cellular damage</p> Signup and view all the answers

    Hypocalcemia is due to high levels of calcium in the blood.

    <p>False</p> Signup and view all the answers

    What are the signs of hypocalcemia?

    <p>Numbness, tingling, muscle twitching, positive Chvostek sign</p> Signup and view all the answers

    Match the electrolyte imbalance with its common cause:

    <p>Hypomagnesemia = Malnutrition and chronic alcoholism Hypercalcemia = Prolonged immobilization Hypokalemia = Excessive use of K+-free IV solutions Hyperkalemia = Iatrogenic administration of large IV K+</p> Signup and view all the answers

    Acidosis is characterized by increased ______.

    <p>pH</p> Signup and view all the answers

    Both lungs and kidneys can engage compensatory systems to correct acid-base imbalances.

    <p>True</p> Signup and view all the answers

    What is the primary function of the lungs in acid excretion?

    <p>Excrete carbonic acid</p> Signup and view all the answers

    What is the normal serum potassium level?

    <p>3.5 to 5.0 mEq/L</p> Signup and view all the answers

    What is the primary cause of Extracellular Fluid Volume Deficit?

    <p>Decreased sodium and water intake</p> Signup and view all the answers

    What are common signs of Extracellular Fluid Volume Deficit?

    <p>Sudden weight loss, postural hypotension, tachycardia, dry mucous membranes.</p> Signup and view all the answers

    What laboratory finding indicates Extracellular Fluid Volume Deficit?

    <p>Increased hematocrit</p> Signup and view all the answers

    Sodium and water intake greater than output causes Extracellular Fluid Volume Excess.

    <p>True</p> Signup and view all the answers

    What is hypernatremia?

    <p>A condition of increased sodium levels in the serum caused by water deficit.</p> Signup and view all the answers

    Which hormone is involved in water retention leading to hypernatremia?

    <p>Antidiuretic hormone (ADH)</p> Signup and view all the answers

    What can cause hyponatremia?

    <p>Excessive water intake or loss of salt.</p> Signup and view all the answers

    What is Clinical Dehydration?

    <p>A condition with a combination of Extracellular Fluid Volume Deficit and hypernatremia.</p> Signup and view all the answers

    An electrolyte imbalance involves only the intake and absorption of electrolytes.

    <p>False</p> Signup and view all the answers

    Ca2+ is primarily stored in __________.

    <p>bones</p> Signup and view all the answers

    Match the electrolytes with their main intake sources:

    <p>Potassium (K+) = Fruits and vegetables Calcium (Ca2+) = Dairy products Magnesium (Mg2+) = Dark green leafy vegetables Phosphate = Meat and milk</p> Signup and view all the answers

    What is acidosis?

    Signup and view all the answers

    What is alkalosis?

    Signup and view all the answers

    What does an anion gap indicate?

    Signup and view all the answers

    What is the composition of body fluids primarily made up of?

    <p>Charged particles</p> Signup and view all the answers

    The extracellular fluid (ECF) is located inside the cells.

    <p>False</p> Signup and view all the answers

    What is the difference between intravascular fluid and interstitial fluid?

    Signup and view all the answers

    Which of the following is an example of transcellular fluid?

    <p>Cerebral Spinal Fluid</p> Signup and view all the answers

    Which hormone regulates body fluid osmolality?

    <p>Antidiuretic hormone (ADH)</p> Signup and view all the answers

    Osmosis involves the movement of electrolytes across cell membranes.

    <p>False</p> Signup and view all the answers

    Which fluid compartments are involved in fluid distribution?

    <p>A and C</p> Signup and view all the answers

    What is fluid output primarily regulated by?

    Signup and view all the answers

    Which condition is associated with hypernatremia?

    <p>High sodium levels</p> Signup and view all the answers

    Which of the following conditions can cause respiratory acidosis? (Select all that apply)

    <p>Bacterial pneumonia</p> Signup and view all the answers

    Why is thirst considered an important regulator of fluid intake?

    <p>It is activated by increased plasma osmolality or decreased blood volume</p> Signup and view all the answers

    Hypoventilation can lead to respiratory acidosis.

    <p>True</p> Signup and view all the answers

    Hypercalcemia refers to low calcium levels in the blood.

    <p>False</p> Signup and view all the answers

    What is a common sign of metabolic acidosis?

    <p>Increased rate and depth of respirations</p> Signup and view all the answers

    What laboratory finding indicates respiratory acidosis?

    <p>pH below 7.35, PaCO2 above 45 mm Hg</p> Signup and view all the answers

    Match each condition with its corresponding effect:

    <p>Respiratory acidosis = Increased PaCO2 Respiratory alkalosis = Decreased PaCO2 Metabolic acidosis = Decreased HCO3 Metabolic alkalosis = Increased HCO3</p> Signup and view all the answers

    Light-headedness and confusion are signs of ______.

    <p>respiratory alkalosis</p> Signup and view all the answers

    What is a potential cause of metabolic alkalosis?

    <p>Excessive vomiting</p> Signup and view all the answers

    Increased bicarbonate levels can indicate metabolic acidosis.

    <p>False</p> Signup and view all the answers

    Which of the following is a risk factor for acid-base imbalances? (Select all that apply)

    <p>Chronic disease</p> Signup and view all the answers

    Which of the following factors can cause hypokalemia?

    <p>Chronic diarrhea</p> Signup and view all the answers

    What are the common symptoms of hypokalemia?

    <p>Bilateral muscle weakness, abdominal distention, dysrhythmias.</p> Signup and view all the answers

    Hyperkalemia is characterized by low serum potassium concentration.

    <p>False</p> Signup and view all the answers

    Which condition is associated with hypercalcemia?

    <p>Milk-alkali syndrome</p> Signup and view all the answers

    The laboratory finding for hypocalcemia shows total serum Ca2+ level below _____ mg/dL.

    <p>9.0</p> Signup and view all the answers

    What is a common physical examination finding in someone with hypomagnesemia?

    <p>Positive Chvostek sign and muscle cramps.</p> Signup and view all the answers

    Which of the following is a sign of hypermagnesemia?

    <p>Bradycardia</p> Signup and view all the answers

    What are enzymes?

    <p>Protein-like substances that act as a catalyst to speed up chemical reactions.</p> Signup and view all the answers

    Metabolic acidosis is associated with decreased pH levels.

    <p>True</p> Signup and view all the answers

    What is the primary excretion system for carbonic acid?

    <p>Lungs.</p> Signup and view all the answers

    The measurement for overweight is a BMI of ___ to ___

    <p>25 to 29</p> Signup and view all the answers

    What does the term 'alkalosis' refer to?

    <p>Increased base levels, such as bicarbonate.</p> Signup and view all the answers

    The measurement for obesity is a BMI of ___ or greater.

    <p>30</p> Signup and view all the answers

    Which of the following factors contributes to decreased energy needs in older adults?

    <p>Decreased metabolic rate</p> Signup and view all the answers

    If electrolyte intake is _____ than output, a blood plasma deficit occurs.

    <p>less</p> Signup and view all the answers

    Vitamin and mineral requirements change as people age.

    <p>False</p> Signup and view all the answers

    What dietary restriction is observed during Ramadan?

    <p>No water</p> Signup and view all the answers

    Match the following eating disorders with their primary characteristics:

    <p>Anorexia Nervosa = Restriction of energy intake leading to significantly low body weight Bulimia Nervosa = Recurrent episodes of binge eating followed by inappropriate compensatory behaviors Dysphagia = Difficulty swallowing due to various causes Enteral Nutrition = Nutrients provided to the GI tract via feeding tube</p> Signup and view all the answers

    What are the causes of dysphagia?

    <p>Myogenic, neurogenic, obstructive, and other causes.</p> Signup and view all the answers

    What is the primary purpose of enteral nutrition?

    <p>To provide nutrients directly to the GI tract</p> Signup and view all the answers

    Parenteral nutrition is provided through the gastrointestinal tract.

    <p>False</p> Signup and view all the answers

    What is the purpose of monitoring patients for signs of intolerance to tube feedings?

    <p>To prevent complications such as high gastric residuals, nausea, cramping, vomiting, or diarrhea.</p> Signup and view all the answers

    What is acidosis?

    <p>A condition characterized by an excess of acid in the body fluids.</p> Signup and view all the answers

    What is alkalosis?

    <p>A condition characterized by an excess of base in the body fluids.</p> Signup and view all the answers

    What is the anion gap?

    <p>The difference between the concentrations of serum cations and anions.</p> Signup and view all the answers

    What are the main types of body fluid compartments?

    <p>All of the above</p> Signup and view all the answers

    Which of the following is a positively charged ion (cation)?

    <p>Sodium (Na+)</p> Signup and view all the answers

    What does isotonic mean?

    <p>A fluid with the same tonicity as blood, leading to normal cell size.</p> Signup and view all the answers

    What role does antidiuretic hormone (ADH) play in fluid balance?

    <p>Regulates the osmolality of body fluid by influencing how much water is excreted in urine.</p> Signup and view all the answers

    What is the normal range for osmolality?

    <p>285-295 mOsm/kg</p> Signup and view all the answers

    Match the following fluid types with their descriptions:

    <p>Intravascular Fluid = Liquid part of blood Interstitial Fluid = Fluid located between cells outside of blood vessels Transcellular Fluid = Secreted by epithelial cells Cerebral Spinal Fluid = Fluid surrounding the brain and spinal cord</p> Signup and view all the answers

    What factors increase the secretion of ADH?

    <p>Severely decreased blood volume, pain, and stressors.</p> Signup and view all the answers

    Hypernatremia is a condition characterized by low sodium levels in the body.

    <p>False</p> Signup and view all the answers

    Fluid homeostasis involves only fluid intake.

    <p>False</p> Signup and view all the answers

    What characterizes Isotonic Imbalances?

    <p>Body fluids have decreased volume but normal osmolality</p> Signup and view all the answers

    Extracellular Fluid Volume Deficit occurs when body fluids have decreased volume but increased osmolality.

    <p>False</p> Signup and view all the answers

    Give one cause of ECV deficit.

    <p>Increased gastrointestinal output like vomiting or diarrhea.</p> Signup and view all the answers

    Which of the following is a sign of ECV deficit?

    <p>Thirst and restlessness</p> Signup and view all the answers

    In hypernatremia, the body fluids are too ______.

    <p>concentrated</p> Signup and view all the answers

    What laboratory finding is indicative of hypernatremia?

    <p>Serum Na+ level above 145 mEq/L.</p> Signup and view all the answers

    Hyponatremia is characterized by having more salt than water in the body fluids.

    <p>False</p> Signup and view all the answers

    What is one cause of hyponatremia?

    <p>Excessive ADH.</p> Signup and view all the answers

    Which of the following is a process that can lead to electrolyte imbalance?

    <p>All of the above</p> Signup and view all the answers

    Match the electrolyte with its primary source:

    <p>Potassium = Fruits Calcium = Dairy products Magnesium = Dark green leafy vegetables Phosphate = Milk</p> Signup and view all the answers

    What is one cause of respiratory acidosis?

    <p>Excessive carbonic acid</p> Signup and view all the answers

    Which sign is associated with metabolic acidosis?

    <p>Decreased level of consciousness</p> Signup and view all the answers

    Respiratory alkalosis is caused by hypoventilation.

    <p>False</p> Signup and view all the answers

    What laboratory finding indicates respiratory acidosis?

    <p>pH below 7.35</p> Signup and view all the answers

    What can cause respiratory muscle weakness?

    <p>Hypokalemia or neurological dysfunction</p> Signup and view all the answers

    Acute pain can lead to _______________.

    <p>respiratory alkalosis</p> Signup and view all the answers

    What is one symptom of metabolic alkalosis?

    <p>Muscle cramps</p> Signup and view all the answers

    Oliguric renal disease can lead to metabolic acidosis.

    <p>True</p> Signup and view all the answers

    Which electrolyte imbalance is often found in metabolic alkalosis?

    <p>Hypokalemia</p> Signup and view all the answers

    What is the primary cause of metabolic acidosis?

    <p>Excessive metabolic acids</p> Signup and view all the answers

    Excessive sodium bicarbonate administration can cause metabolic acidosis.

    <p>False</p> Signup and view all the answers

    What condition is caused by low serum potassium (K+) concentration?

    <p>Hypokalemia</p> Signup and view all the answers

    What is a common cause of hyperkalemia?

    <p>Both A and B</p> Signup and view all the answers

    What is the physical examination finding for hypokalemia?

    <p>Bilateral muscle weakness</p> Signup and view all the answers

    Increased calcium levels in the blood condition is known as _____

    <p>Hypercalcemia</p> Signup and view all the answers

    What is a symptom of hypocalcemia?

    <p>Numbness and tingling</p> Signup and view all the answers

    Hypomagnesemia refers to increased levels of magnesium in the serum.

    <p>False</p> Signup and view all the answers

    What is a primary cause of hypomagnesemia?

    <p>Decreased magnesium intake and absorption</p> Signup and view all the answers

    Match the following electrolytes with their common imbalances:

    <p>Potassium = Hypokalemia Calcium = Hypercalcemia Magnesium = Hypomagnesemia Sodium = Hyponatremia</p> Signup and view all the answers

    What acid does the lungs excrete?

    <p>Carbonic acid</p> Signup and view all the answers

    What pH value range is considered normal?

    <p>7.35 to 7.45</p> Signup and view all the answers

    Respiratory acidosis is caused by an increase in pH.

    <p>False</p> Signup and view all the answers

    What are enzymes?

    <p>Protein-like substances that act as a catalyst to speed up chemical reactions.</p> Signup and view all the answers

    What is the BMI range for overweight individuals?

    <p>BMI 25 to 29</p> Signup and view all the answers

    What age group experiences a decreased need for energy due to a slower metabolic rate?

    <p>Older adults 65 and up.</p> Signup and view all the answers

    All older adults experience increased appetite.

    <p>False</p> Signup and view all the answers

    The BMI for obesity is a measurement of _____ or greater.

    <p>30</p> Signup and view all the answers

    Which of the following is a dietary restriction for Ramadan fasting?

    <p>Eating from sunrise to sunset</p> Signup and view all the answers

    What characterizes bulimia nervosa?

    <p>Self-induced vomiting</p> Signup and view all the answers

    Name a possible cause of dysphagia.

    <p>Stroke</p> Signup and view all the answers

    Patients with dysphagia often show overt signs like coughing when food enters the airway.

    <p>False</p> Signup and view all the answers

    Which of the following is a stage of diet progression for dysphagia?

    <p>Dysphagia Puree</p> Signup and view all the answers

    What is enteral nutrition (EN)?

    <p>Provides nutrients to the GI tract via NG tube or surgical feeding tube.</p> Signup and view all the answers

    Parenteral nutrition is given through the gastrointestinal tract.

    <p>False</p> Signup and view all the answers

    The procedure of cleaning a central venous catheter involves using _____ before and after each use.

    <p>sterilized supplies</p> Signup and view all the answers

    What is a complication of parenteral nutrition?

    <p>Pneumothorax</p> Signup and view all the answers

    Study Notes

    Body Fluid Composition

    • The human body is comprised of two major fluid compartments:
      • Extracellular fluid (ECF): Located outside cells, containing intravascular fluid (liquid part of blood) and interstitial fluid (between cells).
      • Intracellular fluid (ICF): Located inside cells.

    Transcellular Fluid

    • Transcellular fluid is secreted by epithelial cells and includes:
      • Cerebral Spinal Fluid
      • Pleural Fluid
      • Peritoneal fluid
      • Synovial fluid

    Electrolytes

    • Electrolytes are compounds that separate into ions (charged particles) and are vital for maintaining fluid balance.
    • Cations are positively charged ions, including:
      • Sodium (Na+)
      • Potassium (K+)
      • Calcium (Ca2+)
      • Magnesium (Mg2+)
    • Anions are negatively charged ions, including:
      • Chloride (Cl-)
      • Bicarbonate (HCO3-)
    • Both anions and cations combine to create salts.

    Normal Lab Values

    • Osmolality (285-295) measures concentration of particles per kg of water.
    • Electrolytes:
      • Sodium (Na+) - 136-145 mEq/L
      • Potassium (K+) - 3.5-5.0 mEq/L
      • Chloride (Cl-) - 98-106 mEq/L
      • Total CO2 - 23-30 mEq/L
      • Bicarbonate (HCO3-) - 21-28 mEq/L
      • Total Calcium (Ca2+) - 9.0-10.5 mg/dL
      • Ionized Calcium (Ca2+)- 4.5-5.6 mg/dL
      • Magnesium (Mg2+) - 1.3-2.1 mEq/L
      • Phosphate - 3.0-4.5 mg/dL
      • Anion Gap - 6 +/- 4 mEq/L
    • Acid-Base Imbalances:
      • pH - 7.35 to 7.45
      • PaCO2 - 35 to 45 mmHg
      • PaO2 - 80-100 mmHg
      • HCO3 - 21 to 28 mEq/L
      • O2 Saturation - 95% to 100%
      • Base Excess -2 to +2 mmEq/L

    Tonicity

    • Tonicity refers to the effective concentration of a fluid, particularly considering particles that cannot cross cell membranes easily.
    • Isotonic fluids have the same tonicity as blood, maintaining normal cell size.
    • Hypotonic fluids (more dilute than blood) cause cells to enlarge.
    • Hypertonic fluids (more concentrated than blood) cause cells to shrink.

    Movement of Water and Electrolytes

    • Active Transport: Requires energy (ATP) to move electrolytes across cell membranes against a concentration gradient (from lower to higher concentration).
    • Diffusion: Passive movement of electrolytes and particles down a concentration gradient (from higher to lower concentration). Diffusion across cell membranes often requires protein channels.
    • Osmosis: The movement of water through a membrane separating fluids with different particle concentrations. Water moves across the membrane to equalize concentration.
    • Filtration: The movement of fluid into and out of capillaries between vascular and interstitial compartments.

    Hydrostatic & Colloid Pressures

    • Hydrostatic Pressure: The force of fluid pressing outward against a surface.
    • Colloid Osmotic (Oncotic) Pressure: The inward pulling force exerted by blood proteins (mainly albumin) that draws fluid back into capillaries from the interstitial space.

    Edema

    • Edema: Excess fluid buildup in the interstitial space, often associated with conditions like:
      • Heart failure (HF)
      • Congestive heart failure (CHF)

    Fluid Balance

    • Fluid Homeostasis requires an equal balance of fluid intake and output. This is achieved through three processes:
      • Fluid intake and absorption
      • Fluid distribution
      • Fluid output

    Average Fluid Intake & Output

    Intake/Output Normal Daily Intake (mL) Prolonged Heavy Exercise (mL/hour)
    Fluids ingested, oral 1100-1400 280-1100
    Foods 800-1000 Highly Variable
    Metabolism 300 16-50
    Total Intake 2200-2700 300-1150
    Skin (insensible & sweat) 400 20
    Insensible Lungs 100-200 Negligible (unless diarrhea during exercise)
    Gastrointestinal 1200-1500 20-1000 (depending on hydration status)
    Urine 500-600 200-2100
    Total Output 2200-2700 340-3120

    Thirst

    • Thirst is the conscious drive for water.
    • It is a key regulator of fluid intake, triggered by increased plasma osmolality or decreased blood volume.
    • The thirst control mechanism is located in the hypothalamus of the brain, where osmoreceptors monitor plasma osmolality.

    Fluid Distribution

    • Fluid distribution refers to the movement of fluid between body compartments, including:
      • Extracellular vs. Intracellular (via osmosis)
      • Vascular vs. Interstitial (via filtration)

    Fluid Output

    • Four organs contribute to fluid output:

      • Skin
      • Lungs
      • GI tract
      • Kidneys

    • Abnormal Output can be caused by various factors, including:

      • Vomiting
      • Wound drainage
      • Hemorrhage
      • Fever
      • Burns
      • Diarrhea

    Fluid Balance Regulation

    • Body mechanisms control fluid balance to maintain homeostasis. These mechanisms include:
      • Antidiuretic Hormone (ADH)
      • Renin-Angiotensin-Aldosterone System (RAAS)
      • Atrial Natriuretic Peptide (ANP)

    Antidiuretic Hormone (ADH)

    • ADH regulates body fluid osmolality by influencing urine water excretion.
    • It is synthesized in the hypothalamus and released by the pituitary gland.
    • ADH acts on collecting ducts in the kidneys, causing water reabsorption and blood dilution.
    • Factors that increase ADH:*
    • Severely decreased blood volume
    • Pain
    • Stressors
    • Certain medications
    • Factors that decrease ADH:*
    • Blood becomes too dilute

    Renin-Angiotensin-Aldosterone System (RAAS)

    • RAAS regulates ECF volume by influencing sodium and water excretion in urine, and also contributes to blood pressure regulation.
    • RAAS begins with renin release from kidney cells.
    • Renin converts angiotensinogen into angiotensin I, and angiotensin I is converted to angiotensin II by enzymes in lung capillaries.
    • Angiotensin II acts as a vasoconstrictor in some vascular beds, and stimulates the release of aldosterone from the adrenal cortex.
    • Aldosterone causes reabsorption of sodium and water in the distal renal tubules, increasing ECF volume.
    • Aldosterone also plays a role in electrolyte balance by increasing potassium and hydrogen ion excretion in urine.
    • Stimuli that increase or decrease RAAS activity include:
      • Hemorrhage (decreases ECV)
      • Vomiting

    Atrial Natriuretic Peptide (ANP)

    • ANP regulates ECV by influencing sodium and water excretion in urine.
    • ANP is released from cells in the atria of the heart when these cells are stretched.
    • Factors that affect ANP:*
    • Medications
    • Diarrhea
    • Alcohol
    • Sweat
    • Fever
    • Trauma/blood loss -Not drinking enough liquids
    • Vomiting
    • Diseases

    Fluid Imbalance

    • There are two major types of fluid imbalance:

      • Volume Imbalance: Disturbances in the amount of fluid in the ECF compartment.
      • Osmolality Imbalance: Disturbances in the concentration of body fluids.

    • Volume and osmolality imbalances can occur separately or together.

    Respiratory Acidosis (Hypoventilation)

    • Caused by excessive carbonic acid due to alveolar hypoventilation.
    • Impaired gas exchange contributes to this condition.
    • Examples include Type B COPD (chronic bronchitis), End-stage type A COPD (emphysema), Bacterial Pneumonia, Airway Obstruction, Extensive Atelectasis (collapsed alveoli), and Severe acute asthma.

    Neuromuscular Causes of Respiratory Acidosis

    • Respiratory muscle weakness or paralysis due to hypokalemia or neurological dysfunction.
    • Respiratory muscle fatigue leading to respiratory failure.
    • Chest wall injury or surgery causing pain with respiration.

    Other Causes of Respiratory Acidosis

    • Dysfunction of the brainstem respiratory control, including drug overdose with a respiratory depressant and some types of head injuries.

    Respiratory Alkalosis (Hyperventilation)

    • Caused by hypoxemia, acute pain, anxiety, psychological distress, sobbing, inappropriate mechanical ventilator settings, and stimulation of the brainstem respiratory control (e.g., meningitis, gram-negative sepsis, head injury, aspirin overdose).

    Metabolic Acidosis (Excessive Metabolic Acids)

    • High Anion Gap:
      • Ketoacidosis (diabetes, starvation, alcoholism)
      • Hypermetabolic State (severe hyperthyroidism, burns, severe infection)
      • Oliguric renal disease (acute kidney injury, end-stage renal disease)
      • Circulatory shock (lactic acidosis)
      • Ingestion of acid or acid precursors (e.g., methanol, ethylene glycol, boric acid)
    • Normal Anion Gap:
      • Diarrhea
      • Pancreatic fistula or intestinal decompression
      • Renal tubular acidosis

    Metabolic Alkalosis (Deficient Metabolic Acids)

    • Increased Bicarbonate:
      • Excessive administration of sodium bicarbonate
      • Massive blood transfusion (liver converts citrate to HCO3-)
      • Mild or moderate ECV deficit (contraction alkalosis)
    • Loss of Metabolic Acid:
      • Excessive vomiting or gastric suctioning
      • Hypokalemia
      • Excess aldosterone

    Risk Factors of Acid-Base Imbalances

    • Age: Young (ECV deficit, Osmolality imbalances, Clinical dehydration), Old (ECV excess or deficit, Osmolality imbalance)
    • Environmental: Sodium-rich diet (ECV excess), Electrolyte-poor diet (electrolyte deficits), Hot weather (clinical dehydration)
    • Gastrointestinal Output: Diarrhea, Drainage, Vomiting
    • Chronic Disease: Cancer, COPD, Cirrhosis, HF, Oliguric renal disease
    • Trauma: Burns, Crash Injuries, Head Injuries, Hemorrhage
    • Therapies: Diuretics, IV Therapy, PN

    Fluid, Electrolyte and Acid Alteration Diagnoses

    • Fluid Imbalance
    • Dehydration
    • Acid-Base Imbalance
    • Lack of knowledge of fluid regimen

    Enteral Fluid Replacement (By Mouth)

    • Contraindications: Mechanical Obstruction of GI tract, Severe Nausea, Increased risk of aspiration, Impaired swallowing

    Parenteral Fluid Replacement (IV)

    • Types: PN (Parenteral Nutrition), Electrolyte therapy, Blood, Blood Components

    Types of IV Solutions

    • Dextrose in Water:
      • D5W (Dextrose 5% in water): Isotonic
      • D10W (Dextrose 10% in water): Hypertonic
    • Saline Chloride (NaCl) in Water Solutions:
      • 0.225% NaCl (1/4 Normal Saline): Hypotonic
      • 0.45% NaCl (1/2 Normal Saline): Hypotonic
      • 0.9% NaCl (normal saline): Isotonic
      • 3-5% NaCl (hypertonic saline): Hypertonic
    • Dextrose in Saline Solutions:
      • Dextrose 5% in 0.45% NaCl (1/2 normal saline): Hypertonic
      • Dextrose 5% in 0.9% NaCl (D5NS): Hypertonic
    • Multiple Electrolyte Solutions:
      • Lactated Ringers (LR): Isotonic
      • Dextrose 5% (LR, D5LR): Hypertonic

    Biochemical Units of Nutrition

    • The body requires fuel to provide energy for cellular metabolism and repair, organ function, growth and body movement.

    Factors Affecting Energy Requirements

    • Age, Body mass, Gender, Fever, Starvation, Menstruation, Illness, Injury, Infection, Activity, Level of thyroid function

    Factors Affecting Metabolism

    • Illness, Pregnancy, Lactation, Activity level

    Proteins

    • Provide a source of energy equal to 4Kcal/g
    • Essential for growth, maintenance, and repair of body tissue
    • Include collagen, hormones, enzymes, immune cells, DNA, RNA
    • Roles: Blood Clotting, Fluid Regulation, Acid-Base Balance

    Water

    • Critical for cell function
    • Makes up 60-70% of total body weight
    • Leaner people have a higher percentage of water due to muscle composition

    Fluid Release

    • Respiration, Sweating, Urine, Stools, Fever, Vomiting, Trauma (blood loss), Clinical Dehydration, Medications

    Digestion of Food

    • Mechanical breakdown through chewing, churning, and mixing with fluids
    • Chemical reactions reduce food to its simplest form

    Enzymes

    • Protein-like substances that act as catalysts to speed up chemical reactions
    • Essential for the chemistry of digestion

    Factors Affecting Nutrition

    • Environmental: Cost of healthy food increasing, fewer safe places to walk and play
    • Age: Older adults have decreased energy needs due to a slower metabolic rate. However, vitamin and mineral requirements remain unchanged.
      • Age-related changes: Decreased appetite, Decreased taste cells, Decreased income, Increased cost of medication, Decreased health, No desire to eat, Lack of transportation
    • Religion: Muslim, Christianity, Hinduism, Judaism, Mormons

    Religious Dietary Restrictions

    • Seventh Day Adventists avoid pork, shellfish, and alcohol.
    • Some faiths, such as Baptists, allow minimal or no alcohol consumption.
    • Some meatless days are observed by some faiths during the calendar year, commonly during Lent.
    • Ramadan is observed by fasting from sunrise to sunset for a month.
    • Kosher dietary laws require specific food preparation methods.
    • Mixing milk or dairy products with meat dishes is prohibited in Kosher diet.

    Eating Disorders

    • Anorexia nervosa involves restriction of energy intake, intense fear of gaining weight, and distorted perception of body size.
    • Bulimia nervosa involves binge eating followed by inappropriate compensatory behaviors like vomiting or excessive exercise.

    Dysphagia - Difficult Swallowing Causes

    • Myogenic: Myasthenia Gravis, Aging, Muscular Dystrophy, Polymyositis
    • Neurogenic: Stroke, Cerebral Palsy, Guillain-Barre Syndrome, Multiple Sclerosis, Amyotrophic Lateral Sclerosis, Diabetic Neuropathy, Parkinson's Disease
    • Obstructive: Benign peptic stricture, Lower esophageal ring, Candidiasis, Head and neck cancer, Inflammatory masses, Trauma/surgical restriction
    • Other: Gastrointestinal or esophageal resection, Rheumatological disorders, Connective tissue disorders, Vagotomy

    Warning Signs of Dysphagia

    • Coughing during eating
    • Change in voice tone or quality after swallowing
    • Abnormal movements of the mouth, tongue, or lips
    • Slow, weak, imprecise, or uncoordinated speech
    • Abnormal gag, delayed swallowing, incomplete oral clearance or pocketing, regurgitation, pharyngeal pooling, delayed or absent trigger of swallow, and inability to speak consistently.

    Diet Progression & Therapeutic Diets

    • Clear Liquid: Broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices, and popsicles
    • Full Liquid: Clear liquids, adding smooth textured dairy products, strained or blended cream soups, custards, refined or cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherberts, puddings, and frozen yogurt
    • Dysphagia Stages: Thickened liquids and purees, scrambled eggs, pureed meats, vegetables, fruits, mashed potatoes and gravy
    • Mechanical Soft: Dysphagia stages, adding creamed soups, ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter, eggs (not fried)
    • Soft Low Residue: Easily digested foods, pasta, casseroles, moist tender meats, cooked fruits and vegetables, desserts, cakes, and cookies without nuts or coconut
    • High Fiber: Uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruit
    • Low Sodium: No added salts
    • Diabetic:: Focuses on total energy, nutrient and food distribution, balanced intake of carbohydrates, fats, and proteins. Varied caloric recommendations to accommodate patients metabolic demands
    • Gluten Free: No wheat, oats, rye, barley, and their derivatives
    • Regular Diet: No restrictions

    Promoting Diet or Food Intake

    • Environment free of odors
    • Providing oral hygiene
    • Maintaining patient comfort
    • Offering smaller meals more frequently

    Four Levels of Diet for Dysphagia

    • Dysphagia puree
    • Dysphagia Mechanically Altered
    • Dysphagia Advanced
    • Regular

    Enteral Nutrition (EN)

    • Provides nutrients through the GI tract via NG tube or surgical feeding tube
    • Indications for EN:
      • Cancer
      • Head/Neck Upper GI
      • Critical Illness or Trauma
      • Brain Neoplasm
      • Cerebrovascular Accident
      • Dementia
      • Myopathy
      • Enterocutaneous Fistula
      • Inflammatory bowel disease
      • Mild pancreatitis
      • Respiratory Failure with prolonged intubation
      • Anorexia Nervosa
      • Difficulty Chewing or Swallowing
      • Severe Depression

    Parenteral Nutrition (PN)

    • Specialized nutrition support through intravenous route
    • Indications of PN:
      • Nonfunctioning GI Tract
        • Massive small bowel resection
        • GI surgery
        • GI Bleed
        • Paralytic ileus
        • Intestinal Obstruction
        • Trauma to abdomen, head, neck
        • Sever Malabsorption
        • Intolerance to enteral feeding
        • Chemotherapy, radiation, bone marrow transplants

    Complications of PN

    • Tension pneumothorax from tube insertion: Monitor patients for up to 24 hours after insertion.
    • When patients reach 1/3 to ½ of daily Kcal intake per day they can be moved from PN/EN feeding.

    Measurement for NG Tubes

    • Measure from tip of catheter at the nose, back to the ear, and down to the xyphoid process, mark where the tube should stop being inserted.

    Location of NG Tube

    • Best confirmation of tube placement is x-ray.
    • Aspiration of stomach contents and testing the acidity of the contents is the second-best way.

    Signs of Intolerance of Tube Feedings

    • High gastric residuals, nausea, cramping, vomiting, or diarrhea
    • Flush NG with water before and after feeding to prevent microorganisms and bacteria.

    Procedural Guidelines for Obtaining Gastrointestinal Aspirate for pH Measurement and Large-Bore, and Small-Bore Feeding Tubes: Intermittent and Continuous Feeding

    • The responsibility for verifying tube placement and irrigating a feeding tube is with the nurse.
    • AP can be directed to: Immediately inform the nurse if patient's respirations change or patient complains of shortness of breath, coughing, or choking; immediately inform the nurse if the patient vomits or the AP notices vomitus in patient's mouth during oral hygiene; immediately inform the nurse if nasal skin irritation or excoriation is present; immediately inform the nurse if a change in the external length of the tube occurs, which could indicate displacement of the tube; report when a continuous tube feeding stops infusing.
    • Equipment: 60-mL ENFit syringe, water, towel, stethoscope, clean gloves, pH indicator strip, small medication cup, measuring tape, pulse oximeter.

    Procedural Steps:

    1. Review agency policy and procedures for frequency of irrigation and frequency and method of checking tube placement. Do not insufflate air into tube to check placement.
    2. Identify patient using at least two identifiers.
    3. Review patient's medication record for orders for enteral feeding, a gastric acid inhibitor, or a proton pump inhibitor.
    4. Review patient's medical record for history of prior tube displacement.
    5. Observe for signs and symptoms of respiratory distress during feeding: coughing, choking, or reduced oxygen saturation.
    6. Identify conditions that increase risk for spontaneous tube migration or dislocation: altered level of consciousness, agitation; retching, vomiting; nasotracheal suction.
    7. Perform hand hygiene. Assess bowel sounds and perform abdominal examination.
    8. Obtain pulse oximetry reading.
    9. Note ease with which previous tube feedings infuse through tubing. Monitor volume of continuous enteral formula administered during shift and compare with ordered amount.
    10. Assess patient's or family caregiver's knowledge, experience, and health literacy.
    11. Perform hand hygiene and apply clean gloves. Be sure pulse oximeter is in place.
    12. Verify tube placement.

    Parenteral Nutrition (PN)

    • PN is a form of specialized nutritional support provided intravenously.
    • Benefits patients who are unable to digest or absorb EN and patients in highly stressed physiological states.

    Cleaning and maintaining PN Central Venous Catheter

    • Use Standard Precautions, maintain aseptic field management, nontouch technique, and sterilized supplies.
    • Change the CVC dressing per institution policy and any time it becomes wet, disrupted, or contaminated.
    • Use 2% alcohol-based chlorhexidine gluconate, 70% alcohol, or povidone iodine to clean the injection port or catheter hub 15 seconds before and after each time it is used.

    Complications of PN

    • Pneumothorax can result from catheter insertion when the tip accidentally enters the pleural space.

    Respiratory Acidosis

    • Occurs due to excessive carbonic acid caused by alveolar hypoventilation
    • Conditions that impair gas exchange such as Type B COPD, end-stage type A COPD, bacterial pneumonia, airway obstruction, extensive atelectasis, and severe acute asthma can cause this
    • Neuromuscular causes include respiratory muscle weakness or paralysis from hypokalemia, neurological dysfunction, respiratory muscle fatigue, respiratory failure, chest wall injury or surgery causing pain with respiration
    • Other causes include drug overdose with respiratory depressant, and some types of head injuries
    • Signs and symptoms include headache, light-headedness, decreased level of consciousness, confusion, lethargy, coma and dysrhythmias
    • Lab findings:
      • pH decreased
      • PaCO2 increased
      • HCO3- normal if uncompensated or increased if partially compensated

    Respiratory Alkalosis

    • Occurs due to deficient carbonic acid caused by alveolar hyperventilation
    • Causes include hypoxemia, acute pain, anxiety, psychological distress, sobbing, inappropriate mechanical ventilator settings, and stimulation of the brainstem respiratory control
    • Signs and symptoms include light-headedness, numbness and tingling of fingers, toes and circumoral region, increased rate and depth of respirations, excitement, confusion followed by decreased level of consciousness and dysrhythmias
    • Lab findings:
      • pH increased above 7.45
      • PaCO2 decreased below 35 mm Hg (4.7 kPa)
      • HCO3- normal if uncompensated or below 21 mEq/L (21 mmol/L) if partially compensated

    Metabolic Acidosis

    • Occurs due to excessive metabolic acids
    • Causes include increased metabolic acids (high anion gap), ketoacidosis, hypermetabolic state, oliguric renal disease, circulatory shock (lactic acidosis), ingestion of acid or acid precursors, loss of bicarbonate (normal anion gap), diarrhea, pancreatic fistula or intestinal decompression, and renal tubular acidosis
    • Signs and symptoms include decreased level of consciousness, lethargy, confusion, coma, abdominal pain, dysrhythmias, and increased rate and depth of respirations
    • Lab findings:
      • pH decreased below 7.35
      • PaCO2 normal if uncompensated below 35 if partially compensated
      • HCO3 below 21

    Metabolic Alkalosis

    • Occurs due to deficient metabolic acids
    • Causes include increased bicarbonate due to excessive administration of sodium bicarbonate, massive blood transfusion, mild or moderate ECV deficit (contraction alkalosis), loss of metabolic acid due to excessive vomiting, gastric suctioning, hypokalemia, or excessive aldosterone
    • Signs and symptoms include light-headedness, numbness and tingling of fingers, toes and circumoral region, muscle cramps, possible excitement and confusion followed by decreased levels of consciousness, dysrhythmias, and concurrent hypokalemia
    • Lab findings:
      • pH increased above 7.45
      • PaCO2 normal if uncompensated, above 45 if partially compensated
      • HCO3 increased above 28

    Risk Factors For Imbalances

    • Age: Young (ECV deficit, Osmolality imbalances, Clinical dehydration) and old (ECV excess or deficit, Osmolality imbalance)
    • Environmental: Sodium rich diet (ECV excess), Electrolyte poor diet (Electrolyte deficits), Hot weather (Clinical dehydration)
    • Gastrointestinal Output: Diarrhea, Drainage, Vomiting
    • Chronic Disease: Cancer, COPD, Cirrhosis, HF, Oliguric renal disease
    • Trauma: Burns, Crash Injuries, Head Injuries, Hemorrhage
    • Therapies: Diuretics, IV Therapy, PN

    Different Types of RN Diagnosis For Fluid, Electrolyte Or Acid Alteration

    • Fluid Imbalance
    • Dehydration
    • Acid-Base Imbalance
    • Lack of Knowledge of Fluid Regimen

    Enteral Fluid Replacement

    • Given by mouth
    • Ice chips count as ½ of a volume measurement
    • Contraindications:
      • Mechanical obstruction of GI tract
      • Severe nausea
      • Increased risk of aspiration
      • Impaired swallowing

    Parenteral Fluid Replacement

    • Given by IV
    • Includes PN (Parenteral Nutrition), Electrolyte therapy, Blood, and Blood Components

    Types of IV Solutions

    • Isotonic:
      • D5W (Dextrose 5% in water)
      • 0.9% NaCl (Normal saline)
      • Lactated Ringers (LR)
    • Hypotonic:
      • 0.225% NaCl (1/4 Normal Saline)
      • 0.45% NaCl (1/2 Normal Saline)
    • Hypertonic:
      • D10W (Dextrose 10% in water)
      • 3-5% NaCl (Hypertonic saline)
      • Dextrose 5% in 0.45% NaCl (1/2 normal saline)
      • Dextrose 5% in 0.9% NaCl (D5NS)
      • Dextrose 5% (LR, D5LR)

    Biochemical Units of Nutrition

    • The body requires fuel to provide energy for cellular metabolism and repair, organ function, growth, and body movement

    Factors Affecting Energy Requirements

    • Age, body mass, gender, fever, starvation, menstruation, illness, injury, infection, activity level, level of thyroid function

    Factors Affecting Metabolism

    • Illness, pregnancy, lactation, activity level

    Proteins

    • Provide a source of energy equal to 4Kcal/g
    • Essential for the growth, maintenance, and repair of body tissue
    • Collagen, hormones, enzymes, immune cells, (DNA), (RNA) are all made of protein
    • Play a crucial role in blood clotting, fluid regulation, and acid-base balance

    Water

    • Critical for cell function, as all cell function depends on a fluid environment
    • Makes up to 60-70% of total body weight
    • Lean people have a greater percentage of water because muscle contains more water than any other tissue except blood
    • Released through respiration, sweating, urine, stools, fever, vomiting, trauma (blood loss), clinical dehydration, and medications

    Digestion of Food

    • Mechanical breakdown through chewing, churning, and mixing with fluid
    • Chemical reactions reduce food to its simplest form

    Enzymes

    • Protein-like substances that act as a catalyst to speed up chemical reactions
    • Essential for the chemistry of digestion

    Factors That Affect Nutrition

    • Environmental: Beyond the control of the patient and contributes to obesity. 68.7% of Americans are overweight or obese (BMI of 25 to 29 for overweight, BMI of 30 or greater for obese). Cost of healthy food is increasing, making it difficult to afford, and fewer safe places to walk and play. Caution older adults to avoid grapefruit and grapefruit juice because they alter absorption of many drugs.
    • Age: Older adults 65 and up have a decreased need for energy because their metabolic rate slows with age; however, vitamin and mineral requirements remain unchanged. Age-related changes include decreased appetite, decreased taste cells, decreased income, increased cost of medication, decreased health, lack of desire to eat, and lack of transportation.

    Religious Dietary Restrictions

    • Dietary practices can be influenced by various religious beliefs including Judaism, Islam, Christianity, Buddhism, Hinduism, and Seventh-Day Adventists.
    • Pork is restricted in Judaism and Islam due to religious beliefs.
    • Alcohol is prohibited in Islam and often restricted by certain denominations of Christianity, such as Baptists.
    • Seventh-Day Adventists follow a predominantly vegetarian diet, with some encouraging ovolactovegetarian diets.
    • Ramadan is a month-long period of fasting during which Muslims avoid food, drink, and smoking from sunrise to sunset.
    • Kosher dietary laws require strict food preparation methods and separation of milk and meat products.
    • Yom Kippur is a day of atonement during which Jewish people fast for 24 hours.
    • Passover is an eight-day festival during which leavened breads are avoided.
    • Sabbath is observed from sundown Friday to sundown Saturday during which certain activities including cooking are prohibited.

    Dysphagia

    • Dysphagia or difficulty swallowing can stem from myogenic, neurogenic, obstructive or other reasons.
    • Myogenic dysphagia is caused by muscle weakness, and neurogenic dysphagia is caused by nerve damage.
    • Obstructive dysphagia results from blockages in the swallowing passage.
    • Gastrointestinal or esophageal resection and rheumatological disorders can also cause swallowing difficulties.
    • Warning signs of dysphagia include coughing during eating, a change in voice after swallowing, abnormal mouth, tongue, or lip movements, and slow or unclear speech.

    Therapeutic Diets

    • Clear liquid diets consist of clear broth, tea, coffee, and clear juices.
    • Full liquid diets include all clear liquid items plus smooth dairy products, strained soups, and pureed foods.
    • Dysphagia stage diets include thick liquids, purees, creamed soups, and finely diced or ground meats.
    • Mechanical soft diets consist of easily chewed foods such as soft meats, cooked vegetables, and mashed potatoes.
    • Soft low residue diets include soft, easily digested foods such as pasta, casserole, and cooked fruits.
    • High fiber diets include bran, oatmeal, fruits, and steamed vegetables.
    • Low sodium diets limit added salts and sodium-containing foods.
    • Diabetic diets focus on balanced intake of carbohydrates, fats, and proteins.
    • Gluten-free diets avoid wheat, oats, rye, barley, and their derivatives.
    • Regular diets have no dietary restrictions.

    Enteral Nutrition

    • Enteral nutrition (EN) delivers nutrients to the GI tract through an NG tube or surgical feeding tube.
    • Indications for EN include cancer, critical illness, trauma, dementia, and difficulty swallowing.

    Parenteral Nutrition

    • Parenteral nutrition (PN) provides specialized nutrition intravenously.
    • Indications for PN include a nonfunctioning GI tract stemming from surgery, GI bleed, trauma, or obstruction.
    • PN complications can include pneumothorax.
    • PN central venous catheter (CVC) maintenance requires meticulous cleaning, dressing changes, and aseptic technique.
    • A patient's transition from PN/EN feeding can occur when they are consuming 1/3 to 1/2 of their daily caloric intake via oral feeding.

    NG Tube Placement and Maintenance

    • NG tube measurement involves measuring from the tip of the nose, back to the ear, and down to the xyphoid process.
    • X-ray is the most reliable way to verify NG tube placement, with aspiration and pH testing as alternative approaches.
    • Signs of NG tube intolerance include high gastric residuals, nausea, cramping, vomiting, and diarrhea.
    • Flushing NG tubes with water before and after feeding helps prevent microorganisms and bacteria buildup.
    • Elevating the head of the bed during and after feedings can prevent complications.
    • Delegation of NG tube care requires careful observation and communication between nurses and assistive personnel (AP).

    Procedural Guidelines for Gastrointestinal Aspiration

    • Frequency of irrigation and tube placement verification should be performed per agency policy.
    • Use of air insufflation to check tube placement is discouraged.
    • Patient identification requires at least two identifiers.
    • Patient medication records should be reviewed for enteral feeding, gastric acid inhibitor, or proton pump inhibitor orders.
    • Respiratory distress during feeding must be monitored by the nurse.
    • Conditions that increase risk of tube migration include altered consciousness, agitation, retching, vomiting, and nasotracheal suction.
    • Bowel sounds and abdominal examination should be performed before tube irrigation.
    • Pulse oximetry readings should be obtained.
    • Ease of previous tube feeding infustions and volume of continuous enteral formula administered should be monitored and documented.
    • Patient or caregiver knowledge and experience with EN should be assessed.
    • Aseptic technique and clean gloves should be used during all procedures.
    • Tube placement verification involves aspiration and pH testing.

    Body Fluid Composition

    • The human body is primarily composed of water, with a higher proportion in males and decreasing with age.
    • Body fluids are separated into two compartments: extracellular fluid (ECF) outside cells and intracellular fluid (ICF) inside cells.
    • ECF is further divided into intravascular fluid (liquid part of blood) and interstitial fluid (located between cells outside blood vessels).
    • Transcellular fluid, secreted by epithelial cells, includes cerebral spinal fluid, pleural, peritoneal, and synovial fluids.
    • Body fluids contain electrolytes, which are compounds that separate into ions.
    • Cations are positively charged ions, including sodium (Na+), potassium (K+), calcium (Ca+), and magnesium (Mg2+).
    • Anions are negatively charged ions, including chloride (Cl-) and bicarbonate (HCO3-).
    • Both anions and cations combine to form salt.

    Normal Lab Values

    • Osmolality: 285-295 mOsm/kg
    • Electrolytes:
      • Sodium (Na+): 136-145 mEq/L
      • Potassium (K+): 3.5-5.0 mEq/L
      • Chloride (Cl-): 98-106 mEq/L
      • Total CO2: 23-30 mEq/L
      • Bicarbonate (HCO3-): 21-28 mEq/L
      • Total Calcium (Ca2+): 9.0-10.5 mg/dL
      • Ionized Calcium (Ca2+): 4.5-5.6 mg/dL
      • Magnesium (Mg2+): 1.3-2.1 mEq/L
      • Phosphate: 3.0-4.5 mg/dL
      • Anion Gap: 6+/-4 mEq/L
    • Acid-Base Parameters:
      • pH: 7.35 to 7.45
      • PaCO2: 35 to 45 mmHg
      • PaO2: 80-100 mmHg
      • HCO3-: 21 to 28 mEq/L
      • O2 Saturation: 95% to 100%
      • Base Excess: -2 to +2 mmEq/L

    Fluid Tonicity

    • Fluid containing a large number of dissolved particles is considered more concentrated than fluid with fewer particles.
    • Osmolality is the number of particles per kilogram of water, with sodium (Na+) playing a significant role in determining tonicity.
    • Isotonic fluids have the same tonicity as blood, maintaining normal cell size.
    • Hypotonic fluids are more dilute than blood, causing cells to swell.
    • Hypertonic fluids are more concentrated than blood, causing cells to shrink.

    Movement of Water and Electrolytes

    • Active transport requires energy to move electrolytes across cell membranes against their concentration gradient.
    • Diffusion is the passive movement of electrolytes or other particles down a concentration gradient, facilitated by ion channels.
    • Osmosis is the movement of water across a membrane separating fluids with different particle concentrations.
    • Filtration refers to fluid movement into and out of capillaries, influenced by hydrostatic pressure and osmotic pressure (oncotic pressure).
    • Hydrostatic pressure is the force of fluid pressing outward against a surface.
    • Colloid osmotic pressure is the inward pulling force caused by blood proteins, mainly albumin, which helps move fluid back into the capillaries.
    • Edema, a collection of fluid in the interstitial space, can result from conditions like heart failure (HF) and congestive heart failure (CHF).

    Fluid Balance

    • Maintaining fluid homeostasis involves fluid intake and absorption, fluid distribution, and fluid output.
    • Input and output should be balanced for proper fluid balance.
    • Average daily fluid intake includes fluids ingested, food, and metabolic water.
    • Average daily fluid output includes losses through skin (insensible and sweat), lungs, gastrointestinal tract, and urine.

    Thirst Regulation

    • Thirst is a conscious desire for water, triggered by increased plasma osmolality or decreased blood volume.
    • The thirst mechanism is located in the hypothalamus.
    • Osmoreceptors monitor plasma osmolality, stimulating neurons in the hypothalamus when osmolality increases.
    • Individuals unable to communicate thirst, such as infants or patients with neurological disorders, are at risk for dehydration.

    Fluid Distribution

    • Fluid distribution refers to fluid movement among compartments.
    • Osmosis governs distribution between the extracellular and intracellular compartments.
    • Filtration regulates distribution between the vascular and interstitial compartments.

    Fluid Output

    • Four organs contribute to fluid output: skin, lungs, GI tract, and kidneys.
    • Abnormal output can be caused by factors such as vomiting, wound drainage, hemorrhage, fever, burns, and diarrhea.
    • Normal output includes insensible losses through skin and lungs, and visible losses through sweat, GI tract, and feces.

    Mechanisms Regulating Fluid Balance

    • When fluid output exceeds intake, mechanisms like antidiuretic hormone (ADH), the renin-angiotensin-aldosterone system (RAAS), and atrial natriuretic peptide (ANP) are activated.

    Antidiuretic Hormone (ADH)

    • ADH regulates body fluid osmolality by influencing water excretion in urine.
    • Synthesized in the hypothalamus and released from the pituitary gland.
    • Acts on collecting ducts in the kidneys, causing reabsorption of water and dilution of blood.
    • Factors increasing ADH release include decreased blood volume, pain, stress, and certain medications.
    • Factors decreasing ADH release include diluted blood.

    Renin-Angiotensin-Aldosterone System (RAAS)

    • RAAS regulates ECF volume by influencing sodium and water excretion in urine.
    • It also contributes to blood pressure regulation.
    • Renin, released from the kidneys, initiates a cascade of reactions converting angiotensinogen to angiotensin II.
    • Angiotensin II is a vasoconstrictor and stimulates the release of aldosterone from the adrenal cortex.
    • Aldosterone acts on the kidneys, promoting sodium and water reabsorption, increasing ECF volume.
    • Aldosterone also influences electrolyte and acid-base balance by increasing potassium and hydrogen ion excretion.
    • RAAS activity is influenced by stimuli like hemorrhage, vomiting, and decreased blood flow, leading to increased renin release and sodium/water retention for ECF restoration.

    Atrial Natriuretic Peptide (ANP)

    • ANP regulates ECF volume by influencing sodium and water excretion in urine.
    • Released by cells in the atria of the heart when stretched.
    • Released in response to factors like medication, diarrhea, alcohol, sweat, fever, trauma/blood loss, dehydration, vomiting, and disease.

    Fluid Imbalance

    • Two main types of fluid imbalance: volume imbalance and osmolality imbalance.
    • Volume imbalance affects the amount of fluid in the extracellular compartment.
    • Osmolality imbalance disrupts the concentration of body fluids.
    • Both types of imbalance can occur separately or together.

    Respiratory Acidosis

    • Caused by excessive carbonic acid due to alveolar hypoventilation
    • Impaired gas exchange can be caused by:
      • Type B COPD (chronic bronchitis)
      • End-stage Type A COPD (emphysema)
      • Bacterial pneumonia
      • Airway obstruction
      • Extensive atelectasis (collapsed alveoli)
      • Severe acute asthma
    • Neuromuscular function impairment can be caused by:
      • Respiratory muscle weakness or paralysis from hypokalemia or neurological dysfunction
      • Respiratory muscle fatigue and respiratory failure
      • Chest wall injury or surgery causing pain with respiration
    • Other causes include:
      • Dysfunction of brainstem respiratory control
        • Drug overdose with a respiratory depressant
        • Some types of head injury

    Respiratory Alkalosis

    • Caused by deficient carbonic acid due to alveolar hyperventilation (Kussmaul respirations)
    • Can be caused by:
      • Hypoxemia (e.g., initial part of asthma episode, pneumonia)
      • Acute pain
      • Anxiety, psychological distress, sobbing
      • Inappropriate mechanical ventilator settings
      • Stimulation of brainstem respiratory control (e.g., meningitis, gram-negative sepsis, head injury, aspirin overdose)

    Metabolic Acidosis

    • Caused by excessive metabolic acids
    • Increase of metabolic acids (high anion gap) can be caused by:
      • Ketoacidosis (diabetes, starvation, alcoholism)
      • Hypermetabolic state (severe hyperthyroidism, burns, severe infection)
      • Oliguric renal disease (acute kidney injury, end-stage renal disease)
      • Circulatory shock (lactic acidosis)
      • Ingestion of acid or acid precursors (e.g., methanol, ethylene glycol, boric acid)
    • Loss of bicarbonate (normal anion gap) can be caused by:
      • Diarrhea
      • Pancreatic fistula or intestinal decompression
      • Renal tubular acidosis

    Metabolic Alkalosis

    • Caused by deficient metabolic acids
    • Increase in bicarbonate can be caused by:
      • Excessive administration of sodium bicarbonate
      • Massive blood transfusion (liver converts citrate to HCO3−)
      • Mild or moderate ECV deficit (contraction alkalosis)
    • Loss of metabolic acid can be caused by:
      • Excessive vomiting or gastric suctioning
      • Hypokalemia
      • Excess aldosterone

    Risk Factors of Imbalances

    • Age
      • Young (ECV deficit) (Osmolality imbalances) (Clinical dehydration)
      • Old (ECV excess or deficit) (osmolality imbalance)
    • Environmental
      • Sodium rich diet (ECV excess)
      • Electrolyte poor diet (electrolyte deficits)
      • Hot weather (clinical dehydration)
    • Gastrointestinal Output
      • Diarrhea
      • Drainage
      • Vomiting
    • Chronic disease
      • Cancer
      • COPD
      • Cirrhosis
      • HF
      • Oliguric renal disease
    • Trauma
      • Burns
      • Crash injuries
      • Head injuries
      • Hemorrhage
    • Therapies
      • Diuretics
      • IV therapy
      • PN

    Different types of RN Diagnosis for Fluid, Electrolyte or Acid Alteration

    • Fluid Imbalance
    • Dehydration
    • Acid Base Imbalance
    • Lack of knowledge of fluid regimen

    Enteral Fluid Replacement (By Mouth)

    • Contraindications:
      • Mechanical obstruction of the GI tract
      • Severe nausea
      • Increased risk of aspiration
      • Impaired swallowing

    Parenteral Fluid Replacement (IV)

    • Types of Fluid Replacement
      • PN (Parenteral Nutrition)
      • Electrolyte therapy
      • Blood
      • Blood components

    Types of IV Solutions

    • D5W-Dextrose 5% in water- Isotonic

    • D10W-Dextrose 10% in water- Hypertonic

    • 0.225% NaCl (1/4 Normal Saline)- Hypotonic

    • 0.45% NaCl (1/2 Normal Saline)- Hypotonic

    • 0.9% NaCl (normal saline)- Isotonic

    • 3-5% NaCl (hypertonic saline)- Hypertonic

    • Dextrose 5% in 0.45% NaCl (1/2 normal saline)- Hypertonic

    • Dextrose 5% in 0.9% NaCl (D5NS)- Hypertonic

    • Lactated Ringers (LR)- Isotonic

    • Dextrose 5% (LR, D5LR)- Hypertonic

    Biochemical Units of Nutrition

    • The body requires fuel to provide energy for cellular metabolism and repair, organ function, growth and body movement.

    Factors Affecting Energy Requirements

    • Age
    • Body mass
    • Gender
    • Fever
    • Starvation
    • Menstruation
    • Illness
    • Injury
    • Infection
    • Activity
    • Level of thyroid function

    Factors Affecting Metabolism

    • Illness
    • Pregnancy
    • Lactation
    • Activity level

    Proteins

    • Provide a source of energy equal to 4Kcal/g
    • Essential for growth, maintenance, and repair of body tissue
    • Collagen, hormones, enzymes, immune cells, (DNA), (RNA) are all made of protein

    Important Factors of Protein

    • Blood clotting
    • Fluid regulation
    • Acid-base balance

    Water

    • Critical for all cell function because it depends on a fluid environment
    • Makes up to 60-70% of total body weight
    • People who are lean have a greater percentage of water because muscle contains the most water of any tissue except blood.

    Fluid Release

    • Occurs through:
      • Respiration
      • Sweating
      • Urine
      • Stools
      • Fever
      • Vomiting
      • Trauma (blood loss)
      • Clinical dehydration
      • Medications

    Digestion of Food

    • Mechanical breakdown from chewing, churning, mixing with fluid and chemical reactions in which food is reduced to its simplest form.

    Enzymes

    • Protein-like substances that act as a catalyst to speed up chemical reactions
    • Essential part of the chemistry of digestion.

    Factors that affect Nutrition

    • Environmental

      • Contributes to obesity, 68.7% of Americans are either overweight or obese.
        • Overweight: BMI 25 to 29
        • Obese: BMI of 30 or greater
      • Cost of healthy food is increasing and it can be difficult to afford
      • Fewer safe places to walk and play
      • Older adults should avoid grapefruit and grapefruit juice because it can alter the absorption of many drugs.

    • Age

      • Older adults (65+) have a decreased need for energy because their metabolic rate slows with age
      • However, vitamin and mineral requirements remain unchanged.
      • Age related changes:
        • Decreased appetite
        • Decreased taste cells
        • Decreased income
        • Increased cost of medication making it difficult to balance between medication, food, and other monthly bills
        • Decreased health
        • Lack of desire to eat
        • Lack of transportation### Religious Dietary Restrictions

    • Some faiths allow minimal or no alcohol consumption

    • Some faiths restrict certain kinds of meat, like pork, predatory fowl, and shellfish

    • Ramadan fasting is a religious practice observed for 1 month from sunrise to sunset

    • Ramadan fasting includes restrictions on food and drink, including alcohol and caffeine

    • Kosher food preparation methods are widely practiced

    • Certain religious practices may require ritualized methods of animal slaughter for meat ingestion

    Eating Disorders

    • Anorexia Nervosa is characterized by food restriction and intense fear of weight gain, leading to significantly low body weight
    • Bulimia Nervosa is characterized by binge eating followed by inappropriate compensation behaviors to prevent weight gain, like self-induced vomiting or rigorous exercise

    Dysphagia (Difficult Swallowing)

    • Caused by conditions affecting muscle function, nerve function, and physical obstructions in the digestive tract
    • Myogenic dysphagia results from muscle problems, such as myasthenia gravis and muscular dystrophy
    • Neurogenic dysphagia is caused by nerve problems, such as stroke and multiple sclerosis
    • Obstructive dysphagia is caused by physical obstructions, such as tumors and strictures
    • Other causes include gastrointestinal or esophageal resection, and various disorders

    Signs and Symptoms of Dysphagia

    • Coughing during eating
    • Change in voice tone or quality after swallowing
    • Abnormal movements of mouth, tongue, or lips
    • Slow, weak, imprecise, or uncoordinated speech
    • Abnormal gag
    • Delayed swallowing
    • Incomplete oral clearance or pocketing
    • Regurgitation
    • Pharyngeal pooling (accumulation of food in the throat)
    • Delayed or absent trigger of swallow
    • Inability to speak consistently

    Diet Progression and Therapeutic Diets

    • Clear Liquid Diet: includes broth, bouillon, coffee, tea, clear fruit juices, gelatin, and popsicles
    • Full Liquid Diet: includes all clear liquid items, plus smooth textured dairy products, strained or blended cream soups, custards, refined or cooked cereals, and fruit juices
    • Dysphagia Stages: includes thickened liquids and purees, scrambled eggs, pureed vegetables and fruits, mash potatoes, and gravy
    • Mechanical Soft Diet: includes all previous diet items, plus creamed soups, ground or finely diced meats, flaked fish, and cottage cheese
    • Soft Low Residue Diet: easily digested foods, pasta, casseroles, moist tender meats, cooked fruits and vegetables, and desserts
    • High Fiber Diet: includes uncooked fruits and steamed vegetables, bran, oatmeal, and dried fruit
    • Low Sodium Diet: no added salts
    • Diabetic Diet: focuses on total energy, nutrient and food distribution, and balanced intake of carbohydrates, fats, and proteins
    • Gluten Free Diet: no wheat, oats, rye, barley, and their derivatives
    • Regular Diet: no restrictions

    Promoting Diet or Food Intake

    • Environment free of odors
    • Providing oral hygiene
    • Maintaining patient comfort
    • Offering smaller meals more frequently

    Enteral Nutrition (EN)

    • Provides nutrients to the gastrointestinal tract through a nasogastric tube or surgical feeding tube
    • Indications for EN include cancer, head/neck and upper GI issues, critical illness or trauma, brain neoplasm (tumor), cerebrovascular accident (stroke), dementia, myopathy, enterocutaneous fistula (abnormal connection between the intestine and skin), mild pancreatitis, prolonged intubation, anorexia nervosa, difficulty chewing or swallowing, and severe depression

    Parenteral Nutrition (PN)

    • Specialized nutrition support delivered intravenously
    • Indications for PN include a nonfunctioning gastrointestinal tract, massive small bowel resection, GI surgery, GI bleed, paralytic ileus, intestinal obstruction, trauma to abdomen, head or neck, severe malabsorption, intolerance to enteral feeding, chemotherapy, radiation, and bone marrow transplants

    Complications of PN

    • Pneumothorax is a possible complication that occurs when the catheter tip accidentally enters the pleural space during insertion

    Tube Feeding Intolerance

    • Signs of intolerance include high gastric residuals, nausea, cramping, vomiting, or diarrhea
    • Keep the head of the bed elevated a minimum of 30 degrees during and after feeding

    Procedural Guidelines for Obtaining Gastrointestinal Aspirate for pH Measurement

    • Ensure the skill of verifying tube placement and irrigating a feeding tube is the responsibility of a registered nurse
    • Direct assistive personnel to report immediately any changes in patient respirations or complaints of shortness of breath, coughing, or choking
    • Direct assistive personnel to immediately report vomiting or the presence of vomit in the patient's mouth during oral hygiene
    • Direct assistive personnel to report any signs of nasal skin irritation or excoriation
    • Direct assistive personnel to report any change in the external length of the tube, which could indicate displacement
    • Direct assistive personnel to report when a continuous tube feeding stops infusing

    Equipment for Tube Feeding

    • 60-mL ENFit syringe
    • Water (tap water or sterile)
    • Towel
    • Stethoscope
    • Clean gloves
    • pH indicator strip (scale of 1.0--11.0)
    • Small medication cup
    • Measuring tape/device
    • Pulse oximeter

    Procedural Steps for Tube Feeding

    • Review agency policy and procedures for frequency of irrigation and frequency and method of checking tube placement
    • Identify patient using at least two identifiers
    • Review patient's medication record for enteral feeding orders, and orders for gastric acid inhibitors or proton pump inhibitors
    • Review patient's medical record for history of prior tube displacement
    • Observe for signs and symptoms of respiratory distress during feeding
    • Identify conditions that increase risk for spontaneous tube migration or dislocation, such as an altered level of consciousness, agitation, retching, vomiting, or nasotracheal suction
    • Perform hand hygiene, assess bowel sounds, and perform abdominal examination
    • Obtain pulse oximetry reading
    • Note how easily previous tube feedings infused through tubing
    • Monitor the volume of continuous enteral formula administered during a shift and compare with the ordered amount
    • Assess patient's or family caregiver's knowledge, experience, and health literacy
    • Perform hand hygiene and apply clean gloves
    • Verify tube placement

    Cleaning and Maintaining PN Central Venous Catheter (CVC)

    • Use Standard Precautions
    • Change the CVC dressing per institution policy and any time it becomes wet, disrupted, or contaminated
    • Use 2% alcohol-based chlorhexidine gluconate, 70% alcohol, or povidone iodine to clean the injection port or catheter hub 15 seconds before and after each use

    Fluid Composition and Electrolyte Balance

    • Adult males have 60% body weight as water, decreasing to 50% in older males.
    • Body fluid exists in two compartments: Extracellular Fluid (ECF) outside cells and Intracellular Fluid (ICF) within cells.
    • ECF further divides into: Intravascular Fluid (liquid part of blood) and Interstitial Fluid (between cells, outside blood vessels).
    • Transcellular Fluids, secreted by epithelium cells, include Cerebral Spinal Fluid, Pleural, Peritoneal, and Synovial fluids.
    • Essential Electrolytes that separate into charged particles (ions) include:
      • Cations (positively charged): Sodium (Na+), Potassium (K+), Calcium (Ca+), Magnesium (Mg2+)
      • Anions (negatively charged): Chloride (Cl-), Bicarbonate (HCO3-)
    • Electrolytes combine to form salts.

    Normal Lab Values

    • Osmolality: 285-295 mOsm/kg H2O
    • Sodium (Na+): 136-145 mEq/L
    • Potassium (K+): 3.5-5.0 mEq/L
    • Chloride (Cl-): 98-106 mEq/L
    • Total CO2: 23-30 mEq/L
    • Bicarbonate (HCO3-): 21-28 mEq/L
    • Total Calcium (Ca2+): 9.0-10.5 mg/dL
    • Ionized Calcium (Ca2+): 4.5-5.6 mg/dL
    • Magnesium (Mg2+): 1.3-2.1 mEq/L
    • Phosphate: 3.0-4.5 mg/dL
    • Anion Gap: 6+/-4 mEq/L
    • pH: 7.35 to 7.45
    • PaCO2: 35 to 45 mmHg
    • PaO2: 80-100 mmHg
    • HCO3-: 21 to 28 mEq/L
    • O2 Saturation: 95% to 100%
    • Base Excess: -2 to +2 mmEq/L

    Fluid Concentration and Tonicity

    • Fluid with high dissolved particles is more concentrated than fluid with fewer particles.
    • Osmolality is the number of particles per kilogram of water.
    • Sodium (Na+) doesn't easily pass through cell membranes, affecting tonicity (effective concentration).
    • Isotonic: Fluid with the same tonicity as blood, cells remain normal.
    • Hypotonic: More dilute than blood, cells enlarge.
    • Hypertonic: More concentrated than blood, cells shrink.

    Movement of Water and Electrolytes

    • Active Transport: Requires ATP (energy) to move electrolytes against their concentration gradient (lower to higher concentration).
    • Diffusion: Passive movement of electrolytes down a concentration gradient (higher to lower concentration), requiring proteins as ion channels.
    • Osmosis: Water moves across a semi-permeable membrane to equalize particle concentration between fluids.
    • Filtration: Movement of fluid between capillaries and interstitial space, driven by hydrostatic pressure and osmotic pressure.

    Hydrostatic and Osmotic Pressure

    • Hydrostatic Pressure: Force of fluid pressing outward against a surface.
    • Colloid Osmotic Pressure (Oncotic Pressure): Inward pulling force caused by blood proteins (mainly albumin) that helps pull fluid from the interstitial space back into capillaries.
    • Edema: Fluid buildup in the interstitial space, seen in conditions like heart failure (HF) and congestive heart failure (CHF).

    Fluid Balance Components

    • Fluid homeostasis involves:
      • Intake and absorption
      • Fluid distribution
      • Fluid output
    • Intake should equal output for balance.
    • Fluid intake can occur orally, through IV fluids, rectal enemas, and surgical irrigation.
    • Average daily fluid intake is 2200-2700 mL, with output also in that range.
    • Prolonged exercise can significantly increase both fluid intake and output.

    Thirst Regulation

    • Thirst is a conscious desire for water triggered by:
      • Increased plasma osmolality
      • Decreased blood volume
    • The thirst control center is located in the hypothalamus.
    • Osmoreceptors monitor plasma osmolality and stimulate neurons in the hypothalamus.
    • Vulnerable individuals with impaired communication (infants, neurologically impaired, older adults) might not effectively express thirst.

    Fluid Distribution

    • Movement of fluid between:
      • Extracellular and intracellular compartments (Osmosis)
      • Vascular and interstitial parts of ECF (Filtration)

    Fluid Output

    • Four organs contribute to fluid output:
      • Skin
      • Lungs
      • Gastrointestinal Tract
      • Kidneys
    • Abnormal Output can be caused by:
      • Vomiting
      • Wound drainage
      • Hemorrhage
      • Fever
      • Burns
      • Diarrhea
    • Normal Output includes:
      • Insensible loss (skin, lungs)
      • Sweat
      • Gastrointestinal loss (feces)

    Hormonal Regulation of Fluid Balance

    • Antidiuretic Hormone (ADH): Regulates osmolality by influencing water excretion in urine.
      • Synthesized in hypothalamus, released from pituitary gland.
      • Acts on collecting ducts, stimulating water reabsorption and diluting blood.
      • Increased by decreased blood volume, pain, stress, and medication.
      • Decreased by dilute blood levels.
    • Renin-Angiotensin-Aldosterone System (RAAS): Regulates ECF volume by influencing sodium and water excretion.
      • Renin released from kidneys converts angiotensinogen to angiotensin I, then to angiotensin II in lungs.
      • Angiotensin II constricts blood vessels and stimulates aldosterone release from the adrenal cortex.
      • Aldosterone increases sodium and water reabsorption in distal renal tubules, increasing ECV.
      • Aldosterone also increases potassium and hydrogen ion excretion.
      • RAAS activity increases with decreased ECV, hemorrhage, vomiting.
    • Atrial Natriuretic Peptide (ANP): Regulates ECV by influencing sodium and water excretion.
      • Released from atrial cells in response to stretching.
      • Stimulated by medications, diarrhea, alcohol, sweat, fever, trauma, blood loss, dehydration, vomiting, and disease.

    Fluid Imbalances

    • Two major types:
      • Volume Imbalance: Disturbance in the amount of fluid in the extracellular compartment.
      • Osmolality Imbalance: Disturbance in the concentration of body fluids.
    • Both can occur independently or simultaneously.

    Respiratory Acidosis

    • Caused by alveolar hypoventilation
    • Impaired gas exchange
    • Type B COPD
    • End stage type A COPD
    • Bacterial Pneumonia
    • Airway Obstruction
    • Extensive Atelectasis (Collapsed Alveoli)
    • Severe acute asthma
    • Neuromuscular causes: Respiratory muscle weakness or paralysis from hypokalemia or neurological dysfunction
    • Respiratory muscle fatigue, respiratory failure
    • Chest wall injury or surgery causing pain with respiration
    • Dysfunction of the brainstem respiratory control
    • Drug overdose with respiratory depressant
    • Some types of head injuries

    Respiratory Alkalosis

    • Caused by alveolar hyperventilation
    • Hypoxemia from any cause (e.g., initial part of asthma episode, pneumonia)
    • Acute pain
    • Anxiety, psychological distress, sobbing
    • Inappropriate mechanical ventilator settings
    • Stimulation of brainstem respiratory control (e.g., meningitis, gram-negative sepsis, head injury, aspirin overdose)

    Metabolic Acidosis

    • Increase of metabolic acids (high anion gap)
    • Ketoacidosis
    • Hypermetabolic state (severe hyperthyroidism, burns, severe infection)
    • Oliguric renal disease (acute kidney injury, end-stage renal disease)
    • Circulatory shock (lactic acidosis)
    • Ingestion of acid or acid precursors (e.g., methanol, ethylene glycol, boric acid)
    • Loss of Bicarbonate (Normal anion gap)
    • Diarrhea
    • Pancreatic Fistula or intestinal decompression
    • Renal tubular acidosis

    Metabolic Alkalosis

    • Increase of Bicarbonate
    • Excessive administration of sodium bicarbonate
    • Massive blood transfusion (liver converts citrate to HCO3−)
    • Mild or moderate ECV deficit (contraction alkalosis)
    • Loss of metabolic acid
    • Excessive vomiting or gastric suctioning
    • Hypokalemia
    • Excessive aldosterone

    Risk Factors

    • Age
      • Young: ECV deficit, osmolality imbalances, clinical dehydration
      • Old: ECV excess or deficit, osmolality imbalances
    • Environmental
      • Sodium rich diet: ECV excess
      • Electrolyte poor diet: Electrolyte deficits
      • Hot weather: Clinical dehydration
    • Gastrointestinal Output
      • Diarrhea
      • Drainage
      • Vomiting
    • Chronic Disease
      • Cancer
      • COPD
      • Cirrhosis
      • Heart failure
      • Oliguric renal disease
    • Trauma
      • Burns
      • Crash Injuries
      • Head Injuries
      • Hemorrhage
    • Therapies
      • Diuretics
      • IV Therapy
      • PN

    Nursing Diagnoses

    • Fluid Imbalance
    • Dehydration
    • Acid Base Imbalance
    • Lack of knowledge of fluid regimen

    Enteral Fluid Replacement

    • By Mouth
    • Remember ice chips are ½ of a volume measurement, i.e.give a pt 240 mL of ice chips the actual intake volume is 120 mL
    • Contraindications
      • Mechanical Obstruction of GI tract
      • Severe Nausea
      • Increased risk of aspiration
      • Impaired swallowing

    Parenteral Fluid Replacement

    • IV
    • Types of Fluid Replacement
      • PN (Parenteral Nutrition)
      • Electrolyte therapy
      • Blood
      • Blood Components

    Types of IV Solutions

    • D5W-Dextrose 5% in water- Isotonic
    • D10W-Dextrose 10% in water- Hypertonic
    • Saline Chloride (NaCl) in water solution
      • 0.225% NaCl (1/4 Normal Saline)- Hypotonic
      • 0.45% NaCl (1/2 Normal Saline)- Hypotonic
      • 0.9% NaCl (normal saline)- Isotonic
      • 3-5% NaCl (hypertonic saline)- Hypertonic
    • Dextrose in Saline Solution
      • Dextrose 5% in 0.45% NaCl (1/2 normal saline)- Hypertonic
      • Dextrose 5% in 0.9% NaCl (D5NS)- Hypertonic
    • Multiple Electrolyte Solutions
      • Lactated Ringers (LR)- Isotonic
      • Dextrose 5% (LR, D5LR)- Hypertonic

    Nutrition

    • Biochemical Units of Nutrition
      • The body requires fuel to provide energy for cellular metabolism and repair, organ function, growth and body movement.
    • Factors affecting Energy Requirements
      • Age
      • Body mass
      • Gender
      • Fever
      • Starvation
      • Menstruation
      • Illness
      • Injury
      • Infection
      • Activity
      • Level of thyroid function
    • Factors affecting Metabolism
      • Illness
      • Pregnancy
      • Lactation
      • Activity level
    • Proteins: provide a source of energy equal to 4Kcal/g; they are essential for the growth, maintenance, and repair of body tissue. Collagen, hormones, enzymes, immune cells, (DNA), (RNA) are all made of protein.
    • Factors of Protein
      • Blood Clotting
      • Fluid Regulation
      • Acid-Base Balance
    • Water: is critical because all cell function depends on a fluid environment. Water makes up to 60-70% of total body weight. People who are lean have a greater percentage of water because muscle contains more water than any other tissue except blood.
    • Fluid Release
      • Respiration
      • Sweating
      • Urine
      • Stools
      • Fever
      • Vomiting
      • Trauma (blood loss)
      • Clinical Dehydration
      • Medications
    • Digestion of Food: is the mechanical breakdown that results from chewing, churning, and mixing with fluid and chemical reactions in which food is reduced to its simplest form.
    • Enzymes: are protein-like substances that act as a catalyst to speed up chemical reactions. They are an essential part of the chemistry of digestion.
    • Factors that affect Nutrition
      • Environmental: this is beyond the control of the patient and contributes to obesity. 68.7 % of Americans are overweight or obese. Overweight Measurement: BMI 25 to 29, Obese Measurement: BMI of 30 or greater. Cost of healthy food is increasing, unable to afford, and there are fewer safe places to walk and play.
      • Age: Older adults 65 and up have a decreased need for energy because their metabolic rate slows with age. However, vitamin and mineral requirements remain unchanged.
      • Age related changes
        • Decreased appetite
        • Decreased taste cells
        • Decreased income
        • Increase cost of medication/ making it difficult to balance between medication and food and other monthly bills
        • Decreased health
        • No desire to eat
        • Lack of transportation
      • Cautions for older adults
        • Avoid grapefruit and grapefruit juice because they alter absorption of many drugs.

    Seventh Day: Religious Dietary Restrictions

    • Some religions prohibit consuming pork, others limit consumption to fish with scales
    • Alcohol restrictions vary by religion, with some allowing minimal or no alcohol, while others don't allow alcohol at all.
    • During Ramadan, Muslims fast from sunrise to sunset for a month. It's a period of abstaining from food, drink, and sexual activity.
    • There are specific methods for animal slaughter required for meat consumption in certain religious communities.
    • Mixing of milk or dairy products with meat dishes is strictly prohibited in some religions.
    • 24 hours of fasting on Yom Kippur, a day of atonement for Jewish people, is mandatory.

    Eating Disorders

    • Anorexia nervosa is characterized by restricted energy intake leading to a significantly low body weight, an intense fear of gaining weight or becoming fat, and a distorted perception of body size and shape.
    • Bulimia nervosa is characterized by recurrent episodes of binge eating followed by inappropriate compensatory behaviors to prevent weight gain, such as purging or excessive exercise.

    Dysphagia: Difficulty Swallowing

    • Myogenic: Muscle weakness or disease causes the difficulty.
    • Neurogenic: Nerve damage or dysfunction is the cause.
    • Obstructive: Something physically blocks the passage of food.
    • Other: Various conditions can contribute to dysphagia.
    • Signs and symptoms include coughing during eating, change in voice tone, abnormal mouth, tongue, or lip movements, slow speech, abnormal gag, delayed swallowing, and regurgitation.

    Diet Progression & Therapeutic Diets

    • Clear liquid: Broth, bouillon, coffee, tea, clear fruit juices, gelatin, fruit ices, and popsicles.
    • Full liquid: Clear liquids plus smooth dairy products, strained cream soups, custards, refined or cooked cereals, pureed vegetables, and puddings.
    • Dysphagia Stages: Clear and full liquid foods plus thickened liquids and purees, scrambled eggs, pureed meats, vegetables, fruits, and mashed potatoes.
    • Mechanical soft: Dysphagia stage foods plus creamed soups, ground meats, flaked fish, cottage cheese, and soft breads.
    • Soft low residue: Easily digested foods, pasta, casseroles, moist tender meats, cooked fruits and vegetables, desserts, cakes, and cookies.
    • High fiber: Uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruit.
    • Low sodium: No added salt.
    • Diabetic: Balanced intake of carbohydrates, fats, and protein.
    • Gluten Free: No wheat, oats, rye, barley, and their derivatives.
    • Regular: No restrictions.

    Promoting Diet or Food Intake

    • Maintain a pleasant environment free of odors
    • Provide oral hygiene
    • Offer smaller meals more frequently

    Four Levels of Diet for Dysphagia

    • Dysphagia puree: Pureed food
    • Dysphagia mechanically altered: Soft food
    • Dysphagia advanced: A mixture of pureed and soft foods
    • Regular: No restrictions

    Enteral Nutrition (EN)

    • Provides nutrients to the GI tract through a tube.
    • Indications for EN: Cancer, head/neck upper GI, critical illness or trauma, brain neoplasm, cerebrovascular accident, dementia, myopathy, enterocutaneous fistula, inflammatory bowel disease, mild pancreatitis, respiratory failure with prolonged intubation, anorexia nervosa, difficulty chewing or swallowing, and severe depression.

    Parenteral Nutrition (PN)

    • Provides nutrients intravenously.
    • Indications for PN: Nonfunctioning GI tract, massive small bowel resection, GI surgery, GI bleed, paralytic ileus, intestinal obstruction, trauma to abdomen, head, or neck, severe malabsorption, intolerance to enteral feeding, chemotherapy, radiation, and bone marrow transplants.
    • Complications of PN: Tension pneumothorax, monitor patient for this complication up to 24 hours after insertion.

    Measurement for NG Tubes

    • Tip of catheter at the nose, back to the ear, and down to the xyphoid process

    Location of NG Tube

    • Best way to see if the tube is in the correct location is via x-ray.
    • Second-best way is by aspirating stomach contents from the tube and testing the acidity of the contents.

    Signs of Intolerance of Tube Feedings

    • High gastric residuals, nausea, cramping, vomiting, or diarrhea.
    • Flush NG with water to prevent microorganisms and bacteria.
    • Keep the head of the bed elevated at least 30 degrees during feedings and for 30-60 minutes afterward.

    Procedural Guidelines for Obtaining Gastrointestinal Aspirate for pH Measurement and Large-Bore and Small-Bore Feeding Tubes: Intermittent and Continuous Feeding

    • Delegation and collaboration: Verification of tube placement and irrigation can't be delegated to assistive personnel (AP).
    • Equipment: 60-mL ENFit syringe, water, towel, stethoscope, clean gloves, pH indicator strip, small medication cup, measuring tape, and pulse oximeter.
    • Procedural steps: Review agency policy, identify patient by two identifiers, review medication record, review patient's medical record for history of tube displacement, observe signs and symptoms of respiratory distress during feeding, identify conditions that increase risk of tube migration or dislocation, perform hand hygiene, obtain pulse oximeter readings, assess patient's knowledge and experience, perform hand hygiene, apply clean gloves, be sure pulse oximeter is in place, and verify tube placement.

    Parenteral Nutrition (PN)

    • Specialized nutritional support provided intravenously.
    • Patients unable to digest or absorb EN benefit from PN.
    • Patients in highly stressed physiological states are candidates for PN therapy.

    Cleaning and Maintaining PN Central Venous Catheter

    • Standard precautions like hand hygiene, PPE, aseptic field management, nontouch technique, and sterilized supplies are crucial.
    • Change CVC dressing per institution policy and any time it becomes wet, disrupted, or contaminated.
    • Use 2% alcohol-based chlorhexidine gluconate (preferred), 70% alcohol, or povidone iodine to clean the injection port or catheter hub.

    Complications of PN

    • Pneumothorax can occur from an initial puncture during catheter insertion.

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