Podcast
Questions and Answers
What is the normal range for osmolality?
What is the normal range for osmolality?
What are cations?
What are cations?
Positively charged ions
Hyperkalemia refers to low levels of potassium in the blood.
Hyperkalemia refers to low levels of potassium in the blood.
False
Which fluid has the same tonicity as blood?
Which fluid has the same tonicity as blood?
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The hormone responsible for regulating the osmolality of body fluid is called ______.
The hormone responsible for regulating the osmolality of body fluid is called ______.
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What are the main compartments of body fluid?
What are the main compartments of body fluid?
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Which of the following is a condition where fluid remains in the interstitial space?
Which of the following is a condition where fluid remains in the interstitial space?
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Osmosis is the movement of water across a membrane that separates fluids with the same concentration.
Osmosis is the movement of water across a membrane that separates fluids with the same concentration.
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The primary role of __________ is to regulate ECV by influencing sodium and water excretion.
The primary role of __________ is to regulate ECV by influencing sodium and water excretion.
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What fluid movement mechanism requires energy to move electrolytes against a concentration gradient?
What fluid movement mechanism requires energy to move electrolytes against a concentration gradient?
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What would the body fluid composition of an adult male typically be?
What would the body fluid composition of an adult male typically be?
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What condition occurs when the body fluids have decreased volume but normal osmolality?
What condition occurs when the body fluids have decreased volume but normal osmolality?
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Which of the following is a sign of Extracellular Fluid Volume Deficit?
Which of the following is a sign of Extracellular Fluid Volume Deficit?
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What is characterized by increased blood volume with normal osmolality?
What is characterized by increased blood volume with normal osmolality?
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Hypernatremia is caused by a gain of relatively more salt than water.
Hypernatremia is caused by a gain of relatively more salt than water.
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Hyponatremia results from excessive water intake when sodium loss is present.
Hyponatremia results from excessive water intake when sodium loss is present.
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What does ECV stand for?
What does ECV stand for?
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Which hormone is associated with water retention?
Which hormone is associated with water retention?
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The condition called __________ occurs when body fluids are too concentrated due to water deficit.
The condition called __________ occurs when body fluids are too concentrated due to water deficit.
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What happens to cells during hypernatremia?
What happens to cells during hypernatremia?
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Name one cause of ECV Excess.
Name one cause of ECV Excess.
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Match the electrolyte with its intake source:
Match the electrolyte with its intake source:
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What can occur if electrolyte intake is greater than output?
What can occur if electrolyte intake is greater than output?
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What is the serum potassium level classified as hypokalemia?
What is the serum potassium level classified as hypokalemia?
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Hyperkalemia is classified as a serum potassium level above 5.0 mEq/L.
Hyperkalemia is classified as a serum potassium level above 5.0 mEq/L.
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What are some signs of hypocalcemia?
What are some signs of hypocalcemia?
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_______ is a medical sign that indicates low calcium levels.
_______ is a medical sign that indicates low calcium levels.
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What can excessive intake of calcium lead to?
What can excessive intake of calcium lead to?
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What is the primary buffer in extracellular fluid?
What is the primary buffer in extracellular fluid?
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Metabolic acids are excreted by the kidneys.
Metabolic acids are excreted by the kidneys.
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List the two types of acidosis.
List the two types of acidosis.
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What can hypomagnesemia lead to regarding muscle function?
What can hypomagnesemia lead to regarding muscle function?
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Match the following types of acid production with their sources:
Match the following types of acid production with their sources:
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What causes respiratory acidosis?
What causes respiratory acidosis?
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Diarrhea is a cause of metabolic acidosis.
Diarrhea is a cause of metabolic acidosis.
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What are common signs and symptoms of respiratory alkalosis?
What are common signs and symptoms of respiratory alkalosis?
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A decrease in pH below __ indicates metabolic acidosis.
A decrease in pH below __ indicates metabolic acidosis.
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What is a common laboratory finding in respiratory acidosis?
What is a common laboratory finding in respiratory acidosis?
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Match the following causes to their respective acid-base imbalance:
Match the following causes to their respective acid-base imbalance:
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Respiratory alkalosis can be caused by anxiety.
Respiratory alkalosis can be caused by anxiety.
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What is a consequence of metabolic alkalosis?
What is a consequence of metabolic alkalosis?
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A decrease in the HCO3 level below __ indicates compensation for metabolic acidosis.
A decrease in the HCO3 level below __ indicates compensation for metabolic acidosis.
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Which of the following is NOT a sign of metabolic acidosis?
Which of the following is NOT a sign of metabolic acidosis?
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Drugs can cause alterations in acid-base balance.
Drugs can cause alterations in acid-base balance.
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What are enzymes?
What are enzymes?
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What is the BMI range for overweight individuals?
What is the BMI range for overweight individuals?
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Older adults have a decreased need for energy due to a slower metabolic rate.
Older adults have a decreased need for energy due to a slower metabolic rate.
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Which of the following factors can affect nutrition?
Which of the following factors can affect nutrition?
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What is the primary fear associated with anorexia nervosa?
What is the primary fear associated with anorexia nervosa?
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Which eating disorder is characterized by recurrent episodes of binge eating?
Which eating disorder is characterized by recurrent episodes of binge eating?
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Name one cause of dysphagia.
Name one cause of dysphagia.
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What is a sign of dysphagia?
What is a sign of dysphagia?
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What is the first stage in diet progression for dysphagia?
What is the first stage in diet progression for dysphagia?
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Which of the following is an indication for enteral nutrition?
Which of the following is an indication for enteral nutrition?
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What is parenteral nutrition?
What is parenteral nutrition?
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Complications of parenteral nutrition can include tension pneumothorax.
Complications of parenteral nutrition can include tension pneumothorax.
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Which type of fluid is located outside of cells?
Which type of fluid is located outside of cells?
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Acidosis refers to a decrease in blood pH.
Acidosis refers to a decrease in blood pH.
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What is the average body water percentage in an adult male?
What is the average body water percentage in an adult male?
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Osmolality is the number of particles per kg of ______.
Osmolality is the number of particles per kg of ______.
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Match these ions with their respective charge:
Match these ions with their respective charge:
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What hormone regulates the osmolality of body fluid?
What hormone regulates the osmolality of body fluid?
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What happens in a hypertonic solution?
What happens in a hypertonic solution?
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Filtration is the process of fluid moving into and out of capillaries.
Filtration is the process of fluid moving into and out of capillaries.
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What is an example of an abnormal fluid output?
What is an example of an abnormal fluid output?
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What is the normal range for bicarbonate (HCO3-) levels?
What is the normal range for bicarbonate (HCO3-) levels?
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What is the cause of respiratory acidosis?
What is the cause of respiratory acidosis?
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Dysrhythmias are a common sign of metabolic acidosis.
Dysrhythmias are a common sign of metabolic acidosis.
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What laboratory finding indicates respiratory acidosis?
What laboratory finding indicates respiratory acidosis?
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In metabolic alkalosis, the pH is typically _____ above 7.45.
In metabolic alkalosis, the pH is typically _____ above 7.45.
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Match the following conditions with their symptoms:
Match the following conditions with their symptoms:
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Which of the following is a cause of respiratory alkalosis?
Which of the following is a cause of respiratory alkalosis?
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What clinical condition often leads to increased metabolic acids?
What clinical condition often leads to increased metabolic acids?
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Excessive administration of sodium bicarbonate can lead to metabolic acidosis.
Excessive administration of sodium bicarbonate can lead to metabolic acidosis.
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What happens to bicarbonate levels in metabolic acidosis?
What happens to bicarbonate levels in metabolic acidosis?
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Which factor does NOT affect metabolism?
Which factor does NOT affect metabolism?
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What is an isotonic imbalance?
What is an isotonic imbalance?
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What are the signs of extracellular fluid volume deficit?
What are the signs of extracellular fluid volume deficit?
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What causes hypernatremia?
What causes hypernatremia?
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What laboratory finding indicates hyponatremia?
What laboratory finding indicates hyponatremia?
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Clinical dehydration includes extracellular fluid volume deficit and hypernatremia.
Clinical dehydration includes extracellular fluid volume deficit and hypernatremia.
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The clinical term for a deficit of water in the body is ______.
The clinical term for a deficit of water in the body is ______.
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What hormone is known to influence potassium levels by shifting K+ into cells?
What hormone is known to influence potassium levels by shifting K+ into cells?
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Match the following electrolytes with their associated intake or absorption sources:
Match the following electrolytes with their associated intake or absorption sources:
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What are enzymes?
What are enzymes?
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What is the measurement for being overweight?
What is the measurement for being overweight?
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What is the recommended action for older adults regarding grapefruit and grapefruit juice?
What is the recommended action for older adults regarding grapefruit and grapefruit juice?
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Which of the following can be a cause of dysphagia?
Which of the following can be a cause of dysphagia?
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In the context of a diet, 'Dysphagia' refers to ________.
In the context of a diet, 'Dysphagia' refers to ________.
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What are the four levels of diet for dysphagia?
What are the four levels of diet for dysphagia?
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Match the following diets with their characteristics:
Match the following diets with their characteristics:
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Parenteral nutrition is only given through NG tube.
Parenteral nutrition is only given through NG tube.
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What should be done during the feeding process to avoid signs of intolerance?
What should be done during the feeding process to avoid signs of intolerance?
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What is a complication of PN (Parenteral Nutrition)?
What is a complication of PN (Parenteral Nutrition)?
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Which of these factors can cause plasma electrolyte excess?
Which of these factors can cause plasma electrolyte excess?
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What is hypokalemia?
What is hypokalemia?
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What are common causes of hypokalemia?
What are common causes of hypokalemia?
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Which condition is associated with hyperkalemia?
Which condition is associated with hyperkalemia?
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Hypocalcemia is due to high levels of calcium in the blood.
Hypocalcemia is due to high levels of calcium in the blood.
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What are the signs of hypocalcemia?
What are the signs of hypocalcemia?
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Match the electrolyte imbalance with its common cause:
Match the electrolyte imbalance with its common cause:
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Acidosis is characterized by increased ______.
Acidosis is characterized by increased ______.
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Both lungs and kidneys can engage compensatory systems to correct acid-base imbalances.
Both lungs and kidneys can engage compensatory systems to correct acid-base imbalances.
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What is the primary function of the lungs in acid excretion?
What is the primary function of the lungs in acid excretion?
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What is the normal serum potassium level?
What is the normal serum potassium level?
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What is the primary cause of Extracellular Fluid Volume Deficit?
What is the primary cause of Extracellular Fluid Volume Deficit?
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What are common signs of Extracellular Fluid Volume Deficit?
What are common signs of Extracellular Fluid Volume Deficit?
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What laboratory finding indicates Extracellular Fluid Volume Deficit?
What laboratory finding indicates Extracellular Fluid Volume Deficit?
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Sodium and water intake greater than output causes Extracellular Fluid Volume Excess.
Sodium and water intake greater than output causes Extracellular Fluid Volume Excess.
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What is hypernatremia?
What is hypernatremia?
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Which hormone is involved in water retention leading to hypernatremia?
Which hormone is involved in water retention leading to hypernatremia?
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What can cause hyponatremia?
What can cause hyponatremia?
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What is Clinical Dehydration?
What is Clinical Dehydration?
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An electrolyte imbalance involves only the intake and absorption of electrolytes.
An electrolyte imbalance involves only the intake and absorption of electrolytes.
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Ca2+ is primarily stored in __________.
Ca2+ is primarily stored in __________.
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Match the electrolytes with their main intake sources:
Match the electrolytes with their main intake sources:
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What is acidosis?
What is acidosis?
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What is alkalosis?
What is alkalosis?
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What does an anion gap indicate?
What does an anion gap indicate?
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What is the composition of body fluids primarily made up of?
What is the composition of body fluids primarily made up of?
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The extracellular fluid (ECF) is located inside the cells.
The extracellular fluid (ECF) is located inside the cells.
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What is the difference between intravascular fluid and interstitial fluid?
What is the difference between intravascular fluid and interstitial fluid?
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Which of the following is an example of transcellular fluid?
Which of the following is an example of transcellular fluid?
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Which hormone regulates body fluid osmolality?
Which hormone regulates body fluid osmolality?
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Osmosis involves the movement of electrolytes across cell membranes.
Osmosis involves the movement of electrolytes across cell membranes.
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Which fluid compartments are involved in fluid distribution?
Which fluid compartments are involved in fluid distribution?
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What is fluid output primarily regulated by?
What is fluid output primarily regulated by?
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Which condition is associated with hypernatremia?
Which condition is associated with hypernatremia?
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Which of the following conditions can cause respiratory acidosis? (Select all that apply)
Which of the following conditions can cause respiratory acidosis? (Select all that apply)
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Why is thirst considered an important regulator of fluid intake?
Why is thirst considered an important regulator of fluid intake?
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Hypoventilation can lead to respiratory acidosis.
Hypoventilation can lead to respiratory acidosis.
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Hypercalcemia refers to low calcium levels in the blood.
Hypercalcemia refers to low calcium levels in the blood.
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What is a common sign of metabolic acidosis?
What is a common sign of metabolic acidosis?
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What laboratory finding indicates respiratory acidosis?
What laboratory finding indicates respiratory acidosis?
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Match each condition with its corresponding effect:
Match each condition with its corresponding effect:
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Light-headedness and confusion are signs of ______.
Light-headedness and confusion are signs of ______.
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What is a potential cause of metabolic alkalosis?
What is a potential cause of metabolic alkalosis?
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Increased bicarbonate levels can indicate metabolic acidosis.
Increased bicarbonate levels can indicate metabolic acidosis.
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Which of the following is a risk factor for acid-base imbalances? (Select all that apply)
Which of the following is a risk factor for acid-base imbalances? (Select all that apply)
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Which of the following factors can cause hypokalemia?
Which of the following factors can cause hypokalemia?
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What are the common symptoms of hypokalemia?
What are the common symptoms of hypokalemia?
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Hyperkalemia is characterized by low serum potassium concentration.
Hyperkalemia is characterized by low serum potassium concentration.
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Which condition is associated with hypercalcemia?
Which condition is associated with hypercalcemia?
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The laboratory finding for hypocalcemia shows total serum Ca2+ level below _____ mg/dL.
The laboratory finding for hypocalcemia shows total serum Ca2+ level below _____ mg/dL.
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What is a common physical examination finding in someone with hypomagnesemia?
What is a common physical examination finding in someone with hypomagnesemia?
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Which of the following is a sign of hypermagnesemia?
Which of the following is a sign of hypermagnesemia?
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What are enzymes?
What are enzymes?
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Metabolic acidosis is associated with decreased pH levels.
Metabolic acidosis is associated with decreased pH levels.
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What is the primary excretion system for carbonic acid?
What is the primary excretion system for carbonic acid?
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The measurement for overweight is a BMI of ___ to ___
The measurement for overweight is a BMI of ___ to ___
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What does the term 'alkalosis' refer to?
What does the term 'alkalosis' refer to?
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The measurement for obesity is a BMI of ___ or greater.
The measurement for obesity is a BMI of ___ or greater.
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Which of the following factors contributes to decreased energy needs in older adults?
Which of the following factors contributes to decreased energy needs in older adults?
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If electrolyte intake is _____ than output, a blood plasma deficit occurs.
If electrolyte intake is _____ than output, a blood plasma deficit occurs.
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Vitamin and mineral requirements change as people age.
Vitamin and mineral requirements change as people age.
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What dietary restriction is observed during Ramadan?
What dietary restriction is observed during Ramadan?
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Match the following eating disorders with their primary characteristics:
Match the following eating disorders with their primary characteristics:
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What are the causes of dysphagia?
What are the causes of dysphagia?
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What is the primary purpose of enteral nutrition?
What is the primary purpose of enteral nutrition?
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Parenteral nutrition is provided through the gastrointestinal tract.
Parenteral nutrition is provided through the gastrointestinal tract.
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What is the purpose of monitoring patients for signs of intolerance to tube feedings?
What is the purpose of monitoring patients for signs of intolerance to tube feedings?
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What is acidosis?
What is acidosis?
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What is alkalosis?
What is alkalosis?
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What is the anion gap?
What is the anion gap?
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What are the main types of body fluid compartments?
What are the main types of body fluid compartments?
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Which of the following is a positively charged ion (cation)?
Which of the following is a positively charged ion (cation)?
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What does isotonic mean?
What does isotonic mean?
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What role does antidiuretic hormone (ADH) play in fluid balance?
What role does antidiuretic hormone (ADH) play in fluid balance?
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What is the normal range for osmolality?
What is the normal range for osmolality?
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Match the following fluid types with their descriptions:
Match the following fluid types with their descriptions:
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What factors increase the secretion of ADH?
What factors increase the secretion of ADH?
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Hypernatremia is a condition characterized by low sodium levels in the body.
Hypernatremia is a condition characterized by low sodium levels in the body.
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Fluid homeostasis involves only fluid intake.
Fluid homeostasis involves only fluid intake.
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What characterizes Isotonic Imbalances?
What characterizes Isotonic Imbalances?
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Extracellular Fluid Volume Deficit occurs when body fluids have decreased volume but increased osmolality.
Extracellular Fluid Volume Deficit occurs when body fluids have decreased volume but increased osmolality.
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Give one cause of ECV deficit.
Give one cause of ECV deficit.
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Which of the following is a sign of ECV deficit?
Which of the following is a sign of ECV deficit?
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In hypernatremia, the body fluids are too ______.
In hypernatremia, the body fluids are too ______.
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What laboratory finding is indicative of hypernatremia?
What laboratory finding is indicative of hypernatremia?
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Hyponatremia is characterized by having more salt than water in the body fluids.
Hyponatremia is characterized by having more salt than water in the body fluids.
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What is one cause of hyponatremia?
What is one cause of hyponatremia?
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Which of the following is a process that can lead to electrolyte imbalance?
Which of the following is a process that can lead to electrolyte imbalance?
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Match the electrolyte with its primary source:
Match the electrolyte with its primary source:
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What is one cause of respiratory acidosis?
What is one cause of respiratory acidosis?
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Which sign is associated with metabolic acidosis?
Which sign is associated with metabolic acidosis?
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Respiratory alkalosis is caused by hypoventilation.
Respiratory alkalosis is caused by hypoventilation.
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What laboratory finding indicates respiratory acidosis?
What laboratory finding indicates respiratory acidosis?
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What can cause respiratory muscle weakness?
What can cause respiratory muscle weakness?
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Acute pain can lead to _______________.
Acute pain can lead to _______________.
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What is one symptom of metabolic alkalosis?
What is one symptom of metabolic alkalosis?
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Oliguric renal disease can lead to metabolic acidosis.
Oliguric renal disease can lead to metabolic acidosis.
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Which electrolyte imbalance is often found in metabolic alkalosis?
Which electrolyte imbalance is often found in metabolic alkalosis?
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What is the primary cause of metabolic acidosis?
What is the primary cause of metabolic acidosis?
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Excessive sodium bicarbonate administration can cause metabolic acidosis.
Excessive sodium bicarbonate administration can cause metabolic acidosis.
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What condition is caused by low serum potassium (K+) concentration?
What condition is caused by low serum potassium (K+) concentration?
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What is a common cause of hyperkalemia?
What is a common cause of hyperkalemia?
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What is the physical examination finding for hypokalemia?
What is the physical examination finding for hypokalemia?
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Increased calcium levels in the blood condition is known as _____
Increased calcium levels in the blood condition is known as _____
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What is a symptom of hypocalcemia?
What is a symptom of hypocalcemia?
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Hypomagnesemia refers to increased levels of magnesium in the serum.
Hypomagnesemia refers to increased levels of magnesium in the serum.
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What is a primary cause of hypomagnesemia?
What is a primary cause of hypomagnesemia?
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Match the following electrolytes with their common imbalances:
Match the following electrolytes with their common imbalances:
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What acid does the lungs excrete?
What acid does the lungs excrete?
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What pH value range is considered normal?
What pH value range is considered normal?
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Respiratory acidosis is caused by an increase in pH.
Respiratory acidosis is caused by an increase in pH.
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What are enzymes?
What are enzymes?
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What is the BMI range for overweight individuals?
What is the BMI range for overweight individuals?
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What age group experiences a decreased need for energy due to a slower metabolic rate?
What age group experiences a decreased need for energy due to a slower metabolic rate?
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All older adults experience increased appetite.
All older adults experience increased appetite.
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The BMI for obesity is a measurement of _____ or greater.
The BMI for obesity is a measurement of _____ or greater.
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Which of the following is a dietary restriction for Ramadan fasting?
Which of the following is a dietary restriction for Ramadan fasting?
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What characterizes bulimia nervosa?
What characterizes bulimia nervosa?
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Name a possible cause of dysphagia.
Name a possible cause of dysphagia.
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Patients with dysphagia often show overt signs like coughing when food enters the airway.
Patients with dysphagia often show overt signs like coughing when food enters the airway.
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Which of the following is a stage of diet progression for dysphagia?
Which of the following is a stage of diet progression for dysphagia?
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What is enteral nutrition (EN)?
What is enteral nutrition (EN)?
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Parenteral nutrition is given through the gastrointestinal tract.
Parenteral nutrition is given through the gastrointestinal tract.
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The procedure of cleaning a central venous catheter involves using _____ before and after each use.
The procedure of cleaning a central venous catheter involves using _____ before and after each use.
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What is a complication of parenteral nutrition?
What is a complication of parenteral nutrition?
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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
- Nonfunctioning GI Tract
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:
- 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.
- Identify patient using at least two identifiers.
- Review patient's medication record for orders for enteral feeding, a gastric acid inhibitor, or a proton pump inhibitor.
- Review patient's medical record for history of prior tube displacement.
- Observe for signs and symptoms of respiratory distress during feeding: coughing, choking, or reduced oxygen saturation.
- Identify conditions that increase risk for spontaneous tube migration or dislocation: altered level of consciousness, agitation; retching, vomiting; nasotracheal suction.
- Perform hand hygiene. Assess bowel sounds and perform abdominal examination.
- Obtain pulse oximetry reading.
- Note ease with which previous tube feedings infuse through tubing. Monitor volume of continuous enteral formula administered during shift and compare with ordered amount.
- Assess patient's or family caregiver's knowledge, experience, and health literacy.
- Perform hand hygiene and apply clean gloves. Be sure pulse oximeter is in place.
- 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
- Dysfunction of brainstem respiratory control
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.
- Contributes to obesity, 68.7% of Americans are either overweight or obese.
-
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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Test your knowledge about human body fluid compartments, electrolytes, and their functions. This quiz will cover the roles of extracellular and intracellular fluids, as well as normal lab values for osmolality. Challenge yourself and enhance your understanding of human physiology!