Electrolytes - Chapter 17 PDF

1/13: Electrolytes - Chapter 17 Potassium (3.5-5 mEq/L) Action: Effects muscles/nerves Storage: Potassium is mostly intracellular (not a lot in blood/serum) -​ Small variations in potassium make a big difference due to small range in blood Sources: bananas, DGL, potatoes, avocados -​ Excret...

1/13: Electrolytes - Chapter 17 Potassium (3.5-5 mEq/L) Action: Effects muscles/nerves Storage: Potassium is mostly intracellular (not a lot in blood/serum) -​ Small variations in potassium make a big difference due to small range in blood Sources: bananas, DGL, potatoes, avocados -​ Excreted by kidneys Relationship to insulin: allows glucose AND potassium to exit bloodstream and enter cells Hyperkalemia -​ Causes: -​ Decreased renal functioning (can’t eliminate enough K) -​ Meds: K sparing diuretic (spironolactone) -​ GI dysfunction: Diarrhea, vomiting ? -​ S/sx: -​ Cardiac arrhythmias (have to be on telemetry and get EKG) -​ Muscle weakness -​ Treatments: -​ Stop intake (dietary restriction) -​ Increase output -​ K wasting diuretics (furosemide) **as long as patient can pee/doesn't have urinary retention -​ Sodium polystyrene (kayexalate): osmotic laxative enema **no immediate effect, so use for hyperkalemic patients with no major arrhythmias/not best option in an emergency -​ Hide it (insulin) -​ Give Dextrose (D50) with insulin: to make potassium move from the blood serum into cells -​ Good emergency option for cardiac arrhythmias, but temporary solution so follow up with another treatment within a few hours -​ Block it’s action -​ Calcium gluconate: decreases arrhythmias (block action of potassium on the heart) Hypokalemia -​ Causes -​ Meds: K wasting diuretics (furosemide) and Thiazide diuretic (HCTZ) -​ GI loss: diarrhea, vomiting -​ NG suctioning -​ S/sx: muscle cramping/weakness -​ Treatments -​ Stop K wasting diuretics and add K sparing diuretics -​ Stop the loss (give antiemetic, antidiarrheal) -​ Increase K in diet -​ IV Potassium replacement (aka IV potassium run- give multiple bags back to back) -​ Hang 10 mEq bag, when it runs out hang another 10 or 20 mEq bag, repeat again- over span of 3-4 hours, don't give more than 10 mEq per hour  -​ IV should be in AC or forearm; never use hand IV for K run -​ Dilute with normal saline or slow drip rate, or it will burn the patient Calcium (9-10.5 mEq/L) Action: effects nerves/muscles and bones/bone density, clotting -​ Control over smooth muscles (trachea, heart, GI, around veins) -​ Control over nerves Storage: stored in bones Sources: dairy, DGL, broccoli Regulation: -​ Parathyroid hormone determines how much dietary calcium needs to be absorbed into blood -​ Vitamin D helps calcium absorb into bone from blood serum Relationship to phosphorus: inverse Hypercalcemia -​ Causes -​ Immobility hypercalcemia: calcium leaves bones and enters blood stream -​ Hyperparathyroidism (too much PTH): PTH overcorrects and pulls too much calcium from bones into the blood serum -​ S/sx: -​ Fatigue: bones and muscles working constantly and causes fatigue -​ Bone pain -​ Fractures: losing bone density -​ Elevated BP: vasculature surrounded by smooth muscle contracts and constricts veins -​ Some EKG changes: bc smooth muscle of heart -​ Kidney stones (calcium stones) -​ Low phosphorus -​ Treatment -​ Movement: weight bearing activity will bring more calcium into bone and out of blood serum -​ Increase fluid intake to prevent kidney stones (more urine flowing prevents crystallizations) -​ Bisphosphonates (alendronate [Fosamax], risedronate [Actonel]): helps prevent bone breakdown and stops release of calcium -​ Often seen in osteoporosis patients -​ Give Vitamin D (cholecalciferol): decrease serum calcium by helping calcium enter bones -​ Monitor PTH levels Hypocalcemia -​ Causes -​ Renal disease (only electrolyte that decreases in renal failure- bc kidneys can’t produce Vit D) -​ Decreased PTH (parathyroidectomy, hypoparathyroidism) -​ Inadequate calcium intake, inadequate vitamin D intake (vit D helps uptake of calcium into bone) -​ S/sx: -​ Decrease in BP: relaxation of muscles around vasculature -​ Hyperreflexia: due to increased excitability of neurons (chvostek and trousseau) -​ Chvostek: tap on masseter muscle and if facial muscles twitch=positive chvostek  -​ Trousseau: inflate bp cuff greater than pt normal systolic and hold for 3 minutes; if hand and wrist draws in towards body and flexes = positive trousseau -​ Treatment -​ Oral replacement (oyster shell calcium with vitamin D) -​ IV replacement (calcium gluconate) - need to put on heart monitor -​ Give bisphosphonates (alendronate [Fosamax], risedronate [Actonel]); to prevent bone breakdown -​ Do frequent neuro checks, seizure precautions Magnesium (1.3-2.1 mEq/L) Action: decrease muscle contraction and relax muscles Storage: in muscles, but mostly get from dietary intake Sources: DGL, nuts, whole grains Regulation: regulated by kidneys Hypermagnesemia -​ Causes -​ Overuse of antacids (tums) -​ Renal failure (kidneys don’t excrete enough) -​ S/sx: decrease in… -​ BP, pulse, respirations -​ DTR, muscle tone -​ LOC -​ Increased flushing/warmth -​ Treatment -​ Give calcium gluconate slowly (blocks the effects of magnesium) -​ Dialysis for kidneys (filters out magnesium) -​ Ventilator (treat decreased respirations) Hypomagnesemia -​ Causes: -​ Not enough dietary intake -​ Absorbative issues, crohn’s (IBD), IBS (losing magnesium) -​ Alcohol dependence -​ S/sx: -​ Elevated BP -​ Cardiac problems, EKG changes -​ Treatments -​ Supplemental magnesium (or IV magnesium for pt with absorptive issues) Sodium (135-145 mEq/L) Action: effects nerves/muscles and fluid movement Storage: most sodium is extracellular, found in blood serum -​ mostly comes from dietary intake Sources: processed foods Relationship with HTN: pt with HTN should decrease sodium (water follows salt into bloodstream which would increase pressure) Hypernatremia -​ Causes -​ Too little water -​ Not enough in: nonverbal/can’t verbalize thirst, children, tube feeds (need to make sure these pt are getting flushed w water) -​ Too much loss: excess urine output (Diabetes insipidus, osmotic diuretics [mannitol], thiazide diuretics [HCTZ] -​ Too much sodium -​ Too much in diet -​ Adrenal dysfunction: too much aldosterone (aldosterone keeps sodium in body) -​ S/sx: dehydration -​ Dry mouth and tissues, thirst -​ Cerebral shrinking→neuro changes -​ Elevated BP: fluids shift into vascular system -​ Some tachycardia -​ Treatment -​ Increase fluid -​ Monitor I&O and daily weight, neuro checks Hyponatremia -​ Causes: -​ Too little sodium -​ Diuretics -​ GI loss -​ Too much water -​ SIADH: syndrome of inappropriate ADH (too much ADH=body holds on to too much water) -​ Water intoxication (psychogenic polydipsia) -​ S/sx: -​ Edema: not enough sodium to hold water in vascular system- water enters tissues and causes edema -​ Pulmonary edema (fluid in lungs, shallow breaths) -​ Cerebral edema (neuro changes) -​ If a pt is bed bound, edema may be more present in back and butt- risk for ulcers -​ Treatment: -​ Add sodium (IV fluids/saline) -​ Fluid restriction -​ Administer osmotic diuretics 1/27: Fluids and Parenteral Nutrition Fluid volume deficit Causes -​ Excessive loss -​ Sweating (fever) -​ Diarrhea, vomiting -​ Diuretics -​ Addison’s disease (adrenal insufficiency) - too little aldosterone: aldosterone pulls sodium into vascular system and fluid follows -​ Inadequate intake -​ Can’t treat own thirst (mental health disorder, no access to water) -​ Excessive hypertonic intake (tube feedings pt don't get enough water) Manifestations (2 types of fluid volume deficits) -​ Dehydration (less severe) -​ Water is pulled from tissues into vascular system to replace deficit -​ Vascular volume maintained, but tissues are depleted -​ Dry mouth and skin, thirst, concentrated urine -​ BP and HR stay normal -​ No signs of poor perfusion -​ Hypovolemia (more severe) -​ Water can’t shift from tissues into vascular system because it has been depleted -​ Not enough fluid in tissues and vascular system -​ BP and HR changes (hypotension) -​ Poor perfusion, cyanosis, slow cap refill -​ Decreased LOC -​ Decreased renal function Labs: -​ Urine specific gravity > 1.03 (means that urine is concentrated) -​ Hct > 52% (male) and >47% (female) - high due to concentration of blood cells -​ BUN increase when creatinine does not (kidney function) S/sx -​ Thirst/dry mucous membranes/skin tenting (fluid shift out of tissues) -​ Cold clammy skin (decreased perfusion) -​ Hypotension (not enough fluid in vascular space) -​ Increased HR and RR -​ Decreased urine output, increased urine osmolality (concentration) -​ Weakness, dizziness (decreased perfusion to brain and muscles) -​ Confusion/lethargy (decreased perfusion to brain) -​ Seizures (fluid exits brain tissue and brain cells shrink) -​ Weight loss Orthostatic vitals (take BP and HR) -​ Have pt lay flat for 2 mins and take vitals, sit up for 2 mins take vitals, stand up for 2 min and take vitals Fluid volume excess Causes -​ Too much sodium and water -​ Sodium is extracellular (in vascular system), and pulls water into vascular system -​ Heart disease, kidney and liver disease -​ Isotonic: everything is equalized -​ Too much water -​ Excess intake -​ Hypotonic -​ Wrong IVF -​ SIADH: too much ADH=body holds on to too much water (pituitary dysfunction) S/sx -​ Peripheral edema -​ JVD -​ S3: atrial and pulmonic valves close twice from slowed emptying -​ Increased BP and bounding pulse -​ Polyuria: excessive urination -​ Dyspnea, crackles, pulmonary edema (with pink frothy sputum): fluid back up in lungs -​ Weight gain: 1 L of water = 2.2lbs -​ Headache, confusion, lethargy: cerebral edema -​ Seizures, coma: cerebral edema Third Spacing (simultaneous fluid volume deficit and excess) Fluid shifts into part of body that it shouldn't be in -​ Ex: ascites (fluid accumulates in belly) -​ Looks like edema, but is different Vascular volume is low bc fluid moves out of vascular system and into tissues Cause: liver disease (excessive drinking), SIADH Treat: move fluid back into vascular space, using proteins (albumin) -​ Don't need extra fluids, need to shift fluid back into vascular system -​ Treat underlying cause of third spacing Assessing fluid status I&Os -​ Intake: orally, IVF and IVabx, liquid foods (ice cream, jello), fluid nutrition -​ Output: urine, liquid stools, emesis, suctioning, wound drainage Weight: be consistent with time of day, clothing Edema: -​ Dependent edema: lower extremities when standing (in butt/back when bed bound) - gravity pulling down -​ Anasarca: total body edema -​ Ascites: in abdomen (late sign of liver failure) -​ Pitting edema: measured in mm -​ Brawny: skin is tight and smooth/shiny Assess perfusion: bilateral pulses, vital signs, cap refill Mucous membranes and skin turgor Mentation Labs -​ Urine specific gravity, Hct and Hbg, BUN -​ BNP: released when too much stretch on atria of heart (increased BNP=fluid volume excess) Replacing fluids Easiest way: using the gut (drink more, NG tube, G tube) IVF -​ Tonicity: how much solute is in the fluid (osmolarity) -​ Hypotonic solutions: lower amount of solute -​ Solution wants to go Out of the vessel, enters cell + cell gets bigger -​ 0.45% Normal saline (half normal saline) -​ 0.33% Normal saline -​ Good for pt with hypertension, renal/cardiac disease, dilution with hypernatremia -​ Isotonic solutions: equal amount of solute to solvent -​ Stay where I put it; want vascular volume to stay where its at (not trying to move fluid into or out of vessel) -​ 0.9% NaCl -​ D5W (Dextrose 5% in water) -​ Lactated Ringers (solution with electrolytes) -​ Hypertonic solution: more solute -​ Volume inside cell exits and Enters vascular system -​ D10W -​ 3% Normal saline -​ 5% normal saline -​ D5LR -​ D5 ½ normal saline (0.45%) -​ D5 normal saline -​ TPN -​ Albumin -​ Good for pt w third spacing, -​ KVO: give fluids slowly just to keep vein open -​ Normal plasma: 280-295 -​ Colloids: IVF composed of large molecules -​ Hypertonic fluid -​ Ex: -​ PRBCs (packed red blood cells) -​ Albumin IV access -​ Peripheral -​ Midlines: catheter inserted into peripheral vein and ends in peripheral vein -​ 3-8 in catheter -​ Usually brachial, cephalic or basilic -​ Purpose: lasts longer than peripheral IV -​ Regular peripheral  -​ Central lines: catheter ends in a central vein -​ Can give large quantities of fluids bc blood volume in central veins is large -​ Can be inserted anywhere, but always ends in a central vein (superior vena cava) -​ PICC -​ Tunneled: first part under the skin, then goes into vein under skin after a few inches (decreases infx risk) -​ IV access (indwelling port) -​ Port on patient’s chest under skin (Inject with huber needle) Parenteral nutrition Hyperalimentation -​ Parenteral nutrition (nutrition given via vein) -​ Mixture of dextrose, electrolytes, minerals, Amino acids -​ Max amount of dextrose that can be given in peripheral line is 10% (if greater than 10%, dextrose needs to be given in central line) - bacteria likes sugar -​ Change tubing every 24 hrs -​ Never abruptly stop TPN -​ Designated line JUST for TPN -​ Hyperal filter always required Intralipids -​ Fat emulsion (chunks); filter is always required TPN: total parenteral nutrition -​ TPN = hyperalimentation + lipids -​ Used when pt can’t absorb nutrients through gut -​ Malabsorption -​ GI obstruction -​ GI bleeds -​ GI surgery (crohn’s, resection, bowel cancer, etc) -​ Pancreatitis -​ Decrease stimulation of gut to focus on other organ systems in critically ill pt -​ Complications of TPN -​ Thrombosis: clot (due to high fat content or crystals from sugar) -​ Hyperglycemia: due to dextrose -​ Infection: bacteria likes sugar Lab Review: Oxygen and IV setup Oxygen flow rate -​ Meter ball shows how many L/min -​ Regular room air: 21% O2 -​ 1L/min: 24% O2 -​ 2L/min: 28% -​ 3L/min: 32% Nasal cannula -​ Watch out for pressure points -​ Add humidification (sterile water) -​ Add extension tubing Simple face mask -​ Openings on the side so that CO2 exhaled can exit -​ Have to have at least 5L to prevent rebreathing exhaled air -​ 5 L/min Non rebreather -​ Face mask with bag attached; bag collects 100% O2 and side valves close during inhalation -​ Exhaled air escapes through valves -​ Used for patients who need 100% O2 -​ 10-15 L/min Venturi mask/venti mask -​ Multiple attachments that provide different precise amounts of O2 (ex: 40% at 8L) -​ Or change % O2 with dial on wall Nebulizer mask -​ Nebulize medications with O2 of air (if not on O2) IV gauge colors 16: grey 18: green 20: pink 22: blue