Condensed Study Guide for Exam 3 PDF

[STUDY GUIDE FOR EXAM 3] [NUTRITION AND FLUID, ELECTROLYTE AND ACID BALANCE] [CHAPTER 42] Acidosis Alkalosis Anion Gap Buffers Extracellular fluid Extracellular volume Extracellular volume excess Extracellular volume deficit Hypercalcemia Hypocalcemia Hyperkalemia Hypokalemia Hypernat...

[STUDY GUIDE FOR EXAM 3] [NUTRITION AND FLUID, ELECTROLYTE AND ACID BALANCE] [CHAPTER 42] Acidosis Alkalosis Anion Gap Buffers Extracellular fluid Extracellular volume Extracellular volume excess Extracellular volume deficit Hypercalcemia Hypocalcemia Hyperkalemia Hypokalemia Hypernatremia Hyponatremia Hypertonic Hypotonic Isotonic Hypomagnesemia Hypermagnesemia Hypovolemia Hypervolemia Interstitial Fluid Intracellular Fluid Intravascular Fluid Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis Respiratory Alkalosis Osmolality Osmosis Filtration Osmotic pressure Oliguria- decreased urine output or end stage renal disease **[Fluid and Electrolyte or Acid-Base Imbalances]** Adult Male- 60% body weight is water Older Adult Male-50% body weight is water (decreases with age) **[Body fluid-]** Is located in 2 distinct compartments - Extracellular fluid (ECF) outside of cells - Intracellular fluid (ICF) located inside cells **[ECF]**- Has 2 Major Divisions - Intravascular Fluid- (liquid part of blood) - Interstitial Fluid- (located between cells outside of the blood vessels) **[Transcellular Fluid-]** Are secreted by epithelial cells - Cerebral Spinal Fluid - Pleural - Peritoneal - Synovial **[Composition of Body Fluids-]** Compounds that separate into ions (charged particles) **[Positively charged ions are called cations]** - Sodium (Na+) - Potassium (K+) - Calcium (Ca+) - Magnesium (Mg 2+) - Chloride (Cl-) - Bicarbonate (HCO 3-) BOTH ANIONS AND CATIONS COMBINE TO MAKE SALT **[Normal Lab Values]** - Osmolality- 285-295 **[Electrolytes]** - Sodium (Na+)- 136-145 - Potassium (K+)- 3.5-5.0 - Chloride (Cl-)- 98-106 - Total CO2- 23-30 - Bicarbonate (HCO3-)21-28 - Total Calcium (Ca2+)-9.0-10.5 - Ionized Calcium (Ca2+)-4.5-5.6 - Magnesium (Mg2+)- 1.3-2.1 - Phospate-3.0-4.5 - Anion Gap-6+/-4 mEq/L - pH-7.35 to 7.45 - PaCO2- 35 to 45 - PaO2-80-100 - HCO3- 21 to 28 - O2 Saturation- 95% to 100% - Base Excess -2 to +2 mmEq/L **[Fluid-]**Contains a large number of dissolved particles is more concentrated than the same amount of fluid that contains only a few particles **[Osmolality-]** Number of particles in per kg of water, (Na+) does not pass easily through the cell membrane. Particles that cannot cross the cell membranes easily determine the tonicity (effective concentration) of a fluid. **[Isotonic-]**Fluid with the same tonicity of blood, cells are normal **[Hypotonic-]** (Remember Hippo) is more dilute than blood, cells enlarge **[Hypertonic-]**(Remember Hyper/Active) is less dilute, more concentrated, cells shrink Diagram of cell membrane and cell shrinks Description automatically generated with medium confidence **[MOVEMENT OF WATER AND ELECTROLYTES]** **[Active Transport-]**Requires energy in the form of ATP to move electrolytes across cell membranes against the concentration gradient (from areas of lower concentration to areas of higher concentration) **[Diffusion-]**Passive movement of electrolytes or other particles down a concentration gradient (from areas of higher concentration to areas of lower concentration) with diffusion of electrolytes across the cell membranes it requires proteins that serve as ion channels. **[Osmosis-]**A process by with water moves through a membrane that separates fluids with different particles of concentration (water moves across the membrane) if particle concentration in interstitial compartment changes osmosis occurs. **[Filtration-]**Fluid moving into and out of the capillaries (between the vascular & interstitial compartments) The net effect of forces (4 of them) (2 of them move fluid out of the capillaries)(2 of them move fluid back into the capillaries) **[Hydrostatic pressure-]**is the force of fluid pressing outward against a surface.  A diagram of a blood vessel Description automatically generated **[Colloid-]** is albumin and other proteins in the blood. A Colloid is a larger particle that stay in the blood stream, they are to large to pass through the capillaries, colloids exsert osmotic pressure. **[Osmotic Pressure or Oncotic Pressure-]**Is the inward pulling force caused by blood proteins that helps move fluid from the interstitial area back into the capillaries. **[Edema-]**a collection of fluid that remains in the interstitial space. - Heart Failure (HF) - Congestive Heart Failure (CHF) **[FLUID BALANCE]** Fluid homeostasis consists of 3 processes - Fluid intake and absorption - Fluid Distribution - Fluid Output To maintain this balance input must be the same as output. Sometimes we lose fluid through sweat and hypotonic solution, we must stay hydrated. We can also achieve fluid intake through IV, rectal enemas, and irrigation of body cavities during surgery. **[AVERAGE FLUID INTAKE AND OUTPUT]** Normal (per Day) Prolonged Heavy **Fluid Intake** +-----------------------+-----------------------+-----------------------+ | Fluids ingested, oral | 1100--1400 mL | 280--1100 mL/hr | | | | | | Foods | 800--1000 mL | Highly variable | | | | | | Metabolism | 300 mL | 16--50 mL/hr | | | | | | ***Total*** | ***2200--2700 mL*** | ***300--1150 mL/hr*** | | | | | | **Fluid Output** | 500--600 mL | 300--2100 mL/hr | | | | | | Skin (insensible and | 400 mL | 20 mL/h | | sweat) | | | | | 100--200 mL | Negligible, unless | | Insensible lungs | | diarrhea during | | | 1200--1500 mL | exercise | | Gastrointestinal | | | | | ***2200--2700 mL*** | 20--1000 mL/hr, | | Urine | | depending on | | | | hydration status | | ***Total*** | | | | | | ***340--3120 mL/hr*** | +=======================+=======================+=======================+ | | | Rehydration with | | | | Na+-containing fluid | | | | necessary after | | | | prolonged vigorous | | | | exercise | +-----------------------+-----------------------+-----------------------+ **[Thirst-]**Is a conscious desire for water and is an important regulator of fluid intake when plasma osmolality increases or blood volume decreases. - Thirst control mechanism is located in the hypothalamus in the brain. Osmoreceptors continually monitor plasma osmolality; where increased, they cause stimulations of the neurons in the hypothalamus. This causes issues for people who cannot communicate thirst, (infants, patients with neurological disorders, psychosocial problems, and some older adults)  **[Fluid Distribution-]**Refers to the movement of fluid among its various compartments - Distribution between extracellular and intracellular (Osmosis) - Distribution between vascular and interstitial parts of the ECF (Filtration) **[Fluid Output-]**4 organs contribute to fluid output 1. Skin 2. Lungs 3. GI tract 4. Kidneys **[Abnormal Output-]**several factors are involved with abnormal output 1. Vomiting 2. Wound drainage 3. Hemorrhage 4. Fever 5. Burn to skin 6. Diarrhea **[Normal Output-]**How our bodies regularly excrete fluid from our bodies *Insensible (not visible)* 1. Skin-Continuous 2. Lungs-Continuous 1. Sweat 2. GI Tract 3. Feces NOTE: When a person loses more fluid in their output than they take in- an adjustment takes place/primarily caused by antidiuretics (ADH), the renin angiotensin aldosterone system (RAAS) and atrial natriuretic peptides (ANP) Diagram of a diagram showing the internal organs of a human heart Description automatically generated **[Antidiuretic Hormone (ADH)]** Regulates the osmolality of body fluid by influencing how much water is excreted in the urine. 1. Synthesized by neurons in the hypothalamus that release it from the pituitary gland 2. It circulates in the blood and kidneys where it acts on collecting ducts 3. It causes renal cells to reabsorb water, while diluting the blood by adding water. **[Factors that increase (ADH)]** - Severely decreased blood volume - Pain - Stressors - Medication **[Factors that decrease (ADH)]** - Levels become too dilute **[Renin -- angiotensin- aldosterone system (RAAS)]** Regulates ECF volume by influencing how much sodium and water are excreted in the urine. It also contributes to the regulation of blood pressure. - Special cells release renin in the kidneys - Renin converts to angiotensinogen to angiotensin I - Angiotensin I convert to angiotensin II by way of other enzymes in the lung capillaries - Angiotensin II is a vasoconstrictor in some vascular beds - Fluid homeostasis function of angiotensin II stimulate aldosterone which releases from the adrenal cortex - Aldosterone circulates to the kidneys - It reabsorbs sodium and water in the distal renal tubules - Renal tubules remove sodium and water and return it to the blood and it increases the volume of ECF. - Aldosterone also contributes to electrolyte and acid base balance, by increasing urinary excretion of potassium and hydrogen ions. - Certain stimuli can increase or decrease activity - Hemorrhage decreases ECV - Vomiting When blood flow is decreased more renin is released this increase of sodium and water retention is helping to restore ECV. **[Arterial Natriuretic Peptide (ANP)]** Regulates ECV by influencing how much sodium and water are excreted in the urine. Cells in the atria of the heart release ANP when they are stretched. **[Factors affecting ANP]** - Medication - Diarrhea - Alcohol - Sweat - Fever - Trauma/blood loss - Not drinking enough liquids - Vomiting - Disease 2 Major types of fluid imbalance are - Volume imbalance - Osmolality imbalance **[Volume Imbalance-]**The amount of fluid in the extracellular compartment. **[Osmolality Imbalance-]**Disturbances of the concentration of body fluids NOTE: Both volume and osmolality imbalance can occur separately or together.  **[FLUID IMBALANCES]** +-----------------------------------+-----------------------------------+ | Imbalance and Related Causes | | | Signs and Symptoms | | +===================================+===================================+ | Isotonic Imbalances---Water and | | | Sodium Lost or Gained in Equal or | | | Isotonic Proportions | | +-----------------------------------+-----------------------------------+ | **Extracellular Fluid Volume | | | Deficit---Body Fluids Have | | | Decreased Volume but Normal | | | Osmolality** | | +-----------------------------------+-----------------------------------+ | ***Sodium and Water Intake Less | ***Physical examination:*** | | Than Output, Causing Isotonic | Sudden weight loss (overnight), | | Loss:*** | postural hypotension, | | | tachycardia, thready pulse, dry | | Severely decreased oral intake of | mucous membranes, poor skin | | water and salt | turgor, slow vein filling, flat | | | neck veins when supine, dark | | ***Increased GI output:*** | yellow urine | | vomiting, diarrhea, laxative | | | overuse, drainage from fistulas | ***If severe:*** Thirst, | | or tubes | restlessness, confusion, | | | hypotension; oliguria (urine | | ***Increased renal output:*** use | output below 30 mL/hr); cold, | | of diuretics, adrenal | clammy skin; hypovolemic shock | | insufficiency (deficit of | | | cortisol and aldosterone) | ***Laboratory findings:*** | | | Increased hematocrit; increased | | ***Loss of blood or plasma:*** | BUN above 20 mg/dL (7.1 mmol/L) | | hemorrhage, burns | (hemoconcentration); urine | | | specific gravity usually above | | Massive sweating without water | 1.030, unless renal cause | | and salt intake | | +-----------------------------------+-----------------------------------+ | **Extracellular Fluid Volume | | | Excess---Body Fluids Have | | | Increased Volume but Normal | | | Osmolality** | | +-----------------------------------+-----------------------------------+ | ***Sodium and Water Intake | ***Physical examination:*** | | Greater Than Output, Causing | Sudden weight gain (overnight), | | Isotonic Gain:*** | edema (especially in dependent | | | areas), full neck veins when | | Excessive administration of | upright or semi-upright, crackles | | Na+-containing isotonic IV fluids | in lungs | | or oral intake of salty foods and | | | water | If severe: Confusion, pulmonary | | | edema | | ***Renal retention of Na+ and | | | water:*** Heart failure, | ***Laboratory findings:*** | | cirrhosis, aldosterone or | Decreased hematocrit, decreased | | glucocorticoid excess, acute or | BUN below 10 mg/dL (3.6 mmol/L) | | chronic oliguric renal disease | (hemodilution) | +-----------------------------------+-----------------------------------+ | **Osmolality Imbalances** | | | | | | **Hypernatremia (Water Deficit; | | | Hyperosmolar Imbalance)---Body | | | Fluids Too Concentrated** | | +-----------------------------------+-----------------------------------+ | ***Loss of Relatively More Water | ***Physical examination:*** | | Than Salt:*** | Decreased level of consciousness | | | (confusion, lethargy, coma), | | Diabetes insipidus (ADH | perhaps thirst, seizures if | | deficiency) | develops rapidly or is very | | | severe | | Osmotic diuresis | | | | ***Laboratory findings:*** Serum | | Large insensible perspiration and | Na+ level above 145 mEq/L (145 | | respiratory water output without | mmol/L), serum osmolality above | | increased water intake | 295 mOsm/kg (295 mmol/kg) | | | | | ***Gain of Relatively More Salt | | | Than Water:*** | | | | | | Administration of tube feedings, | | | hypertonic parenteral fluids, or | | | salt tablets | | | | | | Lack of access to water, | | | deliberate water deprivation, | | | inability to respond to thirst | | | (e.g., immobility, aphasia) | | | | | | Dysfunction of | | | osmoreceptor-driven thirst drive | | +-----------------------------------+-----------------------------------+ | **Hyponatremia (Water Excess; | | | Water Intoxication; Hypoosmolar | | | Imbalance)---Body Fluids Too | | | Dilute** | | +-----------------------------------+-----------------------------------+ | ***Gain of Relatively More Water | ***Physical examination:*** | | Than Salt:*** | Decreased level of consciousness | | | (confusion, lethargy, coma), | | Excessive ADH (SIADH) | seizures if develops rapidly or | | | is very severe | | Psychogenic polydipsia or forced | | | excessive water intake | ***Laboratory findings:*** Serum | | | Na+ level below 136 mEq/L (136 | | Excessive IV administration of | mmol/L), serum osmolality below | | D5W | 285 mOsm/kg (285 mmol/kg) | | | | | Use of hypotonic irrigating | | | solutions | | | | | | Tap-water enemas | | | | | | ***Loss of Relatively More Salt | | | Than Water:*** | | | | | | Replacement of large body fluid | | | output (e.g., diarrhea, vomiting) | | | with water but no salt | | +-----------------------------------+-----------------------------------+ | **Combined Volume and Osmolality | | | Imbalance** | | | | | | **Clinical Dehydration (ECV | | | Deficit Plus | | | Hypernatremia)---Body Fluids Have | | | Decreased Volume and Are Too | | | Concentrated** | | +-----------------------------------+-----------------------------------+ | ***Sodium and Water Intake Less | ***Physical examination and | | Than Output, With Loss of | laboratory findings:*** | | Relatively More Water Than | Combination of those for ECV | | Salt:*** | deficit plus those for | | | hypernatremia (see previous | | All of the causes of ECV deficit | signs) | | (see previous causes) plus poor | | | or no water intake, often with | | | fever causing increased | | | insensible water output | | +-----------------------------------+-----------------------------------+ **[ABBREVIATIONS]** **ADH-**ANTIDIURETIC HORMONE **BUN-**BLOOD UREA NITROGEN **D5W-**DEXTROSE IN WATER **ECV-**EXTRACELLULAR FLUID VOLUME **GI-**GASTROINTESTINAL TRACT **IV-**INTROVENEOUS **SIADH-**SYNDROME OF INAPPROPRIATE SECRETION OF ANTIDIURETIC HORMONE **[Extracellular Volume Excess-]**Occurs when there is too much isotonic fluid in the extracellular compartment (more salt than water) **[Osmolality Imbalances (HYPER or HYPOTONIC)]** **[Hypernatremia-]**Water deficit, more salt than water, water leaves the cell and then shrivels, this is also called clinical dehydration (Remember Hyper/Active) cell shrinks **[Hyponatremia-]**Water excess, more water than salt, or water intoxication, the gain of more water than salt, (Remember Hippo Large/Swollen) the cells increases in size or swells. **[Electrolyte Imbalance]** There are three processes to electrolyte imbalance: 1. Electrolyte intake and absorption 2. Electrolyte disruption 3. Electrolyte output **[Electrolytes Intake and Absorption, Intake and Output]** +-------------+-------------+-------------+-------------+-------------+ | **Intake | | | | | | and | | | | | | Important** | | | | | | | | | | | | **Electroly | | | | | | te | | | | | | Absorption | | | | | | Distributio | | | | | | n | | | | | | Output/Loss | | | | | | Functions** | | | | | +=============+=============+=============+=============+=============+ | Potassium | Fruits | Low in ECF, | Aldosterone | Maintains | | (K+) | | high in | , | resting | | | Potatoes | ICF. | black | membrane | | | | | licorice, | potential | | | Instant | Insulin, | hypomagnese | of | | | coffee | epinephrine | mia, | skeletal, | | | | , | and | smooth, and | | | Molasses | and | polyuria | cardiac | | | | alkalosis | increase | muscle, | | | Brazil nuts | shift K+ | renal | allowing | | | | into cells. | excretion; | normal | | | Absorbs | | oliguria | muscle | | | easily | Some types | decreases | function | | | | of acidosis | renal | | | | | shift K+ | excretion. | | | | | out of | | | | | | cells. | Acute or | | | | | | chronic | | | | | | diarrhea | | | | | | increases | | | | | | fecal | | | | | | excretion | | +-------------+-------------+-------------+-------------+-------------+ | Calcium | Dairy | Ca2+ is low | Thiazide | Influences | | (Ca2+) | products | in ECF, | diuretics | excitabilit | | | | mostly in | decrease | y | | | Canned fish | bones and | renal | of nerve | | | with bones | intracellul | excretion. | and muscle | | | | ar. | | cells; | | | Broccoli | | Chronic | necessary | | | | Some Ca2+ | diarrhea | for muscle | | | Oranges | in blood is | and | contraction | | | | bound and | undigested | | | | Requires | inactive; | fat | | | | vitamin D | only | increase | | | | for best | ionized | fecal | | | | absorption | Ca2+ is | excretion. | | | | | active. | | | | | Undigested | | | | | | fat | Parathyroid | | | | | prevents | hormone | | | | | absorption | shifts Ca2+ | | | | | | out of | | | | | | bone; | | | | | | calcitonin | | | | | | shifts Ca2+ | | | | | | into bone. | | | | | | | | | | | | Ca2+ | | | | | | decreases | | | | | | in blood if | | | | | | phosphate | | | | | | rises and | | | | | | vice versa. | | | +-------------+-------------+-------------+-------------+-------------+ | Magnesium | Dark green | Mg2+ is low | Rising | Influences | | (Mg2+) | leafy | in ECF, | blood | function of | | | vegetables | mostly in | ethanol | neuromuscul | | | | bones and | increases | ar | | | Whole | intracellul | renal | junctions; | | | grains | ar. | excretion; | is a | | | | | oliguria | cofactor | | | Mg2+-contai | Some Mg2+ | decreases | for | | | ning | in blood is | renal | numerous | | | laxatives | bound and | excretion. | enzymes | | | and | inactive; | | | | | antacids | only free | Chronic | | | | | Mg2+ is | diarrhea | | | | Undigested | active. | and | | | | fat | | undigested | | | | prevents | | fat | | | | absorption | | increase | | | | | | fecal | | | | | | excretion. | | +-------------+-------------+-------------+-------------+-------------+ | Phosphate | Milk | Phosphate | Oliguria | Necessary | | | | is low in | and | for | | | Processed | ECF; it is | elevated | production | | | foods | higher in | fibroblast | of ATP, the | | | | ICF and in | growth | energy | | | Aluminum | bones. | factor 23 | source for | | | antacids | | (FGF-23) | cellular | | | prevent | Insulin and | decrease | metabolism | | | absorption | epinephrine | renal | | | | | shift | excretion. | | | | | phosphate | | | | | | into cells. | | | | | | | | | | | | Decreases | | | | | | in blood if | | | | | | calcium | | | | | | rises and | | | | | | vice versa. | | | +-------------+-------------+-------------+-------------+-------------+ **[Factors Affecting Electrolyte Imbalance]** - Diarrhea - Endocrine Disorders - Medications **NOTE:** If electrolyte **intake** is **greater** than **output** or a shift of electrolytes from cells or bone into the ECF it will cause **plasma electrolyte excess**. **NOTE:** If electrolyte **intake** is **less** than **output** or shift from ECF into cells and bones it will cause a **blood plasma deficit**. +-----------------------------------+-----------------------------------+ | **[ELECTROLYTE | | | IMBALANCES]** | | | | | | **Imbalance and Related Causes | | | Signs and Symptoms** | | +===================================+===================================+ | **Hypokalemia**---**Low Serum | | | Potassium (K+) Concentration** | | +-----------------------------------+-----------------------------------+ | ***Decreased K+ Intake:*** | ***Physical examination:*** | | Excessive use of K+-free IV | Bilateral muscle weakness that | | solutions | begins in quadriceps and may | | | ascend to respiratory muscles, | | ***Shift of K+ Into Cells:*** | abdominal distention, decreased | | Alkalosis; treatment of diabetic | bowel sounds, constipation, | | ketoacidosis with insulin | dysrhythmias | | | | | ***Increased K+ Output:*** Acute | ***Laboratory findings:*** Serum | | or chronic diarrhea; vomiting; | K+ level below 3.5 mEq/L (3.5 | | other GI losses (e.g., | mmol/L) | | nasogastric or fistula drainage); | | | use of potassium-wasting | ***ECG abnormalities:*** U waves; | | diuretics; aldosterone excess; | flattened or inverted T waves; ST | | polyuria; glucocorticoid therapy | segment depression | +-----------------------------------+-----------------------------------+ | **Hyperkalemia**---**High Serum | | | Potassium (K+) Concentration** | | +-----------------------------------+-----------------------------------+ | **Increased K+ Intake:** | **Physical examination:** | | Iatrogenic administration of | Bilateral muscle weakness in | | large amounts of IV K+; rapid | quadriceps, transient abdominal | | infusion of stored blood; excess | cramps, diarrhea, dysrhythmias, | | ingestion of K+ salt substitutes | cardiac arrest if severe | | | | | **Shift of K+ out of Cells:** | Laboratory findings: Serum K+ | | Massive cellular damage (e.g., | level above 5 mEq/L (5 mmol/L) | | crushing trauma, cytotoxic | | | chemotherapy); insufficient | **ECG abnormalities:** Peaked T | | insulin (e.g., diabetic | waves; widened QRS complex; PR | | ketoacidosis); some types of | prolongation; terminal sine-wave | | acidosis | pattern | | | | | **Decreased K+ Output:** Acute or | | | chronic oliguria (e.g., severe | | | ECV deficit, end-stage renal | | | disease); use of | | | potassium-sparing diuretics; | | | adrenal insufficiency (deficit of | | | cortisol and aldosterone) | | +-----------------------------------+-----------------------------------+ | **Hypocalcemia**---**Low Serum | | | Calcium (Ca2+) Concentration** | | +-----------------------------------+-----------------------------------+ | **Decreased Ca2+ Intake and | **Physical examination:** | | Absorption:** Calcium-deficient | Numbness and tingling of fingers, | | diet; vitamin D deficiency | toes, and circumoral (around | | (includes end-stage renal | mouth) region, positive Chvostek | | disease); chronic diarrhea; | sign (contraction of facial | | laxative misuse; steatorrhea | muscles when facial nerve is | | | tapped), hyperactive reflexes, | | Shift of Ca2+ Into Bone or | muscle twitching and cramping; | | **Inactive Form:** | carpal and pedal spasms, | | Hypoparathyroidism; rapid | Trousseau\'s sign is a medical | | administration of citrated blood; | sign that indicates low calcium | | hypoalbuminemia; alkalosis; | levels in the blood, or | | pancreatitis; hyperphosphatemia | hypocalcemia. It\'s characterized | | (includes end-stage renal | by involuntary hand and wrist | | disease) | muscle contractions, or | | | carpopedal spasms, that occur | | **Increased Ca2+ Output:** | after inflating a blood pressure | | Chronic diarrhea; steatorrhea | cuff on the upper arm, tetany, | | | seizures, laryngospasm, | | | | | | dysrhythmias | | | | | | **Laboratory findings:** Total | | | serum Ca2+ level below 9.0 mg/dL | | | (2.25 mmol/L) or serum ionized | | | Ca2+ level below 4.5 mg/dL (1.05 | | | mmol/L) | | | | | | **ECG abnormalities:** Prolonged | | | ST segments | +-----------------------------------+-----------------------------------+ | **Hypercalcemia**---**High Serum | | | Calcium (Ca2+) Concentration** | | +-----------------------------------+-----------------------------------+ | **Increased Ca2+ Intake and | **Physical examination**: | | Absorption:** Milk-alkali | Anorexia, nausea and vomiting, | | syndrome | constipation, fatigue, diminished | | | reflexes, lethargy, decreased | | Shift of Ca2+ out of Bone: | level of consciousness, | | Prolonged immobilization; | confusion, personality change, | | hyperparathyroidism; bone tumors; | cardiac arrest if severe | | nonosseous cancers that secrete | | | bone-resorbing factors | **Laboratory findings:** Total | | | serum Ca2+ level above 10.5 mg/dL | | **Decreased Ca2+ Output**: Use of | (2.62 mmol/L) or serum ionized | | thiazide diuretics | Ca2+ level above 5.6 mg/dL (1.3 | | | mmol/L) | | | | | | **ECG abnormalities:** Heart | | | block, shortened ST segments | +-----------------------------------+-----------------------------------+ | **Hypomagnesemia**---**Low Serum | | | Magnesium (Mg2+) Concentration** | | +-----------------------------------+-----------------------------------+ | **Decreased Mg2+ Intake and | **Physical examination:** | | Absorption:** Malnutrition; | Positive Chvostek sign, | | chronic alcoholism; chronic | hyperactive deep tendon reflexes, | | diarrhea; laxative misuse; | muscle cramps and twitching, | | steatorrhea | grimacing, dysphagia, tetany, | | | seizures, insomnia, tachycardia, | | **Shift of Mg2+ Into Inactive | hypertension, dysrhythmias | | Form:** Rapid administration of | | | citrated blood | **Laboratory findings:** Serum | | | Mg2+ level below 1.3 mEq/L (0.65 | | **Increased Mg2+ Output:** | mmol/L) | | Chronic diarrhea; steatorrhea; | | | other GI losses (e.g., vomiting, | ECG abnormalities: Prolonged QT | | nasogastric or fistula drainage); | interval | | use of thiazide or loop | | | diuretics; aldosterone excess | | +-----------------------------------+-----------------------------------+ | **Hypermagnesemia**---**High | | | Serum Magnesium (Mg2+) | | | Concentration** | | +-----------------------------------+-----------------------------------+ | **Increased Mg2+ Intake and | **Physical examination:** | | Absorption:** Excessive use of | Lethargy, hypoactive deep tendon | | Mg2+-containing laxatives and | reflexes, bradycardia, | | antacids; parenteral overload of | hypotension | | mag nesium | | | | **Acute elevation in Mg2+ | | **Decreased Mg2+ Output:** | levels:** Flushing, sensation of | | Oliguric end-stage renal disease; | warmth | | adrenal insufficiency | | | | **Severe acute hypermagnesemia:** | | | Decreased rate and depth of | | | respirations, dysrhythmias, | | | cardiac arrest | | | | | | **Laboratory findings:** Serum | | | Mg2+ level above 2.1 mEq/L (1.05 | | | mmol/L) | | | | | | ECG abnormalities: Prolonged PR | | | interval | +-----------------------------------+-----------------------------------+ **[NORMAL VALUES]** \(P) *Stands for* pH A\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--B *Primary* 7.35 7.45 Source *The 2* PaCO2 A\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--B *Reminds* (**LUNGS)** 35 RESPIRATORY 45 *You this* *Is Second* *(Drop the Sevens* *They go to Heaven)* *The 3* HCO3 A\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--B *Reminds* **(KIDNEYS)** 21 METABOLIC 28 *You this is the* *Third value* **[ACID PRODUCTION]** TWO TYPES - Carbonic- Lungs-(CO2+H2O)= H2CO3 - Metabolic-Kidneys (any acids that are not carbonic) **[ACID BUFFERING]** Pairs of chemicals that work together to maintain normal pH. All body fluids contains, one major buffer in ECF is Bicarbonate (HCO3)-buffers metabolic acid. **[ACID EXCRETION]** 2 Acid excretion systems - Lungs-Respiratory/carbonic - Kidneys-Metabolic/anything but carbonic **[Excretion of carbonic acid-]**when we exhale, we blow off carbon dioxide (CO2) and water. \* If PaCO2 decreases-chemoreceptors trigger slower/ shallower respirations, so that more CO2 produced remains in the blood. \*If PaCO2 increases chemoreceptors are triggered and cause faster/deeper respirations. People with respiratory disease may not be able to blow off CO2- so their blood becomes acidic. If lungs cannot correct the issue then the kidneys will begin compensating and excrete metabolic acid. **[Excretion of Metabolic Acid-]** Kidneys excrete all acids except carbonic acid. \*Phosphate buffers in the renal tubular fluid keep the urine from becoming too acidic. If there are too many H+ ions in the urine, then renal tubular cells excrete ammonia. This process enables metabolic acid excretion through the urine. People who have oliguric kidney disease cannot excrete metabolic acid the acids accumulate in the blood triggering the lungs to increase respiratory rate and depth to cause compensator excretion of carbonic acid. **[Acid Base Imbalance]** Acidosis- increased pH Alkalosis-increased base (bicarbonate) **2 types of acidosis** - Respiratory-Lungs - Metabolic-Kidneys - Respiratory-Lungs - Metabolic-Kidneys **NOTE:** Both lungs and kidneys have a compensatory system that engages when one or the other cannot self-correct the imbalances. **[Acid base imbalances]** +-----------------------------------+-----------------------------------+ | Imbalance and Related Causes | | | Signs and Symptoms | | +===================================+===================================+ | **Respiratory | | | Acidosis**---Excessive Carbonic | | | Acid Caused by Alveolar | | | Hypoventilation | | +-----------------------------------+-----------------------------------+ | **Impaired Gas Exchange:** | **Physical examination:** | | | Headache, light-headedness, | | Type B COPD (chronic bronchitis) | decreased level of consciousness | | or end-stage type A COPD | (confusion, lethargy, coma), | | (emphysema) | dysrhythmias | | | | | Bacterial pneumonia | **Laboratory findings:** Arterial | | | blood gas alterations: pH below | | Airway obstruction | 7.35, PaCO2 above 45 mm Hg (6 | | | kPa), HCO3− level normal if | | Extensive atelectasis (collapsed | uncompensated or above 28 mEq/L | | alveoli) | (28 mmol/L) if compensated | | | | | Severe acute asthma episode | | | | | | **Impaired Neuromuscular | | | Function:** | | | | | | 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 Brainstem | | | Respiratory Control:** | | | | | | Drug overdose with a respiratory | | | depressant | | | | | | Some types of head injury | | +-----------------------------------+-----------------------------------+ | **Respiratory | | | Alkalosis**---Deficient Carbonic | | | Acid Caused by Alveolar | | | Hyperventilation (Kussmal | | | respirations) | | +-----------------------------------+-----------------------------------+ | Hypoxemia from any cause (e.g., | **Physical examination:** | | initial part of asthma episode, | Light-headedness, numbness and | | pneumonia) | tingling of fingers, toes, and | | | circumoral region, increased rate | | Acute pain | and depth of respirations, | | | excitement and confusion possibly | | Anxiety, psychological distress, | followed by decreased level of | | sobbing | consciousness, dysrhythmias | | | | | Inappropriate mechanical | **Laboratory findings:** Arterial | | ventilator settings | blood gas alterations: pH above | | | 7.45, PaCO2 below 35 mm Hg (4.7 | | Stimulation of brainstem | kPa), HCO3− level normal if short | | respiratory control (e.g., | lived or uncompensated or below | | meningitis, gram-negative sepsis, | 21 mEq/L (21 mmol/L) if | | head injury, aspirin overdose) | compensated | +-----------------------------------+-----------------------------------+ | **Metabolic | | | Acidosis**---Excessive Metabolic | | | Acids | | +-----------------------------------+-----------------------------------+ | **Increase of Metabolic Acids | **Physical examination:** | | (High Anion Gap):** | Light-headedness, numbness and | | | tingling of fingers, toes, and | | Ketoacidosis (diabetes, | circumoral region; muscle cramps; | | starvation, alcoholism) | possible excitement and confusion | | | followed by decreased level of | | Hypermetabolic state (severe | consciousness, dysrhythmias (may | | hyperthyroidism, burns, severe | be caused by concurrent | | infection) | hypokalemia) | | | | | Oliguric renal disease (acute | **Laboratory findings:** Arterial | | kidney injury, end-stage renal | blood gas alterations: pH above | | disease) | 7.45, PaCO2 normal if | | | uncompensated or above 45 mm Hg | | Circulatory shock (lactic | (6.0 kPa) if compensated, HCO3− | | acidosis) | above 28 mEq/L (28 mmol/L) | | | | | 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**---Deficient Metabolic | | | Acids | | +-----------------------------------+-----------------------------------+ | **Increase of Bicarbonate:** | **Physical examination:** | | | Light-headedness, numbness and | | Excessive administration of | tingling of fingers, toes, and | | sodium bicarbonate | circumoral region; muscle cramps; | | | possible excitement and confusion | | Massive blood transfusion (liver | followed by decreased level of | | converts citrate to HCO3−) | consciousness, dysrhythmias (may | | | be caused by concurrent | | Mild or moderate ECV deficit | hypokalemia) | | (contraction alkalosis) | | | | **Laboratory findings:** Arterial | | **Loss of Metabolic Acid:** | blood gas alterations: pH above | | | 7.45, PaCO2 normal if | | Excessive vomiting or gastric | uncompensated or above 45 mm Hg | | suctioning | (6.0 kPa) if compensated, HCO3− | | | above 28 mEq/L (28 mmol/L) | | Hypokalemia | | | | | | Excess aldosterone | | +-----------------------------------+-----------------------------------+ **[Respiratory Acidosis (HYPOVENTALATION)]** - **Causes** - Excessive carbonic acid by alveolar (***hypoventilation)*** - Caused by 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 from paralysis from hypokalemia or neurological dysfunction - Respiratory muscle fatigue, respiratory failure - Chest wall injury or surgery causing pain with respiration - **Other Causes** - Dysfunction of the brainstem respiratory control - - Drug overdose with respiratory depressant - Some types of head injuries **[Signs and Symptoms]** - Headache - Light headed - Decreased level of consciousness - Confusion - Lethargy - Coma - Dysrhythmias **[Lab Findings]** - pH-decreased - PaCO2-increased - HCO3-if normal (uncompensated) if increased (partial compensation) **[Respiratory Alkalosis HYPERVENTALATION]** - **Causes** - Hypoxemia - Acute Pain - Anxiety - Psychological Distress - Sobbing - Inappropriate Mechanical Ventilator Setting - Stimulation of the brainstem respiratory control (i.e. meningitis, gram negative sepsis, head injury, aspirin overdose) - **Signs and Symptoms** - Light headedness - Numbness - Tingling of fingers, toes and circumoral region - Increased rate and depth of respirations - Excitement - Confusion, followed by decreased levels of consciousness - Dysrhythmias - **Lab Values** - pH Increased above 7.45 - PaCO2 decreased below 35 - HCO3 Normal (Uncompensated) below 21 (partially compensated) **[Metabolic Acidosis---Excessive metabolic acids]** - **Causes:** - Increase of metabolic acids (high anion gap) - Ketoacidosis - Hypermetabolic State (severe hypothyroidism, burns, severe infection) - Oliguric renal disease (acute kidney injury, end stage renal disease) - Circulating shock (lactic acidosis) - Ingestion of acid or acid precursors (i.e. methanol, ethylene, glycol, boric acid) - Loss of Bicarbonate (Normal anion gap) - Diarrhea - Pancreatic Fistula or intestinal decompression - Renal tubular acidosis - **Signs and Symptoms:** - Decreased level of consciousness - Lethargy, confusion, coma - Abdominal pain - Dysrhythmias - Increased rate and depth of respirations (compensatory hyperventilation) - **Lab Findings** - pH decreased below 7.35 - PaCO2 normal (uncompensated) below 35 (partially compensated) - HCO3 below 21 **[Metabolic Alkalosis deficit in metabolic acids]** - **Causes:** - Increase Bicarbonate - Excessive administration of sodium bicarbonate - Massive blood transfusion (liver converts citrates to HCO3) - Mild or moderate ECV deficit (contraction alkalosis) - Loss of metabolic acid - Excessive vomiting or gastric suctioning - Hypokalemia - Excessive aldosterone - **Signs and Symptoms:** - Light headedness - Numbness and tingling fingers, toes and circumoral region - Muscle cramps - Possible excitement and confusion followed by decreased levels of consciousness - Dysrhythmias - Concurrent hypokalemia - **Lab Findings** - pH increased above 7.45 - PaCO2 normal (uncompensated) above 45 (partially compensated) - HCO3 increased above 28 **[Respiratory Alkalosis-]**(Hyperventilation) lungs excrete, too much CO2 and water, **short lived,** therefore kidneys do not have enough to compensate. If pH rises high enough CNS depression can occur. **[Metabolic Acidosis-]**Increased metabolic or decreased base bicarbonate, kidneys are unable to excrete metabolic acids they then accumulate in the blood (or) bicarb is removed directly from the body (diarrhea) (anion gap) decreased pH stimulates chemoreceptors, lungs compensate by hyperventilation. **[Respiratory Acidosis-]**Increased CO2, Increased PaCO2, causes hypoventilation the kidneys compensate by excretion of metabolic acids in the urine. **[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 **NOTE:** In acute care fluid, electrolyte and acid base imbalances are very common **[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 for enteral fluid replacement]** - 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 **[Chapter 45 Nutrition]** Albumin Anorexia Nervosa Basal Metabolic Rate (BMR) Body Mass Index (BMI) Bulimia Nervosa Carbohydrates Catabolism Chyne Daily Values Dietary Reference Dietary Reference Intakes (DRI's) Dispensable Amino Acids Dysphagia Enteral Nutrition (EN) Fat Soluble Vitamins Fiber Food Security Hypervitaminosis Ideal Body Weight (IBW) Indispensable amino acids Insulin Intravenous Ketones Kilocalories Lipids Macrominerals Malabsorption Malnutrition Medical Nutrition Therapy (MNT) Metabolism Minerals Nitrogen Balance Parenteral Nutrition (PN) Peristalsis Resting Energy Expenditure (REE) Simple Carbohydrates Trace Elements Triglycerides Vitamins Water Soluble Vitamins Villi **[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]** The following important factors of the functioning human body require 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. 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 - 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 **Muslim Christianity.** **Hinduism. Judaism Mormons. Seventh Day** +-----------+-----------+-----------+-----------+-----------+-----------+ | Pork | Some | All meats | Pork | Alcohol | Pork | | | faiths | | | | | | Alcohol | such as | Fish, | Predatory | Tobacco | Shellfish | | | Baptists | shellfish | fowl | | | | Ramadan | allow | with some | | Caffeine | Fish | | fasting | minimal | restricti | Shellfish | such as | | | sunrise | or no | ons | (eat only | in teas, | Alcohol | | to sunset | alcohol | | fish with | coffees, | | | for a | | Alcohol | scales) | and sodas | Caffeine | | month | Some | | | | | | | meatless | | Rare | | Vegetaria | | Ritualize | days may | | meats | | n | | d | be | | | | or | | methods | observed | | Blood | | ovolactov | | of animal | during | | (e.g., | | egetarian | | slaughter | the | | blood | | diets | | required | calendar | | sausage) | | encourage | | for meat | year, | | | | d | | ingestion | commonly | | Mixing of | | | | | during | | milk or | | | | | Lent | | dairy | | | | | | | products | | | | | | | with meat | | | | | | | dishes | | | | | | | | | | | | | | Must | | | | | | | adhere to | | | | | | | kosher | | | | | | | food | | | | | | | preparati | | | | | | | on | | | | | | | methods | | | | | | | | | | | | | | 24 hr of | | | | | | | fasting | | | | | | | on Yom | | | | | | | Kippur, a | | | | | | | day of | | | | | | | atonement | | | | | | | | | | | | | | No | | | | | | | leavened | | | | | | | bread | | | | | | | eaten | | | | | | | during | | | | | | | Passover | | | | | | | (8 days) | | | | | | | | | | | | | | No | | | | | | | cooking | | | | | | | on the | | | | | | | Sabbath | | | | | | | from | | | | | | | sundown | | | | | | | Friday to | | | | | | | sundown | | | | | | | Saturday | | | +-----------+-----------+-----------+-----------+-----------+-----------+ **[Diagnostic Criteria for Eating Disorders]** **[Anorexia nervosa]** Restriction of energy intake relative to requirements, leading to a significantly low body weight in relation to age, sex, developmental trajectory, and physical health Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight Disturbance in the way in which one's body weight, size, or shape is experienced; undue influence of body weight or shape on self-evaluation; or persistent lack of recognition of the seriousness of the current low body weight (e.g., the person claims to "feel fat" even when emaciated, believes that one area of the body is "too fat" even when person is obviously underweight) **[Bulimia nervosa]** Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete time period) A feeling of lack of control over eating behavior during eating binges Recurrent inappropriate compensatory behaviors to prevent weight gain, such as self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise Binge eating and inappropriate compensatory behaviors that both occur, on average, at least once a week for 3 months Self-evaluation unduly influenced by body shape and weight **[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 **NOTE:** **Be aware of warning signs for dysphagia. They include cough during eating; change in voice tone or quality after swallowing; abnormal movements of the mouth, tongue, or lips; and 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 are other signs of dysphagia. Patients with dysphagia often do not show overt signs such as coughing when food enters the airway.** **[Diet Progression & Therapeutic Diets]** **[Clear Liquid-]**Consists of broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices and popsicles **[Full Liquid-]**Same as clear, 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. Same as above added scrambled eggs, pureed meats, vegetables, fruits and mash potatoes and gravy. **[Mechanical Soft-]**Same as above but added creamed soups, ground or finely diced meats, flacked 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, deserts, cakes, and cookies without nuts or coconut. **[High Fiber-]**Uncooked fruits and 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 - Offer smaller meals more frequently **[Four Levels of Diet for Dysphasia]** - Dysphagia puree - Dysphagia Mechanically Altered - Dysphagia Advanced - Regular **[Enteral Nutrition-]**Provides nutrients to the GI tract, by way of 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-]** 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 **NOTE:** Complications of PN can be tension pneumo thorax from the tube insertion getting into the plural space of the lung, monitor patient for this complication up to 24 hours after insertion. **NOTE:** Once the patient reaches 1/3 to ½ of daily Kcal intake per day, they can be moved from PN/EN feeding. **Measurement for NG Tubes** Tip of catheter at the nose, back to the ear, and down to the xyphoid process, mark the area where the tube should stop being inserted. **Location of NG Tube** The best way to see if the tube is in the correct location, is x-ray. The second-best way is by aspirating contents of the stomach from the tube and testing the acidity of the contents. **[Signs of Intolerance of Tube Feedings]** signs of intolerance appear (high gastric residuals, nausea, cramping, vomiting, or diarrhea). Flush NG with water before feeding, and after feeding to eliminate the potential for microorganisms and bacteria Keep the head of the bed elevated a minimum of 30 degrees, preferably 45 degrees, unless medically contraindicated, during feedings and for 30 to 60 minutes after feeding **PROCEDURAL GUIDELINES** Obtaining Gastrointestinal Aspirate for pH Measurement and Large-Bore, and Small-Bore Feeding Tubes: Intermittent and Continuous Feeding **Delegation and collaboration** The skill of verifying tube placement and irrigating a feeding tube is the responsibility of the nurse and cannot be delegated to assistive personnel (AP). The nurse directs the AP 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 (tap water or sterile \[see agency policy\], dated and initialed container at patient's bedside); towel; stethoscope; clean gloves; pH indicator strip (scale of 1.0--11.0); small medication cup; measuring tape/device; pulse oximeter **Procedural steps** 1\. Review agency policy and procedures for frequency of irrigation and frequency and method of checking tube placement. Do not insufflate air into tube to check placement. 2\. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy (TJC, 2021). 3\. Review patient's medication record for orders for enteral feeding, a gastric acid inhibitor (e.g., ranitidine, famotidine, nizatidine), or a proton pump inhibitor (e.g., omeprazole). 4\. Review patient's medical record for history of prior tube displacement. 5\. Observe for signs and symptoms of respiratory distress during feeding: coughing, choking, or reduced oxygen saturation. 6\. Identify conditions that increase risk for spontaneous tube migration or dislocation: altered level of consciousness, agitation; retching, vomiting; nasotracheal suction. 7\. Perform hand hygiene. Assess bowel sounds and perform abdominal examination. 8\. Obtain pulse oximetry reading. 9\. Note ease with which previous tube feedings infuse through tubing. Monitor volume of continuous enteral formula administered during shift and compare with ordered amount. 10\. Assess patient's or family caregiver's knowledge, experience, and health literacy. 11\. Perform hand hygiene and apply clean gloves. Be sure pulse oximeter is in place. 12\. Verify tube placement. **Parenteral Nutrition** Parenteral nutrition (PN) is a form of specialized nutritional support provided intravenously. Patients who are unable to digest or absorb EN benefit from PN. Patients in highly stressed physiological states such as sepsis, head injury, or burns are candidates for PN therapy **Cleaning and maintaining PN Central Venous Catheter** Standard Precautions such as hand hygiene and personal protective equipment with appropriate aseptic field management, nontouch technique, and sterilized supplies (Gorski et al., 2021) (see Chapter 42). Change the CVC dressing per institution policy and any time it becomes wet, disrupted, or contaminated. Use either 2% alcohol-based chlorhexidine gluconate (preferred), 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 results from an initial puncture during catheter insertion and CVC placement when the tip of the catheter accidentally enters the pleural space.