fluid-and-electrolytes-notes.pdf

lOMoARcPSD|22872383 Fluid and Electrolytes Notes Complex Health Care Concepts (Germanna Community College) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university...

lOMoARcPSD|22872383 Fluid and Electrolytes Notes Complex Health Care Concepts (Germanna Community College) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Haleigh Carney ([email protected])  lOMoARcPSD|22872383 Fluid and Electrolytes Acute Kidney Injury & Chronic Renal Failure Fluid and electrolyte balance are the process of regulating the extracellular and intracellular fluid volumes, body fluid osmolality, and plasma concentration of electrolytes. Anything that disrupts the kidneys are putting the body at risk for fluid and electrolyte imbalances. Potassium (3.5-5)  Principal ICF electrolyte  Function: o Heart and muscle contraction, nerve impulses, acid-base balance, and isotonicity  Hyperkalemia signs and symptoms o Heart- tight and contracted  ST elevation and Peaked T waves  V-fib or cardiac standstill if severe  Hypotension and bradycardia o GI Tract- tight and contracted  Diarrhea  Hyperactive bowel sounds o Neuromuscular- tight and contracted  Paralysis in extremities  Increased DTR  Profound muscle weakness  Hypokalemia signs and symptoms o Heart- low and slow  Flat T waves, ST depression, and prominent U waves  Palpitations- late sign o GI- low and slow  Decreased motility, hypoactive/absent bowel sounds  Constipation  Abdominal distention  Paralytic ileus--- can cause small bowel obstruction (*priority*) o Neuromuscular- low and slow  Decreased DTR  Muscle cramping  Flaccid paralysis Sodium (135-145)  Principal ECF electrolyte  Function: o Blood Pressure, Blood Volume, pH balance  Hypernatremia signs and symptoms o Big and bloated o Skin  Flush (red and rosy)  Edema (waterbed skin) o Low grade fever o Polydipsia Downloaded by Haleigh Carney ([email protected])  lOMoARcPSD|22872383 o Late signs  Swollen dry tongue (red and beefy)  Nausea/vomiting  Increased muscle tone  Hypertension  Oliguria  Hyponatremia signs and symptoms o Depressed and deflated o Lethargy o Stomach cramps, vomiting, diarrhea o Neuro  Seizures and coma o Heart  Tachycardia, weak and thready pulses  hypotension  Respiratory arrest Chloride (97-107)  Principal ECF electrolyte  Function o Blood Pressure, Blood Volume, pH balance  Hyperchloremia signs and symptoms o Nausea and vomiting o Swollen dry tongue o Confusion  Hypochloremia o Excessive diarrhea o Vomiting o Sweating o fever Magnesium (1.7-2.2)  Function  Law and order in the muscles o Needed for calcium and vitamin D absorption  Hypermagnesemia o calm and quiet  Heart block  Prolonged PR intervals  Bradycardia and hypotension  Decreased DTR, hyporeflexia  Hypoactive bowel sounds  Depressed, shallow respirations  Hypomagnesemia o Buck wild  ST depression, T wave inversion  Torsade’s de pointes  V-fib  Tachycardia  Increased DTR, hyporeflexia  Nystagmus, abnormal eye movements  Diarrhea Downloaded by Haleigh Carney ([email protected])  lOMoARcPSD|22872383 Calcium (9-10.5)  Function o Keep bones, blood, and heart beat strong  Hypercalcemia signs and symptoms o Swollen and slow- moans, groans, and stones  Constipation  Bone pain  Stones (renal calculi)  Decreased DTR, severe muscle weakness  Hypocalcemia signs and symptoms o Trousseau’s signs  Arm twitch with BP cuf o Chvostek’s signs  Smile when stroking cheek o Diarrhea o Circumoral tingling (tingling around the mouth) and tingling in the extremities o Depression, anxiety, confusion, easily fatigued o Hyperreflexia, muscle cramps o Laryngeal spasm o Tetany, seizures o Ventricular tachycardia Phosphate (2.5-4.5)  Function o Bone and teeth formation, helps regulate calcium (works inversely)  Hyperphosphatemia o Trousseau’s and Chvostek’s signs o Diarrhea o Weak B’s  Weak Bones- fractures  Weak blood- risk for bleeding  Weak beats- cardiac dysrhythmias  Hypophosphatemia o Constipation o Decreased DTR o Severe muscle weakness o Decreased HR, RR o Increased BP o Renal calculi Functions of the Kidney (A WET BED) - Acid-base balance - Water balance - Electrolyte balance - Toxin removal - Blood pressure control - Erythropoietin making - D vitamin metabolism Downloaded by Haleigh Carney ([email protected])  lOMoARcPSD|22872383 Risk Factors for Kidney Disease: - High blood pressure - Diabetes - Heart disease - Obesity - Smoking - Family hx of kidney disease - Across the lifespan: o Newborns:  Immature kidneys  Dehydration  Unable to communicate  Large body and lung surface area and body mass with higher fluid exchange ratios with small reserve capacity  Prevention Strategies: o Monitor wet diapers and a regular feeding schedule o 3-year-old:  Prone to UTI’s  Inconsistent fluid intake  Prevention strategies: o Promote fluid intake and potty-training hygiene o Pregnancy:  Change in size of kidneys, elongation of ureters  GFR increases, osmotic pressure decreases  Increased excretion of glucose and protein- increased risk of UTI  Prevention strategies: o Promote fluid intake and monitor UA o 90-year-old:  Decreased thirst/dehydration  Decreased neurons and renal reserve  More likely to have co-morbidities that afects F&E balance  Laxative use  Malabsorption  Hypotension  Prevention strategies o Encourage hydration o Blood work at regular intervals o Hospitalized pt:  Decreased ability to communicate  Increased fluid demands d/t physiologic processes  Insensible fluid loss through increased respiration and metabolic processes  NPO status  Nephrotoxic medication administration  Increased used of IVF  Prevention strategies: o Monitor I&O o Routine labs o Physical assessment o Encourage mobility Downloaded by Haleigh Carney ([email protected])  lOMoARcPSD|22872383 Labs: Serum BUN and Creatinine- Creatinine: 0.6-1.2 Reflects GFR Rises when kidneys cannot filter properly BUN: 10-20 Indicates extent of renal clearance of urea nitrogenous waste products Increased levels indicate kidney disease or decreased kidney perfusion BUN/Creatinine Ratio- Normal range: 6-25 BUN level is divided by creatinine level Elevated levels suggest renal dysfunction or fluid volume excess Urinalysis- Wash perineal area and use a clean container for collection Obtain 10-15 mL of the first morning void Do not refrigerate or place on ice 24-hour Urine Collection- Discard first sample Collect all urine and place specimen on ice Specific Gravity Determination- Measures the ability of the kidneys to concentrate urine Normal range: 1.003-1.030 High concentration occurs with insufficient fluid intake, decreased renal perfusion, or increased ADH Low concentration occurs with the inability of the kidneys to concentrate urine, DI, or increased fluids Urine Culture and Sensitivity- Identifies the presence of microorganisms and the specific antibiotics to treat the existing microorganism appropriately Obtain a midstream/clean catch sample Creatinine Clearance Test- Evaluates how well the kidneys remove creatinine from the blood Estimate of GFR; normal is 125 mL/min in a young adult and decreases with each decade; by 65 years, the GFR is 65 mL 24-hour urine collection and a blood sample after the 24 hours Encourage fluids before and during test Avoid cafeinated beverages Discard first sample and keep collection over ice Complete Blood Count- Downloaded by Haleigh Carney ([email protected])  lOMoARcPSD|22872383 Determines if the patient is anemic caused by kidney injury and inability to secrete erythropoietin Arterial Blood Gas- pH decreases due to inability of the kidneys to excrete excess hydrogen ions or produce bicarbonate Diagnostics: KUB (kidneys, ureters, bladder) radiography- - x-ray of the urinary system to detect urinary calculi Bladder Ultrasonography- - Measures the volume of urine in the bladder Intravenous Urography- - x-ray procedure in which an IV injection of a contrast dye is used to visualize and identify abnormalities in the renal system  Pre-procedure: o assess creatinine and BUN levels o Assess for allergies to iodine, seafood, and radiopaque dyes and any contraindications such as pregnancy o Caution in pts with asthma, cardiac disease, and renal insufficiency (contrast dye should be avoided with renal disease) o Withhold food and fluids o Administer laxatives if prescribed  Post-procedure: o Monitor vital signs o Instruct pt to drink at least 1L of fluid unless contraindicated o Monitor urinary output o Monitor for signs of allergic reaction to the dye o Contrast dye is potentially damaging to the kidneys; risk is greater in older adults and those with dehydration CT Scan- - Provides three-dimensional information about the kidneys, ureters, bladder, and surrounding tissues - To measure kidney size, evaluate contour to assess for injury, masses, or obstruction in the kidneys or urinary tract  Pre-procedure: o Assess for allergies to iodine, seafood, and radiopaque dyes and any contraindications such as pregnancy o Caution in pts with asthma, cardiac disease, and renal insufficiency (contrast dye should be avoided with renal disease) o Withhold food and fluids o Withhold metformin 24 hours prior  Post-procedure: o Monitor vital signs o Instruct pt to drink at least 1L of fluid unless contraindicated o Monitor urinary output Downloaded by Haleigh Carney ([email protected])  lOMoARcPSD|22872383 o Monitor for signs of allergic reaction o Hold metformin until kidney function is determined o No special post-procedure care if dye is not used Renography (renal scan)- - IV injection of a radioisotope for visual imaging of renal blood flow, glomerular filtration, and excretion  Pre-procedure: o Assess for allergies o Instruct pt. to remain motionless during the test  Post-procedure: o Encourage fluid intake o Assess for S&S of allergic reaction o Wear gloves when encountering excretion due to radioisotope for 24hrs. o Follow standard precautions and double-bag linens o Check BP if captopril was administered during procedure Renal Biopsy- - Insertion of a needle into the kidney to obtain a sample of tissue for examination. - Used to examine for tissue necrosis.  Pre-procedure: o Assess vital signs o Assess baseline coagulation studies o Withhold food and fluids  Intra-procedure: o Position the client prone with a pillow under the abdomen and shoulders  Post-procedure: o Monitor vital signs; specifically, for hypotension and tachycardia which may indicate bleeding o Provide pressure to the biopsy site for 30 minutes o Monitor Hgb and Hct levels for decrease o Strict bedrest in supine position for 2-6 hours and a back roll for additional support o Check site for bleeding o Encourage fluid intake of 1500-2000 mL o Observe urine for gross and microscopic bleeding o Avoid heavy lifting/strenuous activity for 1-2 weeks o Notify HCP of fever > 100F or hematuria occurs after 24 hours from procedure Cystoscopy with/without biopsy- - The bladder mucosa is examined for inflammation, calculi, or tumors by a cystoscope; biopsy may also be obtained during the procedure.  Pre-procedure: o Withhold food and fluids if biopsy is to be obtained o No preparation is necessary if just cystoscopy is planned  Post-procedure: o Monitor vital signs Downloaded by Haleigh Carney ([email protected])  lOMoARcPSD|22872383 o Increase fluid intake o Monitor I&O and assess urine characteristics o Encourage deep-breathing exercises to relieve bladder spasms o Administer analgesics as prescribed o Administer sitz or tub baths for back and abdominal pain o Leg cramps are common because of the lithotomy position maintained during procedure o Burning, pink-tinged or tea-colored urine, and urinary frequency are common and will resolve in a few days o Monitor for bright red urine or clots, fever, or increase in WBC Downloaded by Haleigh Carney ([email protected])  lOMoARcPSD|22872383 Acute Kidney Injury (acute renal failure) Sudden decrease in renal function - Causes a buildup of waste, fluid, and electrolyte imbalance - Leads to cell hypoperfusion, cell death, and decompensation of renal function - Can be reversable, if caught early and dependent on cause and condition of client Prerenal: issue with perfusion to the kidney  Decreases function of kidney  Decreased blood supply to the kidney to filter and deprives kidney nutrients  Eventually leads to intrarenal injury  Causes- cardiac issue, obstruction, vessel tumor o Decreased cardiac output (myocardial infarction) o Low blood pressure MAP 1.010 Diuresis-  Nephrons on their way to recovery  Filters the blood but doesn’t concentrate urine yet  GFR starts improving and BUN and Creatinine starts to decrease  Mental status starts to improve  Osmotic Diuresis- high amounts of urea in newly filtered filtrate o Urine output 3-6 L/day o Can cause hypovolemia, dehydration, hypotension, hypokalemia o Urine spec. grav. 30 mg/g of albumin is found in urine Potassium: - Given when patient becomes hypokalemic - NEVER GIVE K AS AN IV PUSH (SEND THEM INTO CARDIAC ARREST) - Best taken orally since it is absorbed in the intestines o Must be diluted in water or fruit juice to minimize GI irritation o Monitor for N/V, GI pain, and GI bleeding - Must be diluted and given no more than 10 mEq/hr if not on heart monitor OR 20 mEq/hr if on cardiac monitor IV Fluids: Normal serum osmolarity = 270-300 mOsm/L - Isotonic- 270-300 o Does not move water  0.9% NS  Lactated Ringers  5% Dextrose in Water D5W  Normosol-R - Hypotonic- 20% acutely) o Fresh Frozen Plasma (FFP)  Increase clotting factor levels in patients with demonstrated deficiency o Packed Red Blood Cells (PRBC’s)  Increase oxygen carrying capacity in patients with anemia, hemoglobin deficits, and up to 25% loss of total blood volume o Whole Blood  Same indications for PRBC’s but more beneficial with extreme blood loss ( > 25%)  Also contains plasma proteins that draw fluid back into blood vessels from surrounding tissues Nephrotoxic Meds to avoid- o NSAID’s o Milk of Magnesia o Antibiotics- vancomycin o Aminoglycosides- Tobramycin and Gentamicin o CT contrast dye and metformin o ARB’s o ACE inhibitors o Chemotherapy agents o Sulfonamides Downloaded by Haleigh Carney ([email protected])