Fluid & Electrolytes Student Notes PDF

9/4/2024 FLUID AND ELECTROLYTES OBJECTIVES: The student will demonstrate mastery of this content by being able to: 1. Describe process that regulate fluid distribution, extracellular fluid volume, and body fluid osmolality. 2. Identi...

9/4/2024 FLUID AND ELECTROLYTES OBJECTIVES: The student will demonstrate mastery of this content by being able to: 1. Describe process that regulate fluid distribution, extracellular fluid volume, and body fluid osmolality. 2. Identify common fluid and electrolyte imbalances. 3. Apply the nursing process when caring for patients with fluid and electrolyte imbalances. 4. Discuss the purposes of IV therapy. 5. Describe equipment used for the administration of IV fluids. 6. Differentiate various IV tubing and the drip rate each delivers. 7. Describe local and systemic complications of IV fluid therapy. 8. Compare the advantages and disadvantages of peripheral and central IV sites. 9. Describe the role of the nurse in assessing and maintaining an IV infusion. 10. Demonstrate how to assess, change and discontinue intravenous solutions. Readings: Potter and Perry, Chapter 42 (not the section on Acid-Base Balance pages 1051-1054) o IV therapy and Skill 42.1 begins IV Skills o Tables : 42.1, 42.2, 42.3, 42.5, 42.9, 42.10, 42.11 42.12, o Boxes : 42.2, 42.3 (refers to meds we discussed in class), 42.7 Thinking Points: Before coming to class be sure to consider the following –  What electrolytes are important for homeostasis within the human body?  What could affect my patient’s safety when he has an IV?  What sterile principles are important to remember in IV therapy? Media Resources: Clinical Skills: Essentials Collection Videos: o Changing Intravenous Tubing and Fluids o Discontinuing Intravenous Therapy o Troubleshooting Intravenous Infusions o Using an Infusion Pump Clinical Validations: o Change an IV bag (hang a new IV bag) o Determine fluid level in IV bags o Identify various IV tubing types and their components o Assess IV site, identifying local complications o Discontinue an IV infusion 1 9/4/2024 2  9/4/2024 Intracellular 2/3 of body fluids FLUID COMPARTMENT 1/3 of body fluids Interstitial Extracellular Intravascular (Plasma) Transcellular 3  9/4/2024 GOAL= HOMEOSTASIS BALANCE OF THE FLUIDS IN COMPARTMENTS THROUGHOUT THE BODY 4 9/4/2024 5  9/4/2024 OSMOLALITY (CONCENTRATION) 285-295 mOsm/kg normal in humans Largely controlled by sodium Hypertonic – higher osmolality Isotonic – same tonicity as blood Hypotonic – lower osmolality See Table 42.11 for IV Solution Tonicity 6  9/4/2024 OSMOLALITY VS OSMOLARITY BOTH ARE UNITS OF CONSIDER THEM MEASUREMENT …. INTERCHANGEABLE 7  9/4/2024 OSMOSIS 8  9/4/2024 HYDROSTATIC PRESSURE VS OSMOTIC PRESSURE = FILTRATION 9  9/4/2024 FILTRATION Capillaries Another means to the goal of homeostasis Fluid Balance 10  9/4/2024 FLUID BALANCE- TABLE 42.2 Intake 2200-2700 mL Regulators- Liquid/Food Output 2200-2700 mL Regulators- Sensible vs. Insensible 11 9/4/2024 12  9/4/2024 1.ADH (ANTI DIURETIC HORMONE)  PITUITARY GLAND REGULATES OSMOLALITY (CONCENTRATION) BY INFLUENCING HOW MUCH WATER IS EXCRETED IN URINE ANTIDIURETIC- MEANING WATER IS REABSORBED AND DIURESIS OR URINATION DECREASES TO MAINTAIN PROPER FLUID BALANCE. URINE THAT IS CREATED IS MORE CONCENTRATED, BLOOD VOLUME IS MORE DILUTED- DECREASE FLUID OUTPUT 2. ADRENAL CORTEX USES ALDOSTERONE TO STIMULATE THE RAAS (RENIN-ANGIOTENSIN- ALDOSTERONE SYSTEM) REGULATES EXTRACELLULAR FLUID (ECF) VOLUME BY INFLUENCING HOW MUCH SODIUM & WATER ARE EXCRETED IN URINE. IMPACTS BP. NA RETURNS TO BLOOD, WATER WILL FALLOW TO INCREASE ECF- DECREASE FLUID OUTPUT EXAMPLE: HEMORRHAGE OR VOMITING= DECREASE IN ECF. DECREASE ECF = DECREASE PERFUSION TO KIDNEY. POOR KIDNEY PERFUSION STIMULATES RELEASE OF RAAS TO CAUSE VASOCONSTRICTION AND PULL FLUID BACK INTO THE BLOOD VESSELS TO RESTORE ECF BALANCE. 3. ANPS (ARTERIAL NATRIURETIC PEPTIDE) REGULATES ECV (EXTRACELLULAR FLUID VOLUME) BY INFLUENCING HOW MUCH SODIUM AND WATER ARE EXCRETED IN THE URINE. OPPOSITE OF RAAS, INCREASE FLUID OUTPUT! HOW OUR FLUID BALANCE OCCURS IN RENAL SYSTEM IS INFLUENCED BY MULTIPLE FACTORS: ADH, RAAS AND ANP! 13  9/4/2024 PATIENTS WITH FLUID IMBALANCES 14  9/4/2024 FLUID VOLUME DEFICIT Hypovolemia Extracellular Problem Cause: Hemorrhage or Third Spacing SHOCK 15  9/4/2024 FLUID VOLUME DEFICIT Severe vomiting & Dehydration diarrhea Intracellular problem 16  9/4/2024 Daily Weights Intake/Output Dry Mucus Postural – Oliguria Membrane Hypotension Tachycardia, Tenting Skin Confusion/ Thready Pulse Turgor Irritability PHYSICAL ASSESSMENT OF DEHYDRATION 17  9/4/2024 Lab Results with Dehydration BUN NA HCT Elevated Elevated Elevated > 50% >25 >145 mg/100 mL 18  9/4/2024 NURSING INTERVENTIONS *Give fluids as ordered- Oral or IV Monitor lab results Check VS, orientation Skin care Oral care 19  9/4/2024 FLUID VOLUME EXCESS 20  9/4/2024 Overhydration Hypervolemia Circulatory Overload Extracellular Volume Excess 21  9/4/2024 Hear Failure Kidney Failure WHO’S AT RISK FOR Excess Sodium Intake HYPERVOLEMIA? 22  9/4/2024 PHYSICAL ASSESSMENT OF HYPERVOLEMIA Edema Pulmonary Jugular Weight Pitting Edema Vein Gain Dyspnea Distention 1 kg Non-pitting Weeping Crackles (2.2 lbs) 23  9/4/2024 LAB RESULTS WITH HYPERVOLEMIA Below 30 HCT Hemodiluted Below 10 BUN Hemodiluted 24  9/4/2024 Daily Monitor Weights Sodium I/O Restriction Administer Assess Diuretics Monitor Lung Dyspnea sounds Position for Comfort 25 9/4/2024 26 9/4/2024 27  9/4/2024 PURPOSE OF IV THERAPY MAINTAIN OR REPLACE BODY FLUIDS RESTORE ACID-BASE OR ELECTROLYTE BALANCE MEDICATION ADMINISTRATION PROVIDE NUTRITION (PN) 28  9/4/2024 PERIPHERAL CATHETERS BUTTERFLY CATHETERS QUICK CATHETERS 29  9/4/2024 SALINE LOCKS 30 9/4/2024 31  9/4/2024 PRO Easy to insert RN Skill Easy to access/ use CON Easily dislodged Interferes with mobility Risk for infection 32  9/4/2024 VASCULAR ACCESS DEVICES 33  9/4/2024 PICC LINE= PERIPHERALLY- INSERTED CENTRAL CATHETER INDICATIONS: LONG-TERM ANTIBIOTICS, TPN, VESICANT MEDICATIONS 34  9/4/2024 SUBCUTANEOUS PORT 35  9/4/2024 PRO Deliver CON Large Additional Volumes Training Deliver Vesicant Expensive Solutions Long Systemic Lasting Risk of Injection 36  9/4/2024 KNOW YOUR ACCESS DEVICES 37 9/4/2024 38  9/4/2024 Infiltration Extravasation Thrombophlebitis Phlebitis Edema Infiltration of vesicant Blood clot formation Inflammation of vein Pain into subcutaneous at end of catheter Pain tissue with vein Redness Decreased IV flow Tissue Damage inflammation rate Redness Warmth Tissue Necrosis Pale color Vesicants should be Warmth Cool administered via Edema No Blood Return CVA 39  9/4/2024 Circulatory Overload Air Embolism Cause: Excess fluid in vascular system Cause: Air into vascular system leads to S/S: HTN, SOB, Cyanosis, Crackles vascular collapse TX: Reduce IV Flow Rate, Notify MD, S/S: Hypotension, Tachycardia, Weak Monitor VS , Diuretics Pulse, Coughing TX: Left side, Trendelenburg position, Notify MD 40 9/4/2024 41  9/4/2024 INFUSION PUMPS 42  9/4/2024 THE CLINICAL VALIDATION Station 1 Station 2 Station 3 Identify Tubing Measure Assess IV Site State Drop Remaining Discontinue IV Factor Fluid Change IV Bag 43 9/4/2024 44 9/4/2024 45  9/4/2024 Sources Muscle Potassium Contraction (K+) 3.5-5.0 Cardiac MEQ/L Tissue Response Acid Base Balance 46  9/4/2024 Causes: NPO Diuretics N/V Diarrhea Nerve & muscle cells are less excitable, less responsive to stimuli HYPOKALEMIA K5 MEQ/L Kidney Disease Medications Causes: 51  9/4/2024 HYPERKALEMIA > 5 MEQ/L Ask Is the serum level accurate? 52  9/4/2024 MONITOR ECG  PEAKED T WAVE  PROLONGED PR INTERVAL  BRADYCARDIA  CARDIAC DYSRHYTHMIAS 53  9/4/2024 Restrict K+ Diet Adjust Medications Increase Urine Output Extreme Hyperkalemia (7+) Kayexalate Dialysis Bicarbonate Insulin/Glucose IV NURSING INTERVENTIONS LOWER THE LEVEL! 54  9/4/2024 CALCIUM (CA+) 9.0-10.5 MG/DL (TOTAL) Stored in Bones & Bound Ca+ vs. Teeth Ionized Ca+ Cellular membrane Necessary for stabilizer… effective & it ‘calms’ and slows appropriate depolarization muscle contraction 55  9/4/2024 CALCIUM REGULATION 1. Parathyroid hormone (PTH) released to absorb CA from kidneys 2. PTH increases blood calcium levels via intestinal absorption 3. Calcitonin decreases blood calcium levels 56  9/4/2024 800-1200mg daily in general HOW MUCH DO WE NEED? Children ages 9 – 18, pregnant women need more 57  9/4/2024 CAUSES: MALNUTRITION VITAMIN D DEFICIENCY (RENAL DISEASE) MALABSORPTION / CHRONIC DIARRHEA PANCREATITIS 58  9/4/2024 HYPOCALCEMIA INDICATORS PARESTHESIA'S DEEP TENDON REFLEXES (DTRS) INCREASE CHVOSTEK SIGN TROUSSEAU CARDIAC DYSRHYTHMIAS - V TACH REMEMBER…CALCIUM IS A ‘CALMING AGENT’ ON NEUROMUSCULAR TISSUE, A DEFICIT WILL LEAD TO EXCITABILITY 59  9/4/2024 CHRONIC HYPOCALCEMIA MANAGEMENT Give orally with Calcium Calcium citrate is Vitamin D carbonate should absorbed with or be taken with without food food Encourage gentle walking, weight- weight – bearing lifting for chronic exercises: issue 60  9/4/2024 Give IV calcium ACUTE Calcium HYPOCALCEMIA is a Vesicant MANAGEMENT Monitor ECG 61  9/4/2024 HYPERCALCEMIA >10.5 MG/DL Hyperparathyroidism Cancer Milk (Calcium) Alkali Syndrome 62  9/4/2024 HYPERCALCEMIA INDICATORS Bradycardia Fatigue/Confusion REMEMBER-CALCIUM IS A ‘CALMING AGENT’; Decreased Deep Tendon AN EXCESS WILL Reflexes LEAD TO DEPRESSION OF RESPONSES Constipation 63  9/4/2024 HYPERCALCEMIA MANAGEMENT Decrease calcium intake Push oral fluids to dilute & excrete calcium Handle gently to prevent fractures Dialysis if necessary 64  9/4/2024 GOT QUESTIONS? 65  9/4/2024 SODIUM NA+ 136-145 REGULATED BY 2 HORMONES Deli Meat Cheese ADH Aldosterone 0.5-2.7 regulates helps to Canned Food Grams water in retain Daily Chips/Cracke response to sodium and rs serum water Table salt sodium levels Sodium 66  9/4/2024 HYPONATREMIA NA+ < 136 Also called: Osmolality Water Decreased Change= excess Hyponatremia excitable Cellular body fluid Water produces membrane swelling depolarization is diluted intoxicati on 67  9/4/2024 HYPONATREMIA Na+ < 130 is a problem Na+ 145 What is Happening? Related to Dehydration Excessive loss of H20 compared to NA Increased membrane depolarization Cellular dehydration High osmolality of ECF Causes: NPO Decreased Water Intake Dehydration Diabetes Insipidus 77  9/4/2024 HYPERNATREMIA IMPACTS Fever, Flushed Skin Restlessness, Agitation Anorexia Muscle Irritability progressing to weakness Hyper reflexes, seizures, tremors, progressed to stupor/coma *SYMPTOMS DEPEND ON SPEED OF DEVELOPMENT 78  9/4/2024 HYPERNATREMIA MANAGEMENT Hypotonic IV Supply Fluids Water/ Intake/Output Table 42.11 Restrict Salt Daily Neuro Seizure Weights Assessment Precautions Oral Care 79 9/4/2024 80