Week 1 & 2 Nursing 3 Fluid & Electrolytes PDF

Fluid & Electrolytes Fluid and electrolyte balance is necessary for life, homeostasis (internal equilibrium) - Anticipate; identify and respond to possible imbalances. - 60% of your body is fluid (Water & Electrolytes) varies with age, body fat and gender Intr...

Fluid & Electrolytes Fluid and electrolyte balance is necessary for life, homeostasis (internal equilibrium) - Anticipate; identify and respond to possible imbalances. - 60% of your body is fluid (Water & Electrolytes) varies with age, body fat and gender Intracellular fluid is the fluid in your cells - ⅔ of body fluid & skeletal muscle mass Extracellular fluid - Intravascular (plasma, erythrocytes, leukocytes) - Interstitial (fluid that surrounds the cells) - Lymph - Transcellular - cerebrospinal Electrolytes - Active chemicals that carry positive and negative ions Cations: sodium, potassium, calcium, magnesium, hydrogen ions Anions: chloride, bicarbonate, phosphate, Sulfate: negative charged protein ions Active transport: sodium-potassium pump maintains higher concentration Acid Base Imbalances Acid base balance represents homeostasis of hydrogen ion concentration in body fluids. The hydrogen shifts between extra/intracellular compartments to compensate for acid-base imbalances. Acidosis = coming out of a$$ (diarrhea) Alkalosis = coming out of mouth (vomiting) PH 7.35-7.45 CO2 35-45 HCO3 21-28 Acid base is maintained by chemical, respiratory and kidney function. Respiratory Acidosis: hypoventilation (ph below 7.35, co2 above 45) - Respiratory depression from opioids, poisons, anesthetics - Pt’s w/ brain tumors, cerebral aneurysm, stroke, overhydration, trauma or neurologic diseases - Inadequate chest expansion due to muscle weakness, tumors, sleep apnea, obesity, flail chest Manifestations - Anxiety, irritability, shallow rapid breathing, cyanotic, VFIB, initial tachycardia and htn, as acidosis worsens pt develops bradycardia and hypotension Nursing Care - Oxygen therapy, maintain patent airway and enhance gas exchange  Fluid & Electrolytes Respiratory Alkalosis: hyperventilation ( PH above 7.45m Co2 below 35) - Anxiety, intracerebral trauma, excessive mechanical ventilation - Hypoxemia from asphyxiation, high altitudes, shock or early stage asthma/pneumonia Manifestations - Tachypnea, inability to concentrate, numbness, tingling, tinnitus, loc, tachycardia, ventricular/atrial dysrhythmias, rapid deep respirations Nursing Care - Oxygen therapy, anxiety reduction interventions, rebreathing techniques Metabolic Acidosis (ph below 7.35, hco3 below 22) - DKA, starvation, seizure activity, excessive intake of acids, inadequate elimination of hydrogen ions (kidney failure/severe lung problems), liver failure, diarrhea Manifestations - Dysrhythmias, bradycardia, weak peripheral pulses, hypotension, tachypnea, headaches, drowsiness, confusion, rapid deep respirations, warm dry pink skin Nursing Care - Dka > administer insulin - Gi losses > antidiarrheals and provide rehydration - Blood bicarb low > administer sodium bicarb 1 meq/kg Metabolic Alkalosis (ph above 7.45, hco3 above 20) - Oral ingestion of excess antacids, blood transfusions, tpn or sodium bicarb, acid deficit, Manifestations - Tachycardia, normotensive/hypotensive, numbness/tingling, tetany, muscle weakness, hyperreflexia, confusion, convulsion, depressed skeletal muscles resulting in ineffective breathing Nursing Care - GI losses: administer antiemetics, fluids & electrolyte replacements - Potassium depletion > discontinue causative agent  Fluid & Electrolytes Hypovolemia (fluid volume disturbance) What is hypovolemia? - Hypovolemia occurs when loss of ecf volume exceeds the intake of fluid. Hypovolemia happens when the body loses body fluids and occurs rapidly when coupled with decreased fluid intake. - Abnormal fluid losses (vomiting, diarrhea, GI suctioning, sweating, decreased intake (as in nausea or lack of access to fluid) and thirst space fluid shifts. - Can also be caused by Diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage and coma. What are the signs and symptoms of hypovolemia? - Acute weight loss, decreased skin turgor, oliguria , concentrated urine, low BP, flattened neck veins, dizziness, weakness, thirst, confusion, increased pulse, cool clammy pale skin, muscle cramps, nausea, sunken eyes, increased temperature, low CVP. - LABS : high hemoglobin & hematocrit , high serum and urine osmolality and specific gravity, decreased urine sodium, high bun and creatinine, Medical Management - If the deficit is not severe, an oral route is preferred. - If the deficit is severe, IV route is required. - Isotonic electrolyte crystalloid solutions (LR or 0.9% sodium chloride) - Once the patient is normotensive, a hypotonic electrolyte solution (0.45% sodium chloride) is used to provide both electrolytes and water for rental excretion of metabolic wastes. Nursing Management - Monitor and measure I&O every 8 hrs - Monitor vital signs How do you prevent hypovolemia? - Minimize fluid losses.. - If the patient has diarrhea, antidiarrheals should be implemented to control diarrhea and replacement fluids should be given at frequent intervals. How to correct hypovolemia? - Oral fluids are given to replace the lost electrolytes. - If the patient has oral discomfort, the nurse will provide frequent mouth care and nonirritating fluids. - If it cannot be corrected by oral fluids, therapy is initiated (enteral or parenteral) until adequate circulating blood volume and renal perfusion are achieved. - Isotonic fluids are prescribed to increase ECF volume.  Fluid & Electrolytes - Ecf is extracellular fluid volume (the amount of fluid in the body that is outside of the cells. Interstitial is the fluid that surrounds the cells and plasma is the fluid in the circulatory system. Hypervolemia ( fluid volume excess ) What is hypervolemia? - Hypervolemia is the expansion of the ECF caused by the abnormal retention of water and sodium. - Fluid overload or diminished function of the homeostatic mechanisms that are responsible for regulating fluid balance. What are some contributing factors for hypervolemia? - Heart failure, kidney dysfunction, cirrhosis of the liver, or excessive amounts of table or other sodium salts. What are the manifestations? - Edema, distended jugular veins, crackles in the lungs. - For pts who are ambulatory, their edema is evident in the ankles - For pts who are supine, edema is evident over the sacrum. Diagnostic findings - Decreased BUN and Hematocrit. - In CKD, serum osmolality and the sodium level is decreased due to the excessive retention of water. - Chest x ray may reveal pulmonary congestion Medical Management - Diuretics are prescribed when the dietary restriction of sodium is insufficient to reduce edema. - Thiazide diuretic blocks sodium and water reabsorption into the bloodstream - Loop diuretics (furosemide, bumetanide or torsemide) - Thiazide diuretics (hydrochlorothiazide) is prescribed for mild to moderate hypervolemia and loop diuretics for severe hypervolemia Azotemia (increased nitrogen levels in the blood) can occur with hypervolemia. - This happens when the urea and creatinine isnt excreted due to decreased perfusion by the kidneys and decreased excretion of waste which also occurs in renal failure. If the renal function is severely impaired that pharmacologic agents cannot act efficiently > Dialysis may be used to remove nitrogenous wastes and control potassium and acid-base balance, and to remove sodium and fluid. Protein intake may be increased to increase capillary oncotic pressure which pulls fluid out of the tissues into vessels for excretion by the kidneys. Nursing Mgmt - Monitor i&o, weigh daily, assess breath sounds, monitor degree of edema,  Fluid & Electrolytes How to control hypervolemia? - Sodium & fluid restrictions, promote rest, monitor parenteral fluid therapy, meds. - Semi-fowler position to promote lung expansion & turn and reposition at regular intervals. Hyponatremia (ranges 135-145) - Net gain of water or loss of sodium-rich fluids that results in sodium levels less than 136. - Typically caused by fluid imbalance which results in sodium loss. Risk factors - Excessive sweating, diuretics, wound drainage, NG tube suction, hyperlipidemia, kidney disease, NPO, hyperglycemia, low-sodium diet, cerebral salt wasting syndrome - SIADH, HF, kidney failure, anticonvulsants, ssri’s, desmopressin, older adults Manifestations - Bounding pulse, hypothermia, tachycardia, hypotension (orthostatic) headache, confusion, lethargy, muscle weakness, fatigue, dtrs, seizures, lightheadedness, increased motility, hyperactive bowel sounds, abdominal cramping, nausea LAB TESTS - ↓ sodium, ↓ blood osmolarity, ↓ urine specific gravity Nursing Care - If not NPO, encourage food/fluids high in sodium (beef broth, tomato juice) - IV fluids (LR, 0.9% isotonic saline) - Monitor I&O, daily weight, vital signs and LOC. Complications - coma, seizures, respiratory arrest Hypernatremia - Blood sodium level greater than 145 that causes a shift of water out of the cells, resulting in dehydrated cells. - Can cause neurologic, endocrine and cardiac disturbances. Risk Factors - Kidney failure, cushing syndrome, corticosteroids, excessive intake of oral sodium - NPO, diabetes insipidus, heat stroke, hyperventilation, watery stools, burns, excessive sweating Manifestations - Thirst, hyperthermia, tachycardia, ortho hypotension, restlessness, irritability, muscle twitching, seizures, coma, dry mucous membranes, nausea, vomiting, occasional diarrhea, anorexia. LAB TESTS - ↑ sodium, blood osmolarity, urine specific Nursing Care - Monitor LOC, vital signs, heart rhythm, lung sounds, i&o, potassium level if diuretics are administered, weigh daily, low sodium diet.  Fluid & Electrolytes Hypokalemia (ranges 3.5-5.0) - Increased loss of potassium from the body or movement of potassium into the cells which results in a blood potassium less than 3.5 Risk factors - Overuse of diuretics, digitalis, corticosteroids; cushing syndrome, loss via GI tract, NPO, kidney disease, increased secretion of aldosterone. Expected findings - ↓ BP, altered mental status, anxiety, lethargy, thready weak pulse, orthostatic hypotension, hypoactive bowel sounds, nausea, vomiting, constipation, abdominal distension, paralytic ileus can develop, shallow breathing, weakness, flattened t wave Nursing Care - Potassium replacement, never give potassium via IM or Subc > necrosis of tissue - Monitor and maintain urine output - Monitor cardiac rhythm, respirations, LOC, o2 sats, dtrs, - FALL RISK due to muscle weakness FOODS HIGH IN POTASSIUM - Bananas, broccoli, dairy products, dried fruit, cantaloup, melon, lean meats, milk, whole grains, citrus fruits, juices. IV pot supp. - Never IV bolus (cardiac arrest) Complications- respiratory failure, cardiac arrest Hyperkalemia - Increased intake of potassium Risk factors - Chronically ill pts.. Kidney failure, DKA, MI, Surgery, Trauma, Sepsis, Manifestations - Slow irregular pulse, hypotension, restlessness, irritability, Vfib, oliguria, diarrhea, hyperactive bowel sounds, increased motility LAB TESTS - Increased h&h w dehydration, decreased with kidney failure, BUN/CREATININE increased with kidney failure, arterial blood gases: metabolic acidosis Diagnosed with ECG > peaked T waves, widened PR and QRS, flat P waves, ST depression Nursing Care - Monitor cardiac rhythm, I&O, muscle weakness, gi manifestations (nausea, intestinal colic), hypokalemia, Medication to increase potassium excretion - Loop diuretics (furosemide) Monitor I&O - Albuterol (lowers blood potassium by causing potassium to shift into intracellular space ^Monitor for tachycardia and chest pain with b2a. - IV insulin and glucose  Fluid & Electrolytes - Patiromer Complications- cardiac arrest Hypocalcemia - Total blood calcium less than 09.0 Risk Factors - Inadequate intake of calcium, diarrhea/steatorrhea, inadequate vitamin D intake, end-stage kidney disease, wound drainage. - Alkalosis, acute pancreatitis Manifestations - Paresthesia of the fingers and lips (early manifestation) - Muscle twitches (tetany) - Seizure due to irritability of the CNS Muscle spasms (charley horse) - Hyperactive DTRs - Positive chvostek’s & trousseau's sign - Hx of thyroid surgery or irradiation of the upper chest/neck which increases risk for HYC Lab Tests - Calcium below 9mg - Decreased blood albumin level > blood calcium falsely low Diagnostic ECG > prolonged QT & ST interval Nursing Care - Administer oral or iv calcium supplements (vitamin D help enhance calcium) - Seizure and fall precautions - Avoid overstimulation - High calcium foods > dairy products, canned salmon, sardines, fresh oysters, and dark leafy green veggies If a patient has life-threatening manifestations of hypocalcemia, they will require rapid tx with calcium gluconate or calcium chloride. IV administration should be diluted in dextrose 5% and water > given as bolus infusion.. If administered too quickly, pt could go into cardiac arrest. Hypomagnesemia - Blood magnesium level less than 1.3 Risk factors - Celiac or crohn's disease - Malnutrition - Ethanol ingestion - Diarrhea, steatorrhea, or chronic laxative use  Fluid & Electrolytes - Citrate from blood products - Myocardial infarction or heart failure - Concurrent hypocalcemia/hypokalemia - Med therapy (aminoglycoside antibiotics, cisplatin, cyclosporin, amphotericin B) Manifestations - Increased BP, dysrhythmias or ecg changes (presence of PVCs, flat/inverted T waves, ST depression, prolonged PR, widened QRS), increased nurse impulse transmission, tetany, seizures, positive chvostek’s and trousseau’s sign, hypoactive bowel sounds, constipation, abdominal distention, paralytic ileus Nursing Care - High magnesium foods (dark green veggies, nuts, whole grains, seafood, peanut butter, cocoa) - Discontinue magnesium-depleting meds (loop diuretics, osmotic diuretics and meds that contain phosphorus) - Administer oral magnesium sulfate for mild. (Can cause diarrhea and increase magnesium depletion) - IV magnesium sulfate for severe HM. it is administered via infusion pump and does not exceed 150 mg/min or 67 mew over an 8hr period.  Fluid & Electrolytes Shock - Shock is a state of inadequate tissue perfusion that impairs cellular function and can lead to organ failure. Types of shock - cardiogenic : failure of the heart to pump effectively due to cardiac factor - Hypovolemic : decrease in intravascular volume of at least 15-30% - Obstructive : impairment of the heart to pump effectively as a result of noncardiac - Distributive : widespread vasodilation and increased capillary permeability which includes neurogenic, septic, and anaphylactic shock Stages of shock - Initial: minimal changes in client parameters - Compensatory: measures to increase cardiac output to restore tissue perfusion and oxygenation - Progressive: compensatory mechanisms beginning to fail - Refractory: irreversible shock and total body failure Cardiogenic shock - Can be prevented by exercise, diet, stress reduction and smoking cessation - Occurs due to a direct cardiac cause like MI, HF, cardiomyopathy, dysrhythmias, and valvular rupture or stenosis. - Older adults have an increased risk for MI and cardiomyopathy Septic shock - Localized redness, swelling, drainage, fever, urinary frequency and burning Hypovolemic Shock - Excessive fluid loss from diuresis, vomiting, diarrhea or blood loss secondary to surgery, trauma, gynecologic/obstetric causes, burns and DKA. - Older clients at risk due to dehydration Obstructive Shock - Cardiac pump failure due to an indirect cardiac factor such as blockage of great vessels, pulmonary artery stenosis, pulmonary embolism, cardiac tamponade, tension pneumothorax and aortic dissection. Distributive shock - Neurogenic: loss of sympathetic tone causing massive vasodilation.. (head trauma, spinal cord injury, epidural) - Septic: endotoxins and other mediators causing massive vasodilation..most common is gram negative bacteria. - Anaphylactic: allergen exposure resulting in an antigen-antibody reaction causing massive vasodilation. Most common causes are antibiotics, foods, latex and bee stings. Manifestations  Fluid & Electrolytes - Chest pain, lethargy, somnolence, restlessness, anxiousness, dyspnea, diaphoresis, thirst, muscle weakness, nausea and constipation. Diagnostic - Arterial line needed for continuous BP monitoring and blood specimens for abgs - Pulmonary artery catheter insertion to measure central venous pressure, pulmonary artery pressures and cardiac output. Nursing Care - Monitor ECG, hemodynamic waveforms and readings, confirm catheter placement via chest xray, urine output (report if less than 30ml/hr) LOC, skin color, temperature, moisture, capillary refill and turgor. - Clients may need to be on high flow oxygen.. If pt has COPD, 2l min. - Maintain patent iv access, Medication - Milrione lactate, dobutamine = strengthens cardiac contraction and increases cardiac output - Dopamine and norepinephrine = increases kidney perfusion at low doses and decreases at high doses. - Vasopressin = causes vasoconstriction, increases BP and systemic vascular resistance - Epinephrine = rapid acting bronchodilator, increases HR and cardiac output. - Morphine = pain management and anxiety. Complications - Multiple organ dysfunction syndrome - inadequate oxygenation. Most common with sepsis - Disseminated intravascular coagulation (DIC) - complication of septic.. This is where small clots form within organ capillaries (kidney, liver, heart, brain) creating hypoxia and anaerobic metabolism.. Client is at risk for hemorrhage..  Fluid & Electrolytes Burns Types of burns - Dry heat : from open flames and explosions - Moist heat injuries : contact with hot liquid or steam. - Contact : hot metal , tar, or grease contacts the skin - Chemical : exposure to a caustic agent such as cleaning agents. - Electrical : electrical current passes through the body and can cause severe damage - Thermal : when clothes ignite from heat or flames that electrical sparks produce - Flash : contact with an electrical current that travels through air form one conductor to another - Conductive : when a person touches electrical wiring or equipment - Radiation : therapeutic treatment for cancer or from sunburn TBSA : total body surface area rule of nines = (divides the body into multiples of nine) head, arms, legs 9% front/back 18%.. Perineal area 1% Risk factors: exposure to sources of heat, flame, explosion, hot liquids, chemicals or radiation. Lab test - HCT & HGB: elevated due to the loss of fluid volume and third spacing - Glucose elevated due to stress - Bun elevated due to fluid loss - Electrolytes: sodium decreased (hyponatremia), potassium increased due to cell destruction, chloride increased due to fluid volume loss and chlorine reabsorption in urine. Phases of Burn Care Emergent (resuscitative phase) - Begins with injury and continues for 24-48hrs, - Phase ends with completion of fluid resuscitation - Priority: securing airway, supporting circulation and organ perfusion by fluid replacement, pain management, preventing infection through wound care, maintaining body temperature and providing emotional support. - Generalized dehydration, reduced blood volume & hemoconcentration, decreased urine output, trauma causes release of potassium into extracellular fluid = hyperkalemia Burn patients are in metabolic acidosis Acute - Begins 48-72 hrs after injury when fluid shift resolves - Phase ends with closure of the wound - Priority: assessment and maintenance of the cardiovascular, respiratory and GI systems - Prevent infection, burn wound care, pain management, modulation of hypermetabolic response and early positioning/mobility. Rehabilitative  Fluid & Electrolytes - Begins when most of the burn area has healed - Phase ends when the client achieve high functioning,, can last for years - Priority: psychosocial support, prevention of scars and contractures, resumption of activities including work, family and social roles. Minor Burns - Provide analgesics, clean with mild soap and tepid water, use antimicrobial ointment, apply dressing Moderate/major burns - Manifestations: tachycardia, increased RR, decreased GI motility, increased blood glucose Nursing care: - provide humidified supplemental oxygen, support the airway and ventilation, perform chest physiotherapy and have pt cough/breathe deeply. Cardiovascular system: monitory central and peripheral pulses, cap refill, pulse ox, blood pressure and ecg. Fluid replacement: IV access using a large- bore needle.. administer half of the total 24hr iv fluid volume within the first 8 hr and the remaining volume over the next 16hr. Effects of major burn injury - Fluid and electrolyte shifts - Cardiovascular effects - Pulmonary injury ( upper/lower airway, carbon monoxide poisoning, restrictive defects) - Renal & GI alterations - Effect on thermoregulation Medications - Silver nitrate - Silver sulfadiazine - Mafenide acetate - Polymyxin b-bacitracin - mannitol Complications - Airway injury (effects may not manifest for 24-48 hrs, s&s: progressive hoarseness, brassy cough, difficulty swallowing, drooling, copious secretions, wheezes and stridor) Support the airway and ventilation and administer supplemental oxygen - Fluid imbalances (hypovolemic shock is possible with inadequate fluid replacement) ^monitor for inadequate perfusion, confusion , hypotension, decreased urine output.. - Sepsis- (most common cause of death following burn injury) ^ monitor for discoloration, edema, odor and drainage. - Impaired muscle and joint mobility- scarring and contractures can limit movement of bones and joints.. Scar tissue forms and causes shortening and tightening of skin, muscles and tendons.. (Assist with rom 3x a day, encourage use of splits, ambulate as early as possible, compression dressing for 24 mos) - Compartment syndrome- develops as edema increases and the skin has lost elasticity due to damage. (monitor peripheral circulation affected extremities & abdomen)  Fluid & Electrolytes - Paralytic ileus (monitor bowel sounds and for abdominal distention) - PTSD - Curling ulcer (erosion due to burn) First Degree - Superficial injuries that involve the outermost layer of skin. SUNBURN Second Degree - Entire epidermis and varying portions of the dermis. Painful w/ blisters Third Degree - Total destruction of the epidermis, dermis and underlying tissue. “Lack of sensation” Fourth Degree - Deep burn necrosis.. Extends into the deep tissue, muscle or bone. Burn Wound Care - Wound cleaning > hydrotherapy - Use of topical agents - HBO > hyperbaric oxygen - Wound debridement (natural, mechanical, and surgical) - Wound dressing, dressing changes, and skin grafting Burn Pain - Most severe form of acute pain Burn pain types - Background or resting - Procedural - breakthrough Medications - Analgesics IV use during emergent or acute phases Morphine or fentanyl - Role of anxiety in pain and effect of sleep deprivation  Fluid & Electrolytes Allergy - Inappropriate, often harmful response of the immune system to normally harmless substances. - Hypersensitive reaction to an allergen initiated by an immunologic mechanism that is usually mediated by IgE antibodies. Allergen - Substance that causes the allergic response Allergic Reaction - Manifestation of tissue injury resulting from interaction between an antigen and antibody When the body encounters allergens that are types of antigens, the body recognizes it as foreign. IGE > involved in allergic reactions Anaphylaxis - Clinical response to an immediate (type 1 hypersensitivity) immunologic reaction between a specific antigen and an antibody. - Rapid release of IgE-mediated chemicals which can induce a severe, life threatening reaction. Most common causes - Foods (peanuts, tree nuts) shellfish )shrimp, lobster, crab) milk, eggs, soy, wheat - Meds (penicillin, lidocaine, procaine) vaccines, hormones, Nsaids, aspirin - Animal serums, antigens used in skin testing - Insect stings (bees, wasps, hornets, yellow jackets, ants) - Latex Manifestations - Affects multiple organ systems - Mild reactions > peripheral tingling, sensation of warmth accompanied by a sensation of fullness in the mouth and throat. Nasal congestion, periorbital swelling, pruritus, sneezing and tearing of the eyes. Typically within the first 2 hrs after the exposure. - Moderate reactions > flushing, warmth, anxiety and itching. More serious reactions > bronchospasm and edema of the airways or larynx with dyspnea, cough and wheezing. - Severe reactions > progresses to bronchospasm, laryngeal edema, severe dyspnea, cyanosis and hypotension, dysphagia, abdominal cramping, vomiting, diarrhea and seizures. Severe reactions are called anaphylactic shock. Prevention - Strict avoidance of potential allergens - Screening for allergies before a med is prescribed or first administered is an important preventative measure. - Pts who are predisposed to anaphylaxis should wear medical identification such as a bracelet or necklace that identifies allergies to meds, foods and other substances. - Pts w/ diabetes who are allergic to insulin and those who are allergic to penicillin may require to desensitization  Fluid & Electrolytes Medical Management - Depends on the severity of the reaction - CPR and supplemental oxygen is provided of the pt is in cardiac arrest or if the patient is cyanotic, dyspneic or wheezing - Epinephrine 1:1000 dilution is given subcutaneously in the upper extremity or thigh followed by a continuous IV infusion. (pts are at risk for hypertension, arteriopathies or ischemic heart disease) - Antihistamines & corticosteroids are not given in place of epinephrine but can be given for adjunct therapy. - IV fluids, volume expanders and vasopressor agents are given to maintain blood pressure and normal hemodynamic status. - Pts who have received epinephrine due to anaphylactic reactions should be transported to the local emergency department for observation and monitoring due to the risk of a rebound or delayed reaction 4-hrs after the initial allergic reaction. Nursing Management - Allergic response > assess for signs and symptoms of anaphylaxis Airway, breathing pattern and vital signs are assessed. Observed for signs of increasing edema and respiratory distress. - Pt needs to be educated about what happened, how to avoid future exposure to antigens, and how to administer emergency meds to treat anaphylaxis. Hypersensitivity - Excessive or abnormal immune response to any type of stimulus/trigger. Anaphylactic (type 1) - Most severe hypersensitivity - Rapid onset that is characterized by edema, hypotension, bronchospasm and cardiovascular collapse in severe cases. - Primary chemical mediators are responsible for the symptoms because of their effects on the skin, lungs and GI tract. - May include both local and systemic anaphylaxis Cytotoxic (type 2) - Occurs when antibodies are directed against antigens on cells or basement membranes of tissues - Leads to cell lysis (where the cell membrane breaks down and causes the cell to rupture and release its contents into the surrounding environment) and tissue damage. - Example: hemolytic transfusion reaction Immune complex (type 3) - A harmful inflammatory response occurs when insoluble immune complexes form from antigens that attach to antibodies. - Complexes are too large to be cleared from the circulation by phagocytic action - Example: rheumatoid arthritis > this is where an unknown antigen triggers antibody formation > forms immune complexes that are deposited into the joints. - Systemic lupus e. > pt forms autoantibodies that form immune complexes that deposit in the lungs, skin and the kidney.  Fluid & Electrolytes Delayed (Type 4) - T cell mediated immune reaction after exposure to an antigen. - Typically occurs 24-48 hours after exposure to an antigen. - Ex: contact dermatitis (poison ivy) TB skin test reactions and chronic transplant rejection - treatment : corticosteroids and immunosuppressants to reduce inflammation and manage symptoms Mnemonic for hypersensitivity ACID A- allergic/anaphylactic/atopic = type 1 IgE C - cytotoxic (type 2) IgG or IgM (graves disease or myasthenia gravis) I- immune complex deposition (type 3) (antigen antibody reactions) D- delayed (type 4) (tb skin test, poison ivy exposure)