Week 4 - Elimination - Fluids and Electrolytes PDF

Week 4: Elimination Fluid & Electrolytes N 120 P R O F E S S O R F E R N A N D E Z , M S N E D, R N , F N P - C LEWIS: CH 17 AT I M / S 4 4 & 4 5 AT I F U N D S 4 9 , 5 7 & 5 8 Body Fluid compartments Intracellular ◦ Inside the cells ◦ Potassium, Phosphorus, Magnesium Extracellular ◦ Sodium and...

Week 4: Elimination Fluid & Electrolytes N 120 P R O F E S S O R F E R N A N D E Z , M S N E D, R N , F N P - C LEWIS: CH 17 AT I M / S 4 4 & 4 5 AT I F U N D S 4 9 , 5 7 & 5 8 Body Fluid compartments Intracellular ◦ Inside the cells ◦ Potassium, Phosphorus, Magnesium Extracellular ◦ Sodium and chloride ◦ Intravascular ◦ Plasma ◦ Interstitial (AKA 3rd space) ◦ In between the cells  Fluid Volume Deficits Fluid Volume Excess (FVD or HYPOvolemia) (FVE or HYPERvolemia) Etiology: GI losses (vomit diarrhea, Etiology: heart failure, renal suction), hemorrhage, inadequate failure/obstruction, liver disease, IV fluid intake, fever, diuretics, 3rd fluids/polydipsia (overhydration), spacing (burns), diabetes insipidus SIADH Manifestations: ↑HR, ↓ cap refill, Manifestations: bounding pulse, ↑BP, ↑resp rate, confusion, cold clammy confusion, headache, crackles, skin, thirst, seizures/coma, dry pulmonary edema, edema, JVD, mucous membranes, ↓urine output, muscle spasms, S3 heart sounds, weakness, weight loss, ↓skin turgor, seizures/coma, weight gain Thready pulse HCT Dehydration: refers to the Na Urine specific gravity = concentration of urine loss of pure water alone BUN USG=1.010-1.030 without the corresponding Pure water = 1 loss of sodium USG Lewis Table 17-3 Causes & Manifestations  Fluid loss heart failure, renal failure/obstruction, liver disease, IV fluids/polydipsia (overhydration), SIADH diabetes insipidus (urine), GI losses (vomit, diarrhea, Na 125 NGT/OGT suction), hemorrhage, inadequate fluid intake, fever, diuretics, 3rd spacing (burns) Na 150 Fluid retention Body Goal: Na 135-145  Interprofessional Care Correct underlying cause Fluid Volume Deficit Fluid Volume Excess Replace both water & Removing fluid without needed electrolytes producing abnormal Oral hydration, blood changes in electrolyte products, or IV status. solutions Ex: Diuretics and fluid Ex: 0.9% NS or LR restriction, sodium restrictions, paracentesis, thoracentesis Hypovolemia vs. Hypervolemia  Nursing implementation Daily weights ◦ Most accurate measure of volume status ◦ Increase or decrease of 1 kg (2.2 LB) = 1000mL/1L of fluid retention or fluid loss Intake and output ◦ Identify sources of excess intake or fluid loss ◦ Intake = oral and IV fluids, enteral nutrition, tube feedings, retained irrigation solutions ◦ Output = urine, excess perspiration, wound drainage, vomiting and diarrhea Cardiovascular ◦ Vital signs as needed ◦ Pulses (bounding?) Heart sounds (presence of S3?) JVD Respiratory ◦ Auscultate lung sounds - pulmonary congestion or edema? , crackles?, hypoxia (pulse ox)? Patient safety ◦ Risk of falls ◦ Orthostatic hypotension, muscle weakness, changes in level of consciousness, altered gate Skin care ◦ Skin turgor, oral mucosa (dry?) ◦ Edema Fluid therapy ◦ Give IV fluids as ordered ◦ monitor infusion rates - extra care with patients that have heart and renal problems Fluid Volume Deficit Fluid Volume Excess NCLEX ????? time A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following findings would indicate a fluid volume deficit? A. Decreased urine specific gravity B. Increased heart rate C. Decreased hematocrit D. Increased skin turgor Electrolyte abnormalities  Electrolytes Normal range Purpose Sodium (Na) 135-145 mEq/L Fluid balance, muscle contraction, nerve impulse Chloride (Cl) 95-105 mEq/L Fluid balance, pH, digestion (HCl) pairs with Na, K, Ca Potassium (K) 3.5-5.0 mEq/L Nerve, cell, muscle function, cardiac function Calcium (Ca) 9.0-10.5 mEq/L Bones, muscle contraction, blood clotting Magnesium (Mg) 1.3-2.1 mEq/L Muscle and nerve function, DNA, ATP, metabolism, enzymatic Phosphorus (PO43-) 2.5-4.8 mEq/L Bones, DNA, cell energy ATP, RBC production Bicarbonate (HCO−3) 22-29 mEq/L Maintain normal pH Electrolyte relationships Inverse – opposite directions ◦ Sodium and potassium ◦ calcium and phosphorus ◦ magnesium and phosphorus Direct – same direction ◦ calcium and vitamin D ◦ magnesium and calcium ◦ magnesium and potassium Hypo and Hyper ◦ Low and High  Sodium Sodium is the primary cation (positively charged ion) of the extracellular fluid (ECF) One of its most important roles is influencing water distribution between fluid compartments Normal range: 135-145 mEq/L: When we draw serum (blood) sodium levels, the number is telling us the ratio of sodium to water Too low is called “hyponatremia”, too high is “hypernatremia” Think “Water follows salt” and if sodium is off, worry most about the brain Sodium also plays a role in nerve impulses - muscle contraction, and acid-base-balance Sodium HYPONATREMIA Causes: Manifestations ◦ Excess sodium loss ◦ Mild hyponatremia - nonspecific neurological ◦ GI: diarrhea, vomiting, and NG suctioning symptoms ◦ Renal: diuretics, renal damage ◦ Headache, irritability, difficulty concentrating ◦ Skin: burns, wound drainage ◦ Severe hyponatremia ◦ Inadequate intake ◦ Confusion, vomiting, seizures, coma ◦ Fasting diets Management ◦ Excessive water intake ◦ Dilutional hyponatremia - primary polydipsia ◦ Replace slowly (PO broth, IVF: isotonic/hypertonic) ◦ Excess hypotonic IV fluids ◦ Monitor neuro status, I&Os and sodium levels ◦ Diseases ◦ Seizure precautions ◦ Cirrhosis, heart failure, SIADH, renal insufficiency ◦ Suction equipment, oxygen, rails up, bed low, rail padding Sodium HYPERNATREMIA Causes: Manifestations ◦ Excess sodium intake ◦ Agitation, restlessness, lethargy, seizures, coma ◦ Hypertonic enteral nutrition without adequate water ◦ Dry tongue, intense thirst, sticky mucous ◦ IV fluids: excessive hypertonic NaCl membranes ◦ Inadequate water intake ◦ Unconscious or cognitively impaired person Management ◦ Excessive water loss ◦ Oral or isotonic IV fluid replacement with NaCl ◦ Diarrhea ◦ Diuretics ◦ Insensible water loss ◦ Sodium restriction ◦ Fever, heat stroke, prolong hyperventilation ◦ Seizure precautions ◦ Diseases ◦ Monitor neuro status, I&Os and sodium levels ◦ Diabetes insipidus ◦ Uncontrolled diabetes mellitus  Potassium Potassium is the primary cation (positively charged ion) of the intracellular fluid (ICF) One of its most important roles is in the cardiac electrical conduction system Normal range: 3.5-5.0 mEq/L: much lower than sodium because most of the potassium is inside the cells, not in the blood Too low is called “hypokalemia”, too high is “hyperkalemia” When potassium is out of range, think about the heart Potassium also plays a role in nerve impulses - muscle contraction, and acid-base-balance  Potassium HYPOKALEMIA HYPERKALEMIA Causes: Causes: ◦ GI: diarrhea, vomiting, NG suctioning, laxatives ◦ Renal disease or insufficiency ◦ Renal: diuretics (furosemide/Lasix), dialysis, magnesium depletion ◦ Factors that push potassium out of the cells and into the blood ◦ Medications: insulin/IV dextrose, albuterol (shift K into cells) ◦ Acidosis, intense exercise, tissue catabolism (fever, crush injury, sepsis, burns) ◦ Low intake:↓dietary intake, NPO, starvation ◦ Medications: excess IV KCL, spironolactone (potassium sparing diuretic), NSAIDs Manifestations: ◦ GI: Constipation, nausea, paralytic ileus EKG: tall peaked T waves, prolonged QRS, sine wave, v fib, asystole ◦ Muscles: Fatigue, weak pulses, muscle weakness, leg cramp Education: avoid foods high in K (banana, potato, salt substitutes - Mrs. ◦ Resp: shallow respiration Dash) ◦ Hypercalcemia Manifestations: EKG changes: flat or dampened T waves ◦ Dysrhythmia, confusion, fatigue, irritability, muscle weakness, cramps, cardiac ◦ Ventricular dysrhythmia arrest ◦ Cardiac arrest Treatment: Kayexalate, Albuterol, Insulin, Sodium bicarbonate, calcium gluconate, furosemide (Lasix), dialysis Treatment: ◦ PO: do not crush or chew tabs, or liquid ◦ IV KCL: dilute with another IVF, slow administration ◦ never give KCl via IV push or as a bolus – use a pump T wave examples  Calcium Calcium plays a role in blood clotting, nerve impulses, heart muscle contraction, skeletal muscle contraction, and the health of bones and teeth Normal range: 9.0-10.5 mg/dL (deciliter, one tenth of a liter). 99% of calcium is in bones, 50% of the calcium in the blood is bound to albumin, and 40% is ionized “free” calcium Too low is called “hypocalcemia”, too high is “hypercalcemia” When calcium is out of range, think about muscles. They’ll be either hyperactive (spasming) or weak  Calcium HYPOCALCEMIA HYPERCALCEMIA Causes: Causes: ◦ Low dietary intake, malnutrition, vitamin D deficiency, ◦ Excessive dairy intake, excessive supplements/Tums ↓magnesium,, ↑ phosphate, (antacids) ◦ Chronic alcohol use, diarrhea, ↓albumin ◦ Disease: Paget, hyperparathyroidism, prolong ◦ Disease: Hypoparathyroidism, acute pancreatitis (unk immobilization, cancer of the bones cause), renal insufficiency ◦ Medications: Bisphosphonates Manifestations: ◦ Bone pain, arrythmias, cardiac arrest, kidney stones, Manifestations: muscle weakness/depressed reflexes ◦ Tetany, positive Chvostek, positive Trousseau Treatment: ◦ Hyperreflexia, muscle cramps ◦ IVF, calcitonin ◦ Paresthesia in the extremities and around the mouth Education: ◦ Increase PO calcium – supplements, dairy products, green leafy vegs, canned fish (sardines) Tetany Fish bones?  Magnesium The second most abundant cation in the intracellular fluid. Magnesium is involved in Many enzymatic reactions, including those responsible for metabolism, nutrient synthesis, and ATP synthesis, as well as nerve and muscle function Normal range: 1.3-2.1 mg/dL Too low is called “hypomagnesemia”, too high is “hypermagnesemia” Because of a relationship between magnesium and calcium levels, hypomagnesemia shares many of the same signs and symptoms of hypocalcemia Magnesium HYPOMAGNESEMIA HYPERMAGNESEMIA Similar causes and S/S of hypocalcemia Similar causes and S/S of hypercalcemia Positive tetany, positive Chvostek, positive Trousseau EKG: Torsades Treatment: PO or IV replacement  Phosphorus The major anion in the intracellular fluid. Most phosphorus is in bones as calcium phosphate. Phosphate is involved in muscles, nerves, red blood cells, and intracellular metabolism as ATP Normal range: 2.5-4.5 mg/dL Too low is called “hypophosphatemia”, too high is “hyperphosphatemia” Phosphorus and calcium have a reciprocal/inverse relationship: When one goes up, the other goes down. Therefore, the signs of hypophosphatemia are like those of hypercalcemia, and vice versa Phosphate HYPOPHOSPHATEMIA HYPERPHOSPHATEMIA  Educating on low phosphorus diets for patients with renal failure is important. They also take medications to bind and remove phosphorus NCLEX ???? time A nurse is monitoring a client’s laboratory results. Which of the following results should the nurse report to the provider? A. Sodium 142 mEq/L B. Potassium 3.0 mEq/L C. Chloride 100 mEq/L D. Magnesium 2.0 mEq/L Types of IV Access PERIPHERAL CENTRAL IV Therapy Purpose ◦ Administer medications ◦ Supplement fluid intake ◦ Provide fluid, electrolyte, nutrient replacement IV administration ◦ Bolus - large amount of fluids ◦ 500mL, 1L, etc. ◦ IV push - small amount over a short period of time ◦ 0.5mL to 10mL ◦ Intermittent IV - space throughout the day as a scheduled IV therapy when ◦ IV piggyback – antibiotics, electrolytes ◦ Continuous – ongoing, rate order by provider ◦ Maintenance fluids Advantages and disadvantages of IV therapy ADVANTAGES DISADVANTAGES Rapid absorption and onset of action Possibility of circulatory overload – fluid overload Less irritation to subcutaneous and muscle tissue over IM and SQ Rapid absorption can lead to adverse effects Complications of IV therapy ◦ Infection/cellulitis - invasion of tissues by pathogens ◦ Infiltration - leakage of nonvesicant and fluid or medication into tissue (NS, D5, D10) ◦ Extravasation - leakage of a vesicant fluid or medication (medications that can damage tissue) into the tissue ◦ Phlebitis - inflammation of a vein ◦ Thrombophlebitis - inflammation due to a clot ◦ Catheter embolus - breaking off an IV catheter ◦ Hematoma - leakage of blood into the tissue ◦ Air embolism - blockage caused by one or more bubbles of air IV therapy: pre-procedure Why are we placing an IV? What gauge do we need? 14 to 26 ◦ 14 to 16 – trauma ◦ 18 to 20 – surgery, blood transfusion, ◦ 22 to 24 – geriatrics, children, maintenance fluids ◦ 26 – neonates IV therapy: Intra-procedure and post-procedure Intra-procedure ◦ Are there any contraindications to starting an IV on a particular extremity? ◦ Hands and Arms: AV fistula, mastectomy, lymphadenectomy, PICC line ◦ Feet and Legs: diabetes mellitus ◦ Assess and clean the site with an antiseptic swab Post-procedure ◦ Check and verify solution and rate ◦ Consider compatibility of medications or solutions ◦ Not all are compatible with each other ◦ Maintain the patency of the IV ◦ TKO or periodic flushes ◦ Document NCLEX question Administration of IV fluids Provider Nurse ◦ Orders ◦ Implements provider orders ◦ Type of fluid ◦ Regulates or sets the infusion either with a pump or ◦ Volume to infuse manually ◦ Rate to infuse ◦ Ensures the right type of fluid is being administered, the right volume will be infused at the ordered rate Goal is to maintain fluid balance Assessment of fluid volume status Diagnose / Define alterations Plan Implementation Careful monitoring of intake / output Careful monitoring of vital signs and weights IVF – right fluids, right rate, right indication Evaluation Return to defined limits in assessment Types of Intravenous Fluids Effects of Osmolarity Isotonic Solutions Dextrose 5% in Water Normal Saline Lactated Ringer’s (D5W) (NS) 0.9% (LR) Composition: free water, no Composition: Na and Cl are the Composition: sodium, electrolytes, and dextrose 5% only electrolytes potassium, chloride, calcium, and lactate; no magnesium Uses: Uses: Hydration therapy, not for Uses: Hypernatremia hypernatremia Multiple electrolyte loss: GI Trauma, diarrhea, burns, surgery/NPO Most compatible for meds hemorrhage IV flush Contraindicated: Hyperkalemia, lactic acidosis/sepsis, Only fluid for Blood transfusion Hypercalcemia  Hypertonic Solutions Hypotonic Solutions 3% Na Cl D10W 0.45% NS (½ NS) Composition: Higher Composition: free water, no Composition: lower concentration of NaCl electrolytes, and dextrose percentage of sodium and 10% chloride Used in the ICU Uses: when TPN or PPN is Uses: Hypernatremia - since it unavailable is hypotonic, it pulls water Uses: Severe hyponatremia into the cell and sodium follows 41