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Fluid and Electrolytes

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Fluid and Electrolytes CSON Spring 2009 PREPARED BY CARLA HILTON, MSN, RN PRESENTED AND REVISED BY REBECCA POWERS, MSN, RN 15 questions from all of powers stuff – PowerPoint PPT presentation

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Title: Fluid and Electrolytes


1
Fluid and Electrolytes
  • CSON
  • Spring 2009
  • PREPARED BY CARLA HILTON, MSN, RN
  • PRESENTED AND REVISED BY REBECCA POWERS, MSN, RN
  • 15 questions from all of powers stuff

2
Water Balance Homeostasis
  • Water in the body is used to or for
  • Transporting nutrients oxygen to cells
  • Removing waste from cells
  • Provides medium in which electrolyte
    chemical reactions can occur
  • Regulation of body temperature
  • Lubricates joints and membranes
  • Provides medium for food digestion
  • liter of water weighs 2.2 lbs
  • The most accurate way to measure fluid status in
    a person is daily weights, not IO!!!

3
Water Distribution
  • ICF Intracellular fluid
  • ECF Extracellular fluid (lymph system,
    interstitial fluid, intravascular fluid or
    plasma)
  • TCF Transcellular fluid (cerebral spinal fluid,
    fluid in joints, GI tract, and peritoneal fluid)
  • Third spacing (a condition where fluid
    accumulates in a pocket that isnt really serving
    a purpose. Acieties (sp?)- where fluid hangs out
    in your abd. The fluid is coming from somewhere
    else.)
  • More fluid in intracellular than anywhere else in
    the body!

4
Osmolarity / Osmolality
  • Osmole
  • the amount of substance that dissociates in
    solution to form one mole of osmotically active
    particles
  • Concentration of solution measured in osmoles

5
Osmolarity / Osmolality
  • Osmolality is measured in milliOsmols/Kg
    (mOsm/Kg)
  • Osmolarity is measured in milliOsmols/L (mOsm/L)
  • Evaluates serum and urine in clinical practice
  • Normal serum osmolality 275 295 mOsm/K
  • Lality total volume will equal 1 L plus the
    amount of volume taken up by the solids! The
    koolaid and water equal a L
  • Larity volume is going to be less than 1 L. The
    koolaid minus the water.

6
Concentrations of Solutions
  • Isotonic Same osmolarity as blood plasmano
    osmotic pull
  • Hypotonic Less concentration than blood
    plasmalower osmotic pressure
  • Hypertonic More concentration than blood
    plasma.higher osmotic pressure

7
Movement of Water
  • Intracellular extracellular approximately same
    osmolality
  • Solvent (water) and solutes (electrolytes)
  • move across selectively permeable membranes
    (compartments) in the body
  • (the bigger the particle, the slower they move,
    and they may need a little boost)

8
Review of Terms
  • Osmosis
  • Diffusion
  • Active transport
  • Passive transport
  • Filtration
  • Hydrostatic pressure

9
Osmosis Review
  • Movement of water only
  • Speed of movement affected by
  • temperature of fluid
  • concentration of fluid
  • electrical charge of particles in solution
  • The higher the solute concentration, the greater
    the osmotic pressure is.

10
Other Mechanisms of Movement
  • Diffusion Solute (or gas) moves from area of
    higher concentration to area of lower
    concentration
  • Facilitated diffusion Solute moves against
    concentration gradient (passive transport)
  • Active transport Solute moved against
    concentration gradient using ENERGY

11
Active Transport
  • Na/K pump Maintains the higher concentrations
    of extracellular Na and intracellular K
  • In the cell, K is King. i.e. K is the major
    cation of the cell, Na is outside the cell.

12
Continued
  • Filtration solutes solvent move together in
    response to fluid pressure moves from area of
    high pressure (hydrostatic pressure) to area of
    low pressure
  • Hydrostatic pressure The force within a fluid
    compartment (as in the vascular system) The
    pressure that forces the fluid out of your
    capillaries.
  • Colloidal Osmotic Pressure pulls it back into
    the capillaries.

13
Regulation of Body Fluids
  • Intake osmoreceptors sense osmolality of
    serum, signals the hypothalamus, stimulates
    thirst
  • Impact on intake Age (decreases desire to
    drink), conciousness, ability to take in fluids
  • Output kidneys, lungs, GI tract, skin
  • Sensible measurable.urine output,
    excessive perspiration, diarrhea, vomiting
  • Insensible immeasurablenormal
    perspiration, normal breathing
  • Output for adults should be one mL/kg (of body
    weight) an hour

14
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15
Role of the Kidneys
  • Filter approx 180 Liters of blood per day GFR
    (glomerular filtration rate)
  • Produces urine between 1-2 Liters/day
  • If loss of 1 to 2 of body water, will conserve
    water by reabsorbing more water from filtrate
    urine will be more concentrated
  • If gain of excess body water, will excrete more
    water from filtrate urine will be more diluted

16
Hormonal Control
  • Antidiuretic hormone (ADH) Prevents diuresis
    water saving
  • Question Osmoreceptors sensing a/an increase in
    osmolality will cause the release of ADH
  • ADH acts on kidneys via the renal tubules. Makes
    them more permeable to water. The water will move
    from the tubes back into your body.

17
Hormonal Control
  • RAA (Renin-angiotensin-aldosterone) cascade
    initiated by decrease in renal perfusion or low
    Na
  • If extracellular volume is decreased
    renal perfusion decreases renin secreted
    by kidneys renin acts to produce
    angiotensin I which then converts to angiotensin
    II results in massive vasoconstriction
    increases renal arterial perfusion and
    causes increased thirst, a release of aldosterone
    (causes the retention of Na and Water)

18
Hormonal Control
  • Aldosterone
  • Angiotensin II causes the adrenal gland to
    release aldosterone
  • Aldosterone causes the kidneys to retain Na and
    water
  • Volume regulator.released if Na is low and K
    is high increases reabsorption of Na (where
    salt goes, water follows) and the excretion of K

19
ANP
  • Atrial Natriuretic Peptide (ANP) secreted from
    atrial cells of heart (in response to too much
    volume in the blood)
  • acts as diuretic
  • inhibits thirst mechanism
  • suppresses the RAA cascade

20
Thirst Mechanism
  • Regulated by the hypothalamus
  • Stimulates thirst
  • increased osmolality of ECF
  • decreased ECF
  • dry mucous membranes
  • Causes eating salty foods, inadequate intake,
    excessive water loss

21
Pressure Sensors
  • Baroreceptors Nerve receptors that sense
    pressure in blood vessels (think barometer
    measures pressure in the atmosphere, this
    measures pressure in the blood vessels)
  • Low pressure sensors in the cardiac
    atria stimulate SNS (sympathetic nervous system)
    inhibits PSNS (parasympathetic nervous system)
    (sns will increase heart rate and BP)
  • High pressure sensors in the aortic
    arch, carotid sinus, and the juxtaglomerular
    apparatus in the kidney stimulates PSNS and
    inhibits the SNS (psns will decrease your heart
    rate and lower BP)

22
Pressure Sensors
  • Osmorecptors Sense Na concentration
  • Positioned on surface of hypothalamus
  • Increase in Na concentration stimulates release
    of ADH
  • Decrease in Na concentration inhibits release
    of ADH

23
  • ELECTROLYTES and OTHER LABS RELATED TO FLUID
    VOLUME STATUS

24
Electrolytes
  • Minerals and salts electrolytes
  • Cations Positively charged sodium, potassium,
    calcium, magnesium
  • Major cation in ECF is sodium
  • Anions Negatively charged chloride,
    bicarbonate, sulfate
  • Major cation in ICF is potassium

25
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26
HyponatremiaUsually loss of Na w/o loss of fluid
  • Physical Exam
  • Apprehension
  • Personality change
  • Postural hypotension
  • Tachycardia
  • Convulsions/coma
  • NVD
  • Anorexia
  • Causes
  • Salt wasting fr. Kidney
  • Adrenal insufficiency
  • GI losses
  • Profuse sweating
  • Diuretics
  • SIADH
  • Syndrome of inappropriate Anti-Diruetic Hormone
  • Inadequate Na intake

27
Hyponatremia contd
  • Labs
  • Serum Na below 135 mEq/L
  • Serum Osmolality below 280 mOsm/kg
  • Urine specific gravity below 1.010
  • Treatment
  • Restrict water
  • Sodium replacement

28
Hypernatremia
  • Causes
  • ? ingestion of salt
  • Iatrogenic (we caused it)
  • ? aldosterone
  • Water deprivation
  • Signs Sxms
  • Thirst, sticky tongue
  • Dry, flushed skin
  • Fever
  • Convulsions, irritability

29
Hypernatremia contd
  • Labs
  • Serum Na above 145 mEq/L
  • Serum Osmolality above 295 mOsm/kg
  • Urine specific gravity above 1.030
  • Treatment
  • Hypotonic IV solution
  • or D5W

30
Urine Na Studies
  • Urine Na
  • Assesses volume status
  • Aids in diagnosing hyponatremia acute renal
    failure
  • Random normal range 50 -130 mEq/L
  • 24 hour 75-200 mEq/L

31
Hypokalemia
  • Causes
  • Diuretics that waste potassium
  • D, V, gastric suction
  • ? aldosterone
  • Polyuria, sweating
  • Iatrogenic K poor solutions
  • Signs Sxms
  • Weakness, fatigue
  • ? muscle tone
  • Hypoactive bowel sounds and distention
  • Weak, irregular pulse
  • Paresthesias
  • SOMETHING ABOUT CARDIAC FUNCTION

32
Hypokalemia contd
  • Labs
  • K below 3.5 mEq/L
  • ECG abnormalities
  • Treatment
  • Oral K or IV solution w/K
  • Increased dietary K

33
Hyperkalemia
  • Causes
  • Renal failure
  • Fluid vol. deficit
  • Massive cellular injury (trauma/burns)
  • Iatrogenic
  • Potassium sparing diuretics
  • Addisons disease
  • Signs Sxms
  • Anxiety
  • Dysrrhythmias
  • Paresthesia (numbness, pins needles feeling)
  • Weakness
  • Diarrhea

34
Hyperkalemia contd
  • Labs
  • Serum K above 5.0 mEq/L.
  • ECG abnormalities can lead to arrest (if too
    high or too low)
  • Treatment
  • Kayexalate
  • IV Na bicarb
  • IV Ca gluconate
  • Regular insulin and hypertonic dextrose IV
  • Limit via diet
  • Possible dialysis

35
Hypocalcemia
  • Causes
  • Rapid admin of blood w citrate
  • Hypoalbuminemia
  • Hypoparathyroidism
  • Vit. D deficiency
  • Pancreatitis
  • Stuff that relates back to preexisting conditions
  • Signs Sxms
  • Numbness, tingling of fingers mouth
  • Hyperactive reflexes
  • Tetany- a muscle contraction that stays
    contracted
  • Muscle cramps
  • Pathological fractures

36
Hypocalcemia contd
  • Labs
  • Serum Ca below 4.5 mEq/L
  • ECG abnormalities
  • Treatment
  • Increase dietary intake
  • IV calcium gluconate
  • Ca vit D supplements

37
Hypercalcemia
  • Causes
  • Hyperparathyroidism
  • Osteometastasis
  • Pagets disease
  • Osteoporosis
  • Prolonged immobilization
  • Signs Sxms
  • Anorexia, N V
  • Weakness, lethargy
  • Low back pain (stones)
  • Decreased LOC
  • Personality changes
  • Cardiac arrest

38
Hypercalcemia contd
  • Labs
  • Serum Ca above 5.5 mEq/L
  • X-rays showing osteoporosis
  • Stones ? BUN / creatinine fr. FVD or renal
    damage
  • Treatment
  • Lasix (diuretic)
  • Increased fluids

39
Hypomagnesemia
  • Causes
  • Inadequate intake
  • Alcohol, Malnutrition
  • Inadequate absorption
  • VD, Gastric aspirate
  • Fistulas, Sm. Bowel
  • Loss fr. Diuretics
  • Polyuria
  • Signs Sxms
  • Tremors
  • Hyperactive deep tendon reflexes
  • Confusion
  • Dysrhythmias

40
Hypomagnesemia contd
  • Labs
  • Serum Mg below 1.5 mEq/L
  • Treatment
  • Mag sulfate IV
  • Oral replacement
  • Increase dietary intake

41
Hypermagnesemia
  • Causes
  • Renal failure
  • Excess intake of magnesium
  • Signs Sxms
  • Most frequently seen in acute
  • Hypoactive deep tendon reflexes drowsiness
  • Decreased depth and rate of resp.
  • Hypotension
  • flushing

42
Hypermagnesemia contd
  • Labs
  • Serum Mg levels above 2.5 mEq/L
  • Treatment
  • IV calcium gluconate
  • Loop diuretics
  • NS or LR IV solutions
  • Dialysis

43
Additional Lab Data
  • Hematocrit
  • Measures the volume of RBCs in whole blood
  • Normal M 40-50 F 37-47
  • Increases with dehydration (hemoconcentration)
  • Decreases with overhydration (hemodilution)

44
Hematocrit Fluid Volume StatusFrom Fluids
Electrolytes Made Incredibly Easy 4th ed.
Fluids Electrolytes Made Incredibly Easy
45
Lab Data (contd)
  • Blood urea nitrogen (BUN)
  • Measures kidney function
  • Normal range 7-20mg/dL
  • Varies with protein intake, fever, dehydration,
    GI bleeding, liver failure, etc.

46
Lab Data (contd)
  • Creatinine
  • End product of muscle metabolism
  • Better indicator of renal function than BUN
  • Doesnt vary w protein intake or metabolic state
  • Normal range 0.7-1.5mg/dL in 24 hr urine
    collection
  • Serum adult female 0.5 to 1.1mg/dL
  • adult male 0.6 to 1.2mg/dL

47
Lab Data (contd)
  • Urine Specific Gravity
  • Measures ability of kidney to excrete or
    conserve water
  • Normal range 1.010 - 1.025
  • Increased S.G. concentrated urine
  • Decreased S.G. dilute urine

48
Lab Data (contd)
  • Serum Osmolarity
  • Most accurate for kidney function
  • Remember norm?
  • 280-295 mOsm/L
  • Measured directly through blood
  • Indirectly using Serum Osmolarity Formula

49
Maintaining Fluid Balance
50
Fluid Imbalances
  • Isotonic
  • Deficit water, electrolytes and solutes lost in
    equal proportions to body solutions
  • Excess water, electrolytes and solutes gained
    in equal proportions to body solution
  • FVD - fluid volume deficit-HYPOVOLEMIA
  • FVE - fluid volume excess-HYPERVOLEMIA

51
Fluid Disturbances
  • Osmolar Imbalances
  • Hyperosmolar Dehydration
  • Hypoosmolar Water excess
  • Loss or excesses of water only
  • Leads to alteration in concentration of serum

52
  • ISOTONIC FLUID DISTURBANCES

53
Fluid Volume Deficit (FVD)
  • Water AND solutes lost in equal proportion.
  • Diarrhea, vomiting, fistulas, drains
  • Bleeding, burns
  • Fever, excessive perspiration
  • Inadequate fluid intake
  • Diuretics
  • GI suctioning

54
FVD Signs Symptoms
  • Mild
  • Dry mouth, furrowed tongue
  • Orthostatic or postural hypotension
  • Restlessness anxiety
  • Tachycardia
  • Less than 5 weight loss
  • Moderate
  • Confusion, irritability, thirst, cool clammy
  • Urine output 30cc/hr or less
  • Rapid weight loss
  • Slowed vein filling

55
FVD Signs Symptoms (contd)
  • Severe
  • Pale
  • Flattened neck veins, delayed capillary refill
  • Urine output less than 10cc/hr
  • Marked hypotension, tachycardia, weak or absent
    pulses (shock)
  • Can lead to unconsciousness

56
FVD Labs
  • Lab findings vary depending on the cause
  • Decreased H/H with hemorrhage
  • Increased Hct
  • Elevated BUN
  • Urine specific gravity greater
  • than 1.030

57
FVD Nursing Diagnosis Statement
  • Example
  • Fluid volume deficit r/t active fluid volume loss
    as evidenced by decreased blood pressure (90/50
    mmHg), thirst, fever (102), rapid heart rate
    (110 bpm), urine output less than or equal to 25
    mL/hr, urine specific gravity of 1.040.

58
FVD Goal Statement
  • Client will achieve fluid balance AEB
  • urine output equal to or greater than 30 mL/hr
  • Elastic skin turgor and moist mucous membranes

59
FVD Medical Interventions
  • Treat cause
  • Replacing fluids intravenously
  • isotonic if hypotensive (expand plasma
    volume)
  • hypotonic if normotensive (provides
    electrolytes and water)
  • Encourage fluids
  • Ensure adequate O2 and perfusion
  • Increase blood counts, BP, albumin levels
  • Teaching

60
FVD Nursing Interventions
  • Ensure patent airway, adjust O2 levels as ordered
  • Lower HOB if tolerated or not contraindicated
  • Direct pressure to bleeding, if present
  • Administer meds, blood, albumin, IV fluids

61
FVD Nursing Interventions (contd)
  • Weigh patients daily
  • Provide skin care
  • Maintain strict IO
  • Monitor vital signs
  • Monitor lab work

62
FVD Teaching
  • Nature of condition causes
  • Warning S/S
  • Treatments importance of compliance
  • Change positions slowly
  • Monitor BP pulse rate
  • Give prescribed medications

63
Fluid Volume Excess (FVE)
  • Water AND solutes gained in excess of normal body
    levels
  • Causes
  • Isotonic fluid overload
  • Excess sodium intake
  • CHF, renal failure, cirrhosis
  • Increase in steroids or serum aldosterone

64
FVE Signs Symptoms
  • Generalized
  • Acute weight gain
  • Mild-mod 5-10
  • Severe gt 10
  • Edema
  • dependent, sacral, pulmonary
  • Cardiovascular
  • Tachycardia, bounding pulse, distended neck
    veins, increased BP
  • Respiratory
  • Dyspnea, tachypnea, crackles, frothy cough

65
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66
FVE Lab Values
  • Decreased hematocrit
  • Decreased BUN
  • Low O2 levels

67
FVE Nursing Diagnosis Statement
  • Fluid volume excess r/t excess fluid intake aeb
    Hct of 23, 10 weight gain in two days, dyspnea
    (Pt states, I cant get enough air.), and
    crackles on inspiration and expiration in all
    lobes.

68
FVE Related Nursing Diagnoses
  • Ineffective breathing pattern r/t increased
    fluids
  • Impaired skin integrity r/t excess fluids
  • Confusion

69
FVE Client Goals Outcomes
  • Aimed at cause
  • Decrease circulating fluid volume
  • Lower BP and pulse
  • Improve breathing status
  • Maintain skin integrity
  • Teaching

70
FVE Goal Statement
  • Client will achieve fluid balance manifest in
    following outcomes
  • Clear breath sounds
  • Denies dyspnea and affirms the ability to breathe
    adequately

71
FVE Nursing Interventions
  • Restrict Na fluid intake
  • Watch for edema - dependent respiratory
  • Provide measures to facilitate breathing
  • Provide skin care for weeping edema

72
FVE Nursing Interventions (contd)
  • Monitor response to medications
  • Accurate I/O, Consistent daily weight, VS,
    monitor labs
  • Advise HCP if poor response to therapy
  • Hemodialysis may be needed

73
FVE Teaching
  • Nature of condition and causes
  • Signs and symptoms
  • Treatments and importance of compliance
  • Need to monitor BP, P, O2 Sat, weight
  • Rationale for Na and fluid restrictions
  • Medications

74
Osmolar Imbalances
75
Hyperosmolar Dehydration
  • Loss of water increased serum osmolality
  • increased serum Na
  • Compensatory Mechanism water shifts out of cells
    (ICF) into the ECF..if not corrected, water
    continues to move out of cells (ICF) and into ECF
    causing the cells to shrink.shrunken cells dont
    function properly!!

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77
Causes of Dehydration
  • Causes
  • Diabetes insipidus, prolonged fever, watery
    diarrhea, hyperglycemia, failed thirst drive
  • Iatrogenic hypertonic solutions (IV tube
    feeding)
  • Diuresis of water alone

78
Dehydration Signs Symptoms
  • Irritability, confusion, weakness, dizziness
  • Decreased urine output, darkened urine
  • Dry, sticky mucous membranes, sunken eyeballs,
    poor turgor, extreme thirst !!!
  • Fever (insensible continuous)
  • Coma
  • Tachycardia, weak, thready pulse, hypotension

79
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80
Dehydration Labs
  • Elevated hematocrit
  • Elevated serum osmolarity gt 295 mOsm/kg
  • Elevated serum sodium gt 145 mEq/L
  • Urine specific gravity gt 1.030

81
Dehydration Nursing Diagnoses
  • Fluid volume deficit r/t fluid loss
  • Deficient fluid volume r/t excessive fluid loss
    from GI tract
  • Risk for impaired skin integrity r/t altered
    metabolic state
  • If youve lost 20 of you initial weight from
    dehydration, youre probably dead

82
Dehydration Potential Nursing Diagnoses
  • Deficient knowledge unfamiliarity of disease
    process
  • Disturbed thought processes r/t neurologic
    changes / decreased cardiac output
  • Decreased cardiac output r/t excessive fluid loss

83
Dehydration Client Goals Outcomes
  • Aimed at correcting cause
  • Replace fluids hypotonic, slowly re-hydrate
    over 48 hrs (if you go too quickly, you die)
  • Maintain skin integrity
  • Teaching

84
Dehydration Nursing Interventions
  • Replace fluids by PO route first
  • SLOW admin. of salt-free IV solutions
  • Monitor S/S cerebral pulmonary edema
  • Monitor accurate I/O, VS, daily weights
  • Monitor labs
  • Provide skin and mouth care

85
Dehydration Teaching
  • Disease process of dehydration
  • Treatments
  • Warning signs and symptoms
  • Medications / IV (Vasopressin D5W)
  • Importance of compliance with therapy
  • Fluid intake not based on thirst alone

86
Hypoosmolar
  • Water excess
  • Causes
  • SIADH or excess water intake
  • Signs Sxms
  • Decreased LOC, convulsions, coma
  • Labs
  • Serum Na below 135 mEq/L and Serum osmolality
    below 280 mOsm/kg

87
Nsg Dx Goals - Interventions
  • Similar to FVE
  • Make relevant to underlying cause
  • Is very acute illness

88
Physical Assessment
89
History
  • Medical Acute Illness, surgery, burns
  • Environment exercise, hot/cold/dry areas
  • Diet proteins, lytes, fluids
  • Lifestyle smoking/alcohol
  • Medication history

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91
Areas of Concern in PA
  • Mental status
  • BP and pulse
  • Skin
  • I Os WEIGHT
  • Lungs

92
Geriatric Focus
  • Body-water content (mass related)
  • Kidney function
  • Cardiac respiratory function
  • Hormonal regulatory function
  • Thirst sensation
  • Medication Use
  • Skin subcutaneous fat

93
Assessment of Geriatric Clients
  • Skin turgor
  • Assessment is performed where?
  • Cognition
  • Physical being
  • Continence

94
Laboratory Data
  • BMP / CMP
  • Serum osmolarity
  • Urine specific gravity
  • Urine sodium
  • Hematocrit
  • Blood urea nitrogen (BUN)
  • Creatinine

95
Clients at Risk for FE Imbalances
  • Age
  • Very young
  • Very old
  • Chronic Diseases
  • Cancer
  • Cardiovascular disease, such as congestive heart
    failure
  • Endocrine disease, such as Cushing's disease and
    diabetes
  • Malnutrition
  • Chronic obstructive pulmonary disease
  • Renal disease, such as progressive renal failure
  • Changes in level of consciousness

96
Clients at Risk for FE Imbalances
  • Trauma
  • Crush injuries
  • Head injuries
  • Burns
  • Major surgery
  • Therapies
  • Diuretics
  • Steroids
  • Intravenous (IV) therapy
  • Total parenteral nutrition (TPN)
  • Gastrointestinal losses
  • Gastroenteritis
  • Nasogastric suctioning
  • Fistulas

97
Fluid Electrolytes Nursing DXs
  • Risk for imbalanced Body temperature
  • Ineffective Breathing pattern
  • Decreased Cardiac output
  • Deficient Fluid volume
  • Risk for deficient Fluid volume
  • Excess Fluid volume
  • Impaired Gas exchange
  • Knowledge deficient regarding disease management
  • Impaired Mobility
  • Impaired Oral mucous membrane
  • Impaired Skin integrity
  • Risk for impaired Skin integrity
  • Ineffective Therapeutic regimen management
  • Impaired Tissue integrity
  • Ineffective Tissue perfusion

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99
Intravenous Fluid Therapy in Fluid Balance
Disorders
100
ISOtonic solutions
  • Same osmolarity as body fluids
  • 280 - 300 mOsm/kg
  • Expands the IVC without pulling fluids from other
    compartments
  • Examples
  • Normal saline (NS)
  • Lactated Ringers (LR)

101
IVs Normal Saline (NS)
  • Isotonic
  • 0.9 Sodium Chloride
  • Different amounts
  • Sample order
  • NS _at_ 75cc/hr

102
IVs Lactated Ringers (LR)
  • Isotonic Solution
  • Contents
  • Na, Cl-, K, Ca, Lactate in sterile water
  • One strength, two common amounts
  • Sample orders
  • LR _at_ 100cc/hr
  • RL _at_ 75cc/hr

103
HypOtonic solutions
  • Osmolarity less than serum
  • Pulls fluid from the IVC into the ICC causing
    cells to expand
  • Over hydration
  • Rehydration
  • Example
  • ½ NS
  • D5W - after absorbed into body

RISK
104
IVs Dextrose Solutions
  • Concentrations
  • 5 in water (hypotonic after enters body)
  • 10 in water (hypertonic)
  • 50 in water (rescue solution small volume)
  • As additive to NS or LR
  • D5NS or D5LR

105
HypERtonic solutions
  • Osmolarity of solution is higher than serum
    osmolarity
  • gt300 mOsm/kg
  • Pulls fluid from ICC into IVC causing cells to
    shrink
  • dehydrate
  • Examples
  • D51/2 NS - D5NS - D5LR
  • 3 NS (CRITICAL Strength)

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107
IVs Common Additives
  • Potassium (never add to a bag!)
  • Multivitamins
  • Additives makes the solution hypertonic to some
    extent depends on amount

108
IV Additives Potassium
  • Available as KCl (potassium chloride)
  • NEVER add K to a bag of fluid
  • Added by pharmacy or premixed
  • Different strengths
  • Sample orders
  • NS c 20 mEq KCl _at_ 75 cc/hr
  • LR c 40 mEq KCl _at_ 75 cc/hr

109
Medications Used in Fluid Electrolyte Imbalance
Disorders
110
Meds Antidiarrheals
  • Assess I /O electrolytes
  • Provide oral care
  • Monitor for constipation
  • Teaching
  • Take as directed
  • Avoid overdose
  • Examples Lomotil Immodium

111
Meds Antiemetics
  • Assess VS emesis status before and after
  • Monitor for extrapyriamidal side effects
  • involuntary movement of eyes, face or limbs, flat
    affect, shuffled gait, drooling
  • Provide fluid replacements
  • Oral electrolyte solutions
  • Water
  • Sample Meds Zofran, Phenergan Vistaril

112
Meds Diuretics
  • Assess
  • Weight, edema, skin turgor, mucus membranes,
    lung sounds
  • Monitor
  • weight, I /O, electrolytes
  • Teaching
  • diet, weigh daily, dosing times
  • Examples
  • Thiazides (HCTZ) HTN
  • Potassium sparing (spironolactone)
  • Osmotic (mannitol) decrease ICP
  • Loop (lasix) pull fluids

113
Meds Potassium
  • Forms tablets (SR), effervescent, EC, IV
  • Administration considerations
  • PO Give on a full stomach at mealtime am/pm
  • IV NEVER give as bolus, follow protocol, dilute
    for IV administration, can burn lead to
    infiltration
  • Monitor K levels monitor EKG if elevated

114
Meds Kayexelate
  • Removes K from system
  • Available as enema or by PO route
  • Retain enema for ½ to 1 hr
  • Follow resin w 100 mL water
  • After expulsion, rinse colon w 1 liter of water
    and drain out immediately

115
Other Meds r/t F/E status
  • Glucocorticosteroids
  • Digoxin
  • Electrolyte supplements

116
Stuff To Add for the Test
  • A L of fluid weighs 2.2 lbs
  • 1 lb of fluid is 454 mL
  • If a L of fluid weighs 2.2 lbs you need to be
    able to figure out how many mL a ½ lb is
  • 10 fluid loss is serious, but 20 loss is mostly
    death
  • If you have someone who begins to have a
    transfusion reaction (hemolytic) watch for
  • Fever, low back pain, itching, hypotension, N/V,
    drop in urine output, chest pain, dyspnea
  • If you are doing VS for these people and they
    have these symptoms, GO FIND THE NURSE
    IMMEDIATELY! They dont need any more blood
    whatsoever!
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