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Fluid Volume Electrolytes
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ECF Volume deficit Hypovolemia
Causes Abnormal fluid loss Diarrhea Fistula drainage Hemorrhage Polyuria Fever (↑ perspiration) Inadequate intake Osmotic diuresis
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ECF Volume Deficit: Hypovolemia
Cardiovascular Changes Respiratory Renal Changes Neurologic Mild to moderate ↑ HR Peripheral pulses are weak, difficult to find Change in position may cause ↑ HR or ↓ BP Dizziness and light-headedness Severe fluid volume ↓ BP in lying position Pulse: weak, thready Flattened neck veins ↑ respiratory rate UO below 500 mL/day Alteration in Mental Status Restlessness Drowsiness Lethargy Confusion (more common in the elderly; may be first indicator of fluid balance problem) Seizures, coma
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ECF Volume deficit Assessment Findings
Skin turgor is diminished Skin may be warm and dry with mild deficit Skin may be cool and moist with severe deficit Skin may appear dry and wrinkled Oral mucous membranes will be dry, sticky, pastelike coating and the tongue may be furrowed Patient C/O thirst Eyes: soft, sunken Lab data: ↑ H & H; BUN; Josie King
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Nursing Care Plan Therapeutic Interventions
Restore fluid and electrolyte balance IVs and blood products as ordered; small, frequent drinks by mouth Daily weights to monitor progress of fluid replacement Loss or gain of 2.2 lbs is equal to 1 L of fluid I & O, hourly outputs Two most important assessments: HR & Output Avoid hypertonic solutions Promote comfort Frequent skin care Position: change q hr to relieve pressure meds as ordered: antiemetics, antidiarrheal
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Nursing Care Plan Therapeutic Interventions
Prevent physical injury Risk for falls due to orthostatic hypotension, dysrhythmia, muscle weakness, gait stability and level of alertness. Frequent mouth care Dry mucous membrane due to dehydration Monitor IV flow rate Observe for circulatory overload (↑ pulse, ↑ HR) Pulmonary edema (SOB) Monitor vital signs BP should be rising, ↑ LOC: more alert
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ECF Volume excess Hypervolemia
Causes Excessive intake of fluids Abnormal retention of fluids Heart failure Renal failure Long-term corticosteroid therapy
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ECF Volume Excess: Hypervolemia
Cardiovascular Changes Respiratory Skin Neurologic Other ↑ Pulse: full and bounding Full peripheral pulses Distended neck veins ↑ BP ↑ respiratory rate Shallow respirations ↑ dyspnea with exertion or in the supine position Pulmonary congestion and pulmonary edema SOB Irritative cough Moist crackles Edematous may feel cool Skin may feel taut and hard Edema-eyelids, facial, dependent (sacrum), pitting, peripheral extremities Altered LOC Visual disturbances Skeletal muscle weakness Parenthesis Cerebral edema Headache Confusion Lethargy Diminished reflexes Seizures, coma Urine: polyuria, nocturia Lab data ↓Hematocrit, BUN GI Changes Increased motility Enlarged liver
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Nursing Care Plan Therapeutic Interventions
Maintain oxygen to all cells Position: sim-Fowler’s or Fowler’s to facilitate improved gas exchange. Vital signs; q 4 hrs and PRN Tachycardia ↑ BP (overload) and ↓ BP (fluid deficit) Fluid restriction: I & O Promote excretion of excess fluid Meds as ordered: diuretics Monitor electrolytes, esp. Mg and K
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Nursing Care Plan Therapeutic Interventions
Obtain/maintain fluid balance Wt gain is the best indicator of fluid retention and overload Weight daily; 2.2 lbs = 1 Liter (1000 ml) Measure: all edematous parts, abdominal girth, I & O: fluid restriction Limit fluids by mouth, IVs per doctors orders Strict monitoring of IV fluids Prevent tissue injury Skin and mouth care as needed Evaluate feet for edema and discoloration when client is OOB Observe suture line on surgical clients (Potential for evisceration due to excess fluid retention)
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Functions of Sodium Regulates osmolality
ICF: 14 mmol/L & ECF: mmol/L Helps maintain blood pressure by balancing the volume of water in the body Works with other electrolytes to promote nerves, muscles and other body tissues to work properly.
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Hypernatremia Na Excess Water Deficiency H20 ↑ Osmolality
Normal ECF/↑ ECF H20 ↑ Osmolality ↓ ECF (Looks like excessive Na)
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Hypernatremia Water loss: Causes
Water loss: Signs and Symptoms Inadequate water intake (dehydration) Unconscious or cognitively impaired individuals NPO status Excessive water loss ↑ insensible water loss High fever Diuretic therapy Watery diarrhea Disease states Kidney Uncontrolled diabetes mellitus Diabetes insipidus Restlessness, agitation, twitching, confusion Seizures*, Coma Intense thirst Dry, swollen tongue Sticky mucous membranes Weight loss Weakness, lethargy Postural hypotension
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Hypernatremia Na gain: Causes Na gain: Signs and Symptoms Na intake
IV fluids: hypertonic NaCl, excessive isotonic NaCl Hypertonic tube feeding with out water supplement Use of Na containing drugs Corticosteroids Diseases Renal failure Restlessness, agitation, twitching Seizures, Coma Intense thirst Flushed skin Weight gain Peripheral and pulmonary edema ↑ BP
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Nursing Diagnosis for Hypernatremia
Risk for injury related to altered sensorium and seizures secondary to abnormal CNS function Risk for injury related to altered sensorium and seizures secondary to abnormal CNS function Potential complications: seizures and coma leading to irreversible brain damage
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Group learning Discuss with your neighbor
Why in Hypernatremia (water deficit) and hypernatremia (gain of more salt) there is a difference in the BP (blood pressure). List a Nursing Diagnosis for a patient with hypernatremia.
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Hyponatremia H20 Water Excess (↑ ECF Volume) H20 ↓ Osmolality ↑ ECF
Na deficiency (Loss of Na containing fluids) Water Excess (↑ ECF Volume) H20 ↓ Osmolality ↓ ECF Volume Excess Na Loss H20 ↓ Osmolality ↑ ECF Dilutional
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Hyponatremia Dilutional (↑ ECF Volume) Causes
Use of hypotonic irrigation solution Tap water enemas Excessive water gain Excessive hypotonic IV fluid Dilutional (↑ ECF Volume) Signs and Symptoms Headache, apathy, confusion Nausea, vomiting, anorexia Lethargy Weakness Muscle spasms, seizures, coma Diarrhea, Abdominal cramps Weight gain ↑ BP
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Hyponatremia Na Loss: Causes Na Loss: Signs and Symptoms GI Kidney
Vomiting Diarrhea NG suctioning NPO Status Kidney Diuretic Skin Burns Wounds Excessive diaphoresis Na Loss: Signs and Symptoms Irritability, apprehension, confusion Dizziness Personality changes Tremors, seizures, coma Dry mucous membranes Postural hypotension Tachycardia, thread pulse Cold & clammy skin
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Functions of Potassium
Maintains fluid balance in the cells Contributes to intracellular osmotic pressure Direct effect on excitability of nerves and muscles Skeletal, cardiac, and smooth muscle contraction Regulates glucose use and storage
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Hyperkalemia Causes Most cases of hyperkalemia occur in hospitalized patients and in those undergoing medical treatment. Those at greatest risk for hyperkalemia are Chronically ill patients Debilitated patients Older adult
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Hyperkalemia Causes Actual hyperkalemia Relative hyperkalemia
Excess potassium Intake Excessive or rapid parenteral administration Shift of potassium Out of Cells Acidosis Crushing injury Tissue catabolism (fever, sepsis, burns)
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Hyperkalemia Causes Failure to Eliminate Potassium Renal disease
Potassium-sparing diuretics ACE inhibitors
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Hyperkalemia Signs and Symptoms
Clinical Manifestations Electrocardiogram Changes Irritability Abdominal cramping, diarrhea Weakness of lower extremities Irregular pulse Cardiac arrest if hyperkalemia sudden or severe Ventricular fibrillation Ventricular standstill
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Nursing Diagnosis: Hyperkalemia
Risk for injury related to lower extremity muscle weakness and seizures Risk for decreased cardiac output related to dysrhythmias Decreased cardiac output r/t dysrhythmias Activity intolerance r/t weakness Ineffective breathing patterns r/t muscle weakness and paralysis Diarrhea r/t neuromuscular changes and irritability Risk for injury r/t muscle weakness and seizures
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Hypokalemia Causes Potassium Loss Shift of Potassium into Cells
GI losses: diarrhea, vomiting, fistulas, NG suction, NPO status Renal losses: diuretics, Skin losses: diaphoresis Dialysis Shift of Potassium into Cells Alkalosis
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Hypokalemia Causes Lack of Potassium Intake Starvation Diet low in K
Failure to include K in parenteral fluids if NPO TPN
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Hypokalemia Signs and Symptoms
Clinical Manifestations Electrocardiogram Changes Fatigue Muscle weakness, leg cramps Nausea, vomiting, paralytic ileus Soft, flabby muscles Paresthesia, decreased reflexes Weak, irregular pulse Ventricular dysrhythmias (e.g., PVCs) Bradycardia
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Hypokalemia Medical Management
Administration of KCl supplements K may be given orally (K chloride, K gluconate, K citrate) or IV KCl should be administered IV at a rate of 10 to 20 mEq/L over an hour. Rapid infusion could cause cardiac arrest IV K solutions irritate veins and cause phlebitis. Check IV site q 2 hrs. Discontinue IV if infiltrate to prevent necrotic and slough of tissue
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Nursing Diagnosis: HypoKalemia
Risk for injury related to muscle weakness and hyporeflexia Risk for decreased cardiac output related to dysrhythmias Fatigue Constipation Bathing/hygiene self-care deficit
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Functions of Calcium Helps maintain muscle tone
Contributes to regulation of blood pressure by maintaining cardiac contractility Necessary for nerve transmission and contraction of skeletal and cardiac muscle
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Hypercalcemia Causes Increased Total Calcium Prolonged immobilization
Thiazide diuretics Dehydration Renal failure
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Hypercalcemia Signs and Symptoms
Clinical Manifestations Electrocardiogram Changes Lethargy, weakness Depressed reflexes (DTR) Decreased memory Confusion, personality changes, psychosis Anorexia, nausea, vomiting, constipation Bone pain, fractures Ventricular dysrhythmias Hypertension
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Hypercalcemia: Medical Treatment
Administration of IV (.9NS) fluids followed by a loop diuretic (Excretion of Ca is followed by excretion of Na) Calcitonin via IV to promote renal excretion of Ca Nausea treated with antiemetics Stool softeners given for constipation Cardiac monitoring Dialysis: for severe hypercalcemia
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Nursing Diagnosis: Hypercalcemia
Risk for injury related to neuromuscular and sensorium changes Risk for decreased cardiac output related to dysrhythmias
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Hypocalcemia Causes Decreased Total Calcium Decreased Ionized Calcium
Chronic renal failure Loop diuretics (e.g., furosemide [Lasix]) Chronic alcoholism Diarrhea Decreased Ionized Calcium Excess administration of citrated blood
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Hypocalcemia Signs and Symptoms
Clinical Manifestations Electrocardiogram Changes Easy fatigability Depression, anxiety, confusion Numbness and tingling in extremities and region around mouth Hyperreflexia, muscle cramps Chvostek’s sign & Trousseau’s sign Laryngeal spasm Tetany, seizures Ventricular tachycardia
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Nursing Diagnosis: Hypercalcemia
Risk for injury related to tetany and seizures Potential complications: fracture, respiratory arrest Pain Diarrhea Risk for injury
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Functions of Magnesium
Cofactor in clotting cascade Acts directly on myoneural junction, affecting muscular irritability and contractions Maintains strong and healthy bones
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Hypermagnesemia Causes
Renal failure Diabetes Mellitus Clients who ingest large amounts of Mg-containing antacids such as Tums, Maalox, Mylanta, or laxatives such as MOM are also in ↑ risk for developing hypermagnesemia
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Hypermagnesemia Signs and Symptoms
Bradycardia and hypotension Severe hypermagnesemia: cardiac arrest Drowsy or lethargic Coma Deep tendon reflexes are reduced or absent Skeletal muscle contractions become progressively weaker and finally stop
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Hypomagnesaemia Causes
Malabsorption disorders Inflammatory bowel disease (IBD) Bowel resection Bariatric population who undergoes gastric bypass surgery Alcoholism Prolonged diarrhea Draining GI fistulas Diuretics
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Hypomagnesaemia Signs and Symptoms
Confusion Hyperactive deep tendon reflexes Tremors Seizures Neuromuscular changes Hyperactive deep tendon reflexes Numbness and tingling Painful muscle contractions Monitor for positive Chvostek’s and Trousseau’s signs (hypocalemia may
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Group learning Discuss with your neighbor
The questions the nurse asks to elicit risk factors for fluid and electrolyte imbalances How recent surgery causes changes in F & E imbalances How increased GI output can cause changes in F & E imbalances
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Physical Assessment Daily weights Fluid intake and output (I&O)
Indicator of fluid status Use same conditions. Fluid intake and output (I&O) 24-hour I&O: compare intake versus output Intake includes all liquids eaten, drunk, or received through IV. Output = Urine, diarrhea, vomitus, gastric suction, wound drainage Laboratory studies
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Fluid and Electrolyte Assessment
Nutritional-Metabolic Pattern What is your typical daily food intake? Describe a day’s meals, snacks, and vitamins. How much salt do you typically add to your food? Do you use salt substitutes? How is your appetite? Do you have any difficulty chewing or swallowing? What is your typical daily fluid intake? What types of fluids (water, juices, soft drinks, coffee, tea)? How much?
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