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Where can Extracellular Fluid (ECF) be found?
- Spinal column
- interstitial tissue
- cerebral fluid
What are the four major cations in the body?
- Sodium (Na+)
- Potassium (K+)
- Calcium (Ca++)
- Magnesium (Mg++)
What are the three major anions in the body?
- Chloride (Cl-)
- Bicarbonate (HCO---)
- Phosphate (PO4---)
What are the four routes for fluid output?
- Insensible loss through the skin as perspiration, and the lungs as water vapor
- noticeable loss through the skin as sweat
- loss through the intestines as feces
What is the average fluid input/output amount for an adult?
What regulates Sodium in the body?
- dietary input
- aldosterone secretion
(normal extracellular Na+ concentration 136-145 mEq/L)
What regulates Potassium in the body
- dietary intake
- renal excretion
(normal range for serum K+ is 3.5-5.0 mEq/L)
What regulates Calcium in the body?
stored in bone, plasma, and body cells
(normal serum ionized calcium is 4.5-5.3 mg/dL)
What symptoms should a person with high levels of serum Calcium watch out for?
- fragile bones
- kidney stones
What regulates Magnesium in the body?
- dietary intake
- renal mechanisms
- action of the parathyroid hormone (PTH)
(normal plasma concentrations of Mg++ is 1.5-2.5 mEq/L)
What are the four major cations found in the body?
- Sodium (Na+)
- Potassium (K+)
- Calcium (Ca++)
- Magnesium (Mg+++)
What are the three major anions found in the body?
- Chloride (Cl-)
- Bicarbonate (NCO---)
- Phosphate (PO4---)
Where can you find extracellular fluid (ECF) in the body?
- Spinal fluid
- Interstitial fluid
- Cerebral fluid
What substance moves freely in order to equalize solutes across a semi-permeable membrane?
(Solutes MAY move through a permeable membrane, but water moves through a semi-permeable one. This is why cells will shrink or swell when equalizing solutes on either side of the cell membrane.)
What hormonal factors affect thirst?
- Pituitary gland (secretes ADH into bloodstream)
- Adrenal glands (secretes aldosterone, cortisol, epinepherine, norepinephrine)
- Kidneys (RAA system)
- Hypothalamus (produces ADH)
- Thyroid (produces T3 and T3 which affect cardiac output)
- Heart (produces ANP - atrial natriuretic peptides)
How is the pituitary gland involved in fluid balance?
It secretes ADH (anti-diuretic hormone). This conserves water in the bloodstream. ADH causes renal cells to reabsorb water from the renal tubules, and back into the bloodstream.
How are the adrenal glands involved in fluid balance?
- They secrete:
- aldosterone - (affects kidneys) causes resorption of Sodium and water from renal tubes
What releases aldosterone, what triggers it, and what is its function on fluid balance?
- The adrenal glands release aldosterone
- It is triggered by the presence of angiotensin II
- and it causes the kidneys to resorb Sodium (and water follows) into the bloodstream
(Increases blood volume/ increases blood pressure)
What releases ANP, what triggers it, and what is its function in fluid balance?
- ANP comes from the atrial valve in the heart (atrial natriuretic peptide)
- High blood pressure/volume triggers its release
- it affects the kidneys by dilating the afferent artierioles, which increases the filtration rate, causing a loss of fluid in the urine
- it also blocks the release of resin, providing a negative feedback to the RAAS system
(overall effect is to REDUCE blood volume and blood pressure)
What releases ACE, what triggers it, and what is its function in fluid balance?
- ACE is released by the lungs and also the kidneys (but mostly the lungs)
- It is released as a matter of course
- It converts available Angiotensin I to Angiotensin II
(which then causes an increase in blood volume)
What releases renin, what triggers it, and what is its function in fluid balance?
- Renin is released by the kidneys
- When the kidneys detect a decrease in perfusion (low blood volume or pressure)
- It starts the chain reaction of converting angioteninogen (free floating from liver) to angiotensin I
(which eventually will increase blood volume/pressure)
What electrolytes are regulated by the kidneys?
What electrolyte is regulated by the parathyroid (PTH)?
What would an elevated BUN and elevated creatinine indicate?
Kidneys not filtering waste
(waste gets into brain, start seeing mental changes)
What are the 4 usual causes of ECV deficit?
- Abnormal losses (skin, GI, kidneys)
- decreased intake of fluid
- movement of fluid into a third space (edema)
What are 5 nursing interventions that can be done for ECV deficit?
- assess changes in clinical signs
- administer oral fluids as indicated
- provide prn meds for nausea as required
- assess breath sounds (baseline, and later)
- implement measures to prevent skin breakdown (fragile skin near edema)
What is happening in the body during dehydration?
- water loss without proportionate loss of electrolytes, particularly sodium
- loss of only water -> increase in serum sodium levels and concentration (osmolality) -> intracellular dehydration (water from cells follows Na in ECF)
What are the defining characteristics of excess fluid volume/water intoxication/hypervolemia?
direct or indirect result of an increase in fluid intake or decrease in excretion without compensation by intercompartmental fluid shifts or other regulatory mechanisms
What is "brawny edema"?
edema that can't be described by stage, because the fluid can't be displaced when touched
What are 5 nursing interventions for excess fluid volume?
- assess changes in clinical signs of EFV
- encourage intake of low-sodium food, and fluid as ordered
- monitor fluid I/O (looking for more out than in)
- administer diuretics as ordered
- employ measures to prevent skin breakdown
What is a critical symptom of overhydration?
LOC and changes in mentation because of cerebral edema
In what fluid imbalance would you want to watch out for orthostatic hypotension?
deficient fluid volume
What fluid imbalance would extended neck veins be a symptom of?
What electrolyte imbalance will have orthostatic hypotension as a major symptom?
(sodium in cells pull water from ECF into ICF, causing hypovolemia, which affects BP)
What pathophysiological factor can account for many of the clinical signs of hyponatremia?
Water retention in the brain cells
What are five nursing interventions you can do for Hyponatremia?
- Monitor fluid I/O
- Assess clinical signs
- monitor lab data (e.g. serum sodium)
- assess patient closely if administering hypertonic saline solutions (careful with rate - cells can lose water and shrink)
- encourage food and fluid high in sodium if permitted (BACON! ;) )
What electrolyte imbalance suggests daily weighings at the same time?
What happens in the body with hypernatremia?
- water follows the Na+, thus leaving the cells and entering the ECF - cells become dehydrated
- body attempts to conserve as much water as possible through renal reabsorption (if kidneys not working, this won't work well!!!)
What are six nursing interventions that can be done for Hypernatremia?
- monitor fluid I/O
- monitor behavior changes (reslessness, disorientation)
- monitor lab findings (e.g. serum sodium)
- encourage fluids as ordered
- monitor dies as ordered (restrict salt/sodium intake)
- treat with D5W (isotonic in bag, but sugar is quickly matabolized, and then free water available to cells)
What are the main functions of Chloride in the body?
- involved in regulating acid-base balance
- important buffering function in O2 and CO2 exchange in RBCs
What is a critically dangerous result of hypokalemia?
cardiac conduction and function
What is a common cause of hypokalemia?
potassium wasting diuretics (thiazide or loop diuretics - e.g. Lasix)
What should you do with low lab values of potassium?
- Don't sit on them
- assess patient
- look at trending values for individual patient
What is a primary symptom of hypokalemia?
What are some GI symptoms of hypokalemia?
- abdominal distension, leading to paralytic ileus
What are some CNS symptoms of hypokalemia?
- diminished deep-tendon reflexes
- mental depression
what is diminished deep-tendon reflexes a symptom of?
what are some muscular symptoms of hypokalemia?
- flaccid paralysis
- weakness of respiratory muscles leading to respiratory arrest and death
what are some CV symptoms of hypokalemia?
- decrease in BP
- ECG changes
- myocardial damage
- cardiac arrest
what are some renal symptoms of hypokalemia?
- decreased capacity to concentrate waste
- water loss
- kidney damage
What is the primary cause of hyperkalemia? why?
renal failure - any decrease in renal function diminishes the amt of K the kidney can excrete
what is important to do before giving potassium?
always check lab values first
what are 5 nursing interventions for hypokalemia?
- monitor pt receiving digitalis closely, because hypokalemia enhances digitalis toxicity
- administer oral K as ordered with food or fluid to prevent GI upset (K+ burns)
- monitor heart rate and rhythm
- closely monitor pt receiving IV K
- teach pt about K+ rich foods
What drug use should be closely watched with hypokalemia?
What renal symptoms are associated with hyperkalemia?
oliguria leading to anuria
what muscular symptoms are associated with hyperkalemia?
- early: irritability
- late: weakness, leading to flaccid paralysis
what CNS symptoms are associated with hyperkalemia?
what four nursing interventions can you do for hyperkalemia?
- closely monitor pt on diuretics (loss of K+ can overcompensate)
- Check labs before giving IV K+, and follow protocols carefully
- teach pt to avoid foods high in K+
- K+ is always well diluted when given IV (think euthanasia!)
What life threatening symptom is a risk of hypocalcemia?
laryngospasms (can't breathe)
What is a primary symptom of hypocalcemia?
tetany (muscle spasms, cramps, sharp flexion of wrist and ankles)
What is Trousseau's sign, and what is it a symptom of?
- under hypoxic conditions, the hand and fingers go into spasm in plantar flexion
- it is a symptom of hypocalcemia
what is Chvostek's sign? and what is it a symptom of?
- twitching on the face when tapped just below and anterior to the ear (over the facial nerve) to trigger facial twitching
- it's a symptom of hypocalcemia
What are some CNS symptoms of hypocalcemia?
what are some GI symptoms of hypocalcemia?
- increased peristalsis
what are two muscle symptoms of hypocalcemia?
what are 3 nursing interventions for hypocalcemia?
- monitor pt breathing closely because of laryngeal stridor
- take precautions to protect confused pt
- teach menopausal women about calcium and exercise
What is a common cause for hypercalcemia?
immobile patients lose bone, increasing the serum calcium levels
what are some bone related symptoms of hypercalcemia?
- bone pain
- bone fractures
what are some CNS symptoms of hypercalcemia?
- decrease in deep tendon reflexes
what are some kidney symptoms of hypercalcemia?
kidney stones leading to kidney damage
what are 6 nursing interventions for hypercalcemia?
- increase pt movement and exercise
- encourage oral fluids as permitted to maintain dilute uring
- teach pt about food and fluids high in Ca
- protect confused pt
- encourage high fiber diet to prevent constipation
- encourage intake of acid-ash fluids to counteract deposits of Ca salts in urine
What are 3 nursing interventions for hypomagnesium?
- assess pt receiving digitalis closely for digitalis toxicity. hypomagnesium predisposes to toxicity
- take protective measures when there is a possibility of seizures
- encourage pt to eat Mg rich foods (whole grains, meat, seafood, leafy green veg)
What is a primary cause of hypomagnesium?
Alcohol withdrawal syndrome
What are symptoms a result of, for magnesium imbalances (both hypo and hyper)?
changes in neuromuscular excitability
what are 3 nursing interventions for hypermagnesemia?
- monitor VS when pt at risk (esp cardiac, ECG, and resp changes)
- if patellar relexes are absent, notify MD
- advise pt w renal disease to monitor the Mg content of OTC drugs
What is phosphate important for in the body?
it is especially important to the functioning of muscles, nerves, and RBCs
what are 5 nursing interventions for hypophosphatemia?
- monitor malnourished pt closely
- administer IV phosphate well diluted and slowly
- assess pt taking oral Phosphorus supp for diarrhea
- employ precautions to prevent infections
- teach pt to eat foods high in phosphorus (milk, cheese, fish products, whole grains)
what are 4 nursing interventions for hyperphosphatemia?
- monitor for neuromuscular irritability
- administer calcium supp as ordered (with meals)
- teach pt about foods high in phosphates( milk, cheese, meat, poultry, whole grains)
- teach pt to avoid excessive use of phosphorus containing laxatives and enemas (be careful with colace!)
What does a low value of PaCO2 indicate?
What does a high value of PaCO2 indicate?
What might the treatment be for low PaO2?
What are the levels of pH and HCO3 for metabolic alkalosis?
high pH and high HCO3
(when they're the saME, it's MEtabolic, when they're in REverse, it's REspiratory)
What is one of the first signs of hypovolemia associated with fluid volume deficit?
what is the relationship with pulse volume and fluid volume?
pulse volume decreases in FVDeficit and increases with FVExcess
What could changes in respiratory rates and depth affect?
- may cause respiratory acid-base imbalances
- may act a compensatory mechanism in metabolic acidosis or alkalosis
What would you asses for when imbalances of Ca and Mg are suspected?
increased or decreased neuromuscular irritability
What electrolyte imbalances display Trousseau's sign and Chvostek's sign as symptoms?
Hypocalcemia or hypomagnesemia
What is hematocrit measuring?
the volume of RBC in the whole blood?
What is the relationship with hct results and fluid imbalances?
hct increases with severe dehydration (higher percentage of RBC in whole blood) and decreases with severe overhydration
why might you see a low hgb level?
why might you see a high hct level?
what is dark, concentrated urine a symptom of?
How fast must you get a urine specimen to the lab?
< 30 min
what would a high specific gravity result be an indication of?
- disease that increases water reabsorption by kidneys (causing concentrated urine)
What happens with cells when hypotonic solutions are administered?
cells swell, because of the free water availability
what happens with cells when hypertonic solutions are administered
cells shrink, because the water in cells follow the solutes in the solution
What are 3 isotonic solutions?
- normal saline (0.9% NaCl)
- ringer's solution (has Na, K, Ca)
- Lactated Ringers (has Na, Cl, K, Ca, and lactate, similar to normal plasma)
What kind of fluid is CONTRAindicated in acute brain injuries?
hypotonic solutions, because cerebral cells are very sensitive to free water, which could lead to cellular edema, and changed in LOC
What are some hypotonic solutions?
- D5W (dextrose 5% in water) - hypotonic in the bag, but once the dextrose is metabolized, the rest is free water. Roughly 2/3 enters cells, and 1/3 remains in extracellular space
- diluted saline (either 1/2 NS or 1/4 NS) - about 1/2 and 1/2 end up in ICF and ECF
- mainenance fluids (saline mixed with dextrose and water)
what are hypertonic IV fluids used for?
cerebral edema - pulls water from cells, into vascular volume
What is the danger of using hypertonic solutions?
It could cause cell dehydration
What are 3 hypertonic solutions?
- 3% and 5% saline. Used when serum sodium is dangerously low
- dextrose solutions greater than 5% (used on limited basis to treat pt with hypoglycemia)
- 50% dextrose as part of hypoglycemic treatment
what is decreased deep tendon reflexes a symptom of?
what are hyperactive reflexes, muscle twitching and cramps, and tetany symptoms of?
what are numbness, tingling in fingertips and around the mouth symptoms of?
- respiratory alkalosis