Lecture test 6
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What populations have the highest percentage of body fluid?
Body fluid is located in what to fluid compartments?
- Intracellular space
- Extracellular space
Approx 2/3 of body fluid is what?
Intracellular fluid (ICF)
What is it called when extracellular fluid is lost into a space that doesn't contribute to equilibrium?
What are other S/S of third spacing indicating intravascular fluid volume deficit?
- Increased heart rate
- Decreased blood pressure
- Decreased central venous pressure
- Increased body weight
- Imbalances in fluid intake and output
Third-spacing can be seen in what 9 disorders?
- Decreased iron-intake
What is Osmolaity?
Is the concentration of fluid affecting movement of water between fluid compartments. It measures solute concentrations per kilogram in blood and urine
When measured with serum osmolity, what is th emost reliable indicator of urine concentration?
Urine osmolaity miliosmoles per kilogram of water (mOsm/kg) is the MOST RELIABLE indicator of urine concentration.
What increases and decreases HCT value?
What normal physiologic changes with aging affect fluid and electrolyte changes and acid-base disturbances?
- Reduced cardiac function
- Reduced renal function
- Reduced respiratory function and reserve
- Alterations in ratio of fluids to muscle mass
What if loss ECF volume exceeds intake of fluid?
What is the pathophysiology of hypovolemia?
- Loss of body fluids with decreased fluid intake
- Causes- vomiting, diarrhea, GI suctioning and sweating. Edema in burns, ascites, diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage and coma
Colume depleted pt's BUN is elevated out of proportion to the serum creatinine because____?
Dehydration or decreased renal perfusion and function
What careful monitoring is necessary with elderly patients?
- Intake and output of fluids from all sources
- Assessment of daily weight
- Side effects and interactions of medications
- Skin turgor changes (forehead and sternum)
What is isotonic expansion of ECF caused by abnormal retention of water and sodium in approx. Same proportions as in ECF?
- Fluid volume excess (FVE)
What is the pathophysiology of FVE?
- Isotonic expansion of ECF caused by abnormal retention of water and sodium in approx same proportions from which normally exist in ECF
- Secondary to increase in total body sodium content "where salt is water follows"
What are the clinical manifestations of FVE?
- Distended neck veins
- Inc. BP, pulse pressure, and central venous pressure, increased weight, urinary output, SOB or wheezing
What are useful diagnostics for FVE?
- Decrease d/t plasma dilution, low protein intake and anemia
- CXR Pulmonary congestion
What are nursing dx for FVE
- Activity intolerance r/t fatigue aeb
- dyspnea r/t
- Pain r/t
- Impaired spontaneous ventilation r/t resp alkalosis aeb tachypnea and abnormal AGS's impaired gas exchange r/tventilation perfusion imbalance aeb shallow breating
pt presents with fatigue, anorexia, nausea and vomiting, polyuria, leg cramps, low bp, flattened T waves, ST depression and prolonged PR interval
What imbalance is this?
- Potassium Deficit
- Serum potassium <3.5 mEq/L
pt presents with numbness, tingling fingers and toes, positive Trousseau's sign and positive chvostek's sign. Carpopedal spasms, bronchospasms, tetany, seizures are possible. Imparied clotting time, Decreasd pt, BP. ECG- prolonged QT interval and legnthed ST
Lab- decreased Magnesium and decreased calcium
- Calcium deficit
- Serum calcium <8.5 mg/dL
Patient presents with neuromuscular irritability, positive Trosseau's and Chostek's signs, insomnia, mood changes, anorexia, vomiting, increased BP, PVC's, flat or inverted T waves, depressed ST segments, prolonged PR interval and widened QRS
- Magnesium deficit
- Serum Magnesium <1.5mg/dL
What contriubtes to Calcium Deficit?
- Generalized peritonitis
- Massive transfuion of citrated blood
- Chronic diarrhea
- Decreased parathyroid hormone
What are factor of potassium excess?
- Oliguric renal failure (extremely dangerous- metabolic acidosis)
- Addison's disease (adrenocortical insufficiency)
- Rapid infusion of IV potassium
- Certain medications (ACD inhibitors, NSAIDs, cyclosporins)
What is metabolic acidosis?
Low pH (inc. H+ concentration and low plasma bicarbonate concentration)
What are clinical manifestations of metabolic acidosis?
- Increased Respiratory rate and depth
- Nausea and vomiting
- pH<7- dec. cardiac output
- dec. BP
- Cold and clammy skin
- Dysrhythmias and shock
What are diagnostic findings ofmetabolic acidosis?
- Base Bicarbonate Deficit
- ABG- low bicarbonate < 22mEq/L
- Low pH<7.35
- Cardinal feature- dec. serum bicarb level
- hyperkalemia (shift of k+ out of cells)
- Hyperventilation dec. CO2 levels (compensatory action)
What is metabolic Alkalosis?
- Acid-base disturbance
- high pH
- High Plasma Bicarb cone
- HCO3 >24 mEq/L
What lab elements identify Respiratory alkalosis and respiratory acidosis?
- PaCO2 < 40mmHg=respiratory alkalosis d/t hyperventilation or blowing off too much CO2
pH < PaC02 > 40 mmHg= respiratory acidosis d/t hypoventilation with too much CO2 retained
Adrenal insufficiency, water intoxication, loss by diarrhea, vomiting, sweating or diuretics, GI loss, renal disease, SIADH, hypergllycemia, heart failure
Excess water loss, excess Na administration, diabetes insipidus, heat stroke, hypertonic IV solutions, water deprivation, hyperventilation, burns, diaphoresis
GI losses, meds, alterations of acid-base balance, hyperaldosterism, poor diatary intake, diarrhea, vomiting, bulimia, alkalosis, starvation, diuretics, digoxin toxicity
Hypoparathyroidism, malabsorption, pancreatitis, alkalosis, massive transfusion of citrated blood, renal failure, meds, bed rest and immobility, vit D deficiency, subcu infection, generalized peritonitis, chronic diarrhea, decreased PTH, fistulas, burns, alcoholism
Renal failure, malignancy and hyperparathyroidism, bone loss, r/t immobility, malignant neoplastic disease, calcium supplement overuse, vit D excess, acidosis, corticosteroid therapy, diuretic use, digoxin toxicity
Alcoholism, GI losses, enteral/parenteral feeding deficit, meds, rapid administration of citrated blood, diabetic ketoacidosis, sepsis, burns, hypothermia, hyperparathyroidism, hyperaldosteronism, renal failure, malabsorptive disorders, refeeding after starvation, chronic laxative use
renal failure, diabetic ketoacidosis, excessive administration of mg, adrenal insufficiency, hypothyroidism
disorder that is characterized by bone decalcification and the development of renal calculi containing calcium
Hyperparathyroidism occurs more frequently in _____
Females are 2-4 times more likely to suffer from hyperparathyroidism, usually between ages 60 and 70
Similar to primary, occurs in pts who have chronic renal failure and so-called renal rickets as a result of phosphorus retention, increased stimulation of parathyroid glands, and increased secretion of PTH
Clinical Manifestations of Hyperparathyroidism
Apathy, fatigue, muscle weakness, nausea, vomiting, constipation, hypertension, and cardiac dysrhythmias. These may be attributed to the increased concentration of calcium in the blood
What is the recommended treatment for hyperparathyroidism?
Surgical removal of the abnormal parathyroid tissue
_______ can occur with extreme elevation of serum calcium levels (> 15mg/dL) resulting in neurologic, cardiovascular, and renal symptoms that can be life threatening
Hypercalcemic Crisis- Treatment includes rehydration with large volumes of IV fluids, diuretic agents to promote renal excretion of excess calcium, and phosphate therapy to correct hypophosphatemia
Complications of thyroid surgery
possible parathyroid damage causing disturbance in calcium metabolism. Hemorrhage, hematoma formation, edema of the glottis, and injury to the recurrent laryngeal nerve.
The most common cause of hypothyroidism is
autoimmune thyroiditis (Hashimoto's disease) in which the immune system attacks the thyroid gland
S/S of hypothyroidism
Extreme fatigue, hair loss, brittle nails, dry skin, numbness and tingling of the finger, husky or hoarse voice, menorrhagia, amenorrhea and loss of libido
Hypothyroidism affects ____ 5x more frequently than men and occurs most often between ages ____ and ____
Primary treatment for hypothyroidism
Medical management- synthetic levothyroxine
Chronic adrenocortical insufficiency secondary to destruction of the adrenal glands
What is the main cause of Addison's disease?
Autoimmune or idiopathic atrophy of the adrenal glands responsible for the vast majority. Surgical removal of both adrenal glands and infection of the adrenal glands, TB and histoplasmosis
S/S of Addison's disease
- Sodium loss
- Potassium retention
- Bronze skin
- Nausea and Vomiting
Pathophys of Addison's disease
- Deficient cortisol
- and /or aldosterone
- and/or androgens
Diabetes insipidus pathophys
insufficient ADH, Kidneys do not reabsorb water
S/S of diabetes insipidus
- Dilute urine
- Hypovolemic shock
- Decreased LOC
Diagnostics for DI
- Urine specific gravity
- Plasma and Urine osmolality
- CT or MRI
- Water-deprivation test
- ADH levels
- Salt and water retention
- Thin fragile skin
- Facial hair in women
Cushings syndrome dx
- plasma and urine cortisol
- plasma ACTH
- 24 hour urine test
- Dexamethasone suppression test
- Serum potassium
- excess groth hormone in adults
- Bones grow in width, not length
- Organs and connective tissues also enlarge
- Change in extremities size
- Nose, jaw, brow and teeth
- Difficulty speaking and swallowing
- headaches, visual changes
Cardiac changes and dysrhythmias, muscle wekness w/ potential respiratory impairment, paresthesias, anxiety, GI manifestations, flaccid paralysis, colic, irritability, anxiety
Muscle weakness, incoordination, anorexia, constipation, nausea and vomiting, abdominal and bone pain, plyuria, thirst, ECG changes, dysrhythmias, polydipsia, dehydration, hypoactice DTR, lethargy, deep bone pain, flank pain, pathologic fx, calcium stones, HTN
Flushing, Lowered BP, nausea, vomiting, hypoactice reflexes, drowsiness, muscle weakness, depressed respirations, ECG changes, dysrhythmias, cardiac arrest and coma, diaphoresis
Primary treatment of type 2 diabetes
Diet and exercise
- Acid- <3.305
- Normal 7.35-7.45
- Alkaline >7.45
- Acid- >45
- normal 35-45
- Alkaline <35
- Acid <22
- Normal 22-26
- Alkaline >26
Low ph, high or normal HCO3, high Paco2
High or pH, low or normal HCO3, and low PaCO2
low pH, low HCO3, low or norm PaCO2
high pH, high HCO3, high or norm PaCO2
BI. Na+ <135
Ur. Na+ decrease
Hypernatremia lab values
- BI Na+ >145
- Ur. Na+ decrease
Hypokalemia lab values
Hypercalcemia lab values
Hypomagnesemia lab values
Hypermagnesemia lab values
Compartmental fluid, CSF, synovial fluid and gastric juices are _______
Lymph is ____
Fluid in blood vessels, and plasma are
Sodium, potassium, calcium, magnesium, hydrogen ions
chloride, bicarbonate, phosphate, sulfate, and proteinate ions
pressure exerted on the walls of the blood vessels
Pressure exerted by protein in plasma
Direction of fluid mov't depend on
differences of hydrostatic, osmotic pressure
Factors taht influence amount of body fluid
Age, genter, fat. younger age, higher, males, higher, more fat, lower
number of dissolved particles contained in amount of fluid
Sodium is higher in ____ than ___, sodicum tends to enter cells through_____
ECF, ICF, diffusion
Isotonic expansion of ECF, abnormal retention of water and sodium, always secondary to ta total body sodium content. May be fluid overload or diminished function.
Contributing factors to Hypovolemia
Heart failure, renal failure, cirrhosis of the liver, excessive salt intake
When loss of ECF volume exceeds intake- not dehydration
Chromaffin cell tumor, usually benign, located in the adrenal medulla, characterized by secretion of catecholamines resulting in HTN, severe headache, profuse sweating, visual blurring, anxiety and nausea
S/S of hypoglycemia
- sweating, tremor, tachycardia, palpitation, nervous-ness and hunger-
- Moderate-inability to concentrate, headache, lightheadedness, confusion, memory lapses, numbness of the lips and tongue, slurred speech, impaired coordination, emotional changes, irrational or combative behavior, double vision and drowsiness
- Severe- disoriented behavior, seizures, difficulty arousing from sleep or loss of conciousness
BUN, Specific gravity, potassium and sodium
3 main clinical features for diabetic ketoacidosis
- Dehydration and electrolyte loss
decreased or missed dose of insulin, illness or infection, and undiagnosed or untreated diabetes. Insulin errors, decreased insulin, stress, glucagon, epinephrine, norepinephrine, cortisol and growth hormone
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