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Atrial Natriuretic Peptide (ANP)
Triggered by stretching of right atrium-Causes suppression of RAAS/ ADH-increases GFR and causes vasodilation.
- Saves water-Makes the kidney tubules more permeable.
- synthesized by hypothalamus
- secreted by posterior pituitary
- Controlled by osmoreceptors in hypothalamus
- Other factors which stimulate ADH- hypovolemia, stress, nausea, nicotine and morphine.
Distribution of water
- First spacing: Normal distribution
- Second spacing: increased fluid in interstitial compartment: (EDEMA)
- Third spacing: Abnormal fluid distribution in areas where there is minimal to no fluids. (Ascites)/(Pulmonary edema).
Non-compressible edema-leads to release of clotting factors-caused from injury
- Released by kidneys due to decrease in pressure or sodium.
- Converts angiotensinogen to angiotensin 1 which then gets converted by ACE to angiotensin 2 which has vasoconstrictive effects and increases blood flow to kidneys.
angiotensin 2 stimulates release of aldosterone form adrenal glands which act on the kidneys to reabsorb conserve sodium and also increasing water reabsorption. Aldosterone also stimulates ADH.
Hypoabluminemia (third spacing)
- decreased oncotic pressure
- Lack of proteins to draw or pull fluids back into the capillaries. (Malnutrition/decreased protein synthesis/excess renal losses)
Increased Hydrostatic Pressure (third spacing)
inhibits the movement of fluids back into the capillaries.
Increased interstitial oncotic pressure (third spacing)
due to damage to capillaries allowing protein to leak into the tissue.
Inflammation (third spacing)
- Due to histamine ad bradykinins
- Endothelial cells retract allowing openings in the capillaries and venules.-Allowing larger molecules to leave intravascular.
- This can dilute toxins and deliver WBC, O2 and nutrients to the tissue.
- Renal failure
- cirrhosis-liver failure
- cushings syndrome
Nursing plan of care for fluid volume excess
*related to increased sodium and water retention secondary to hyperaldosteronism, excess fluid intake, excess sodium intake, renal failure, heart failure, or liver failure.
Nursing care plan steps
- assessing: systemic collection of data
- diagnosis: data analysis, bases on present illness, problem identification, formulate nursing diagnosis outcome
- identification: what the pt. is expected to acheive
- planning: holistic plan of care-to achieve outcomes.
- implementation: execute nursing care plan
- evaluation: Pt level of outcome achievement
Increased interstitial hydrostatic presure
Obstructed lymph flow which prevents removal of fluids from interstitium causing localized swelling.
Peritoneum and lumen FVE
up to 6L
up to 2-3L
- *Assessing*Inspection, Palpation, Auscultation*
- Treating*Focuses on restoring normal levels, preventing complications, and treating underlying problems*
- Preventing*Prevent injuries and maintain a safe environment*
- Teaching*To provide information that will empower patients to perform self-care and make informed healthcare decisions.
Assessment of FVE
monitor intake and output
Impending renal failure
urine output less than 30cc/hr indicates potential renal failure
Urine specific gravity
<1.010 indicates dilute urine. too much water
Monitor for rapid weight gain in regards to FVE
- 8% severe
Fluid gain or loss calculations
- 1 liter=1kg
- 1kg=2.2 pounds
- 1 pound=454ml
What is an excellent indicator for fluid volume loss or gain?
10% increase in body weight-(FVE)
<280 mOsm/l- sodium determines this less than 280=FVE
- Necessary for transmission of nerve impulses, blood clotting, strengthens capillary membranes.
- Adult-4.5-5.5mEq/L, 9-11mg/dL.
- Child- 4.5-5.8 mEq/L, 9-11.5mg/dL.
- maintaining homeostasis, osmolality of body fluids, Ph balance
- Adult: 95-105 mEq/L
- Child: 98-105 mEq/L
- RBC, hydration status, anemia
- Adult: male-40-54% in 100ml of blood/ Female-36-46% in 100ml of blood.
- Panic value less than 15% or greater than 60%.
Magnesium (Mg) (Serum)
- Neuromuscular activity, influences use of potassium, calcium and protein. responsible for transport of sodium and potassium across cell membrane.
- Adult: 1.5-2.5 mEq/L, 1.8-3.0mg/dL
- Child: 1.6-2.6 mEq/L
- Indicator of hydration status, helpful in diagnosing fluid and electrolyte imbalances. Sodium contributes 85-90% of serum osmolality.
- Adult: 280-300 mOsm/kg
- Child: 270-290 mOsm/kg
- Panic values: <240 or >300 mOsm/kg
- High value indicates: hemoconcentration due to dehydration
- Low value indicates: hemodilution due to overhydration.
- More accurate than specific gravity, indicator of hydration status, helpful in diagnosing fluid and electrolyte imbalances.
- Adult: 50-1200 mOsm/kg/H2O.
- 1.010-specific gravity considered normal
- Principal intracellular anion; exists in blood as phosphate. functions include metabolism of carbohydrates, fats, ph balance, use of B vitamins, promotion of nerve transmission. Requires vitamin D for absorption from gastrointestinal tract-stored with calcium in bones/teeth.
- Adult: 1.7-2.6 mEq/L or 2.5-4.5mg/dL
- Child: 4.5-5.5 mg/dL
- Most abundant intracellular fluids, Narrow range (2.5 mEq/L-7.0 mEq/L)-can lead to cardiac arrest. 90% of potassium excreted by kidneys. *Rhabdomyolysis can lead to hyperkalemia.
- Adult: 3.5-5.3 mEq/L
- Child: 3.5-4.8 mEq/L
Protein (total) (serum)
- Composed mostly of albumin and globulins-important in fluid and electrolyte balance.
- Adult: 6.0-8.0 g/dL
- Child: 6.2-8.0 g/dL
- Major cation in extracellular fluid, retains water,Maintains body fluids, neuromuscular impulses via sodium pump (Na+ shifts into cells as K+ shifts out for cellular activity) Enzyme activity, regulates PH balance by combining with chloride or bicarbonate ions.
- Adult: 135-145 mEq/L
- Panic: < 115 mEq/L
Electrolyte distribution Sodium
- Extracellular: 142 mEq/L
- Intracellular: 10 mEq/L
Electrolyte distribution Potassium
- Extracellular: 4.2 mEq/L
- Intracellular: 150 mEq/L
Electrolyte loss from Sweat
*Sodium and Potassium
- Sodium:45 mEq/L
- Potassium:5 mEq/L
- Chloride: 58 mEq/L
- Bicarb: 0
Electrolyte loss from Gastric
*Sodium and potassium
- Sodium: 60 mEq/L
- Potassium: 9 mEq/L
- Chloride: 84 mEq/L
- Bicarb: 0
Electrolyte loss from diarrhea
- mainly from Lg bowel, but can also come from Sm bowel dependent on severity on diarrhea.
- Mainly going to lose Sodium, Potassium and Bicarb.
- In mEq/L
- Sm bowel:
- Sodium: 129
- Potassium: 11
- Bicarb: 29
- Lg bowel:
- Sodium: 80
- Potassium: 21
- Bicarb: 22
Hypo or Hyper-natremia
Panic values: <115 mEq/L and >150 mEqL
CNS most easily affected by this. <115 mEq/L leads to cerebral edema. Water/fluids from ECF goes into the ICF causing swelling. Opposite is said for >150 mEq/L-Crenation takes place or shrinkage.
Hypo or hyper-kalemia
Panic value: <2.5 mEq/L and >7.0 mEq/L
- Mainly found in ICF, with hypo there is an increase in ICF distribution leading to abnormal amounts. Leads to Cardiac arrest and respiratory insufficiency.
- Respiratory failure #1 cause of death in Hypokalemia.
- Never give potassium supplement if urine output less than 0.5ml/kg/hr. Kidneys main regulator for K+.
- Most common cause of Hyperkalemia is Renal failure
infusion rate: K+ 5-10 mEq/hr never exceed 20 an hour.
concentration of solutes
Distribution of sodium vs potassium on ICF and ECF?
K+ concentrated in ICF while Na+ concentrated in ECF
list a few S&S of Hyponatremia? What is a low value?
- <135 mEq/L is considered Hypo anything below 120 is severe.
- Profound thirst, headache, malaise, tremors, decreased LOC, tachycardia, nausea.
Break: Think of something beautiful!
List a few S&S of Hypernatremia, What is a high value?
- >145 mEq/L is considered high
- S&S are the same as Hyponatremia.
List a few S&S of hypokalemia, What is a low value?
- anything <3.5 mEq/L. <2.5 mEq/L is considered a panic value.
- S&S a similar to Hyper, but their is a higher probability for respiratory insufficiency.
List a few S&S of Hyperkalemia, what is a high value?
- anything >5.3 mEq/L. Panic value > 6.0 -7.0 mEq/L.
- ECG changes, tremors, twitching, anuria, acidotic, malaise, irritable.
- 4.5-5.5 mEq/L, 9-11mg/dL
- Panic value: <7mg/dL causes tetany any lower leads to arrhythmias or death.
- Common cause: is renal failure, hypomagnesemia, hypoparathryoidism, diuretics, malabsorption, hypoalbuminemia, hyperphophatemia (reciprocal relationship).
- hyperexcitability of cells, (think twitchy) cells are easily depolarized due to increased permeability of membranes.
List a few S&S of Hypocalcemia, What is a low value?
- <7mg/dL OR <4.5 mEq/L
- arrhythmias, twitchy, prolonged QT interval, hypotension, weak pulse, confusion,
- 4.5-5.5 mEq/L OR 9-11mg/dL
- Panic value: >13 mg/dL
- Causes: Renal failure, hyperparathyroidism, vitamin D intoxication,
- (Think floppy), decreased neuromuscular excitability, bradyarrhythmias, decreased LOC, confusion, hypophophatemia.
List a few S&S of hypercalcemia, what is a high value?
- >13mg/dL or >5.5 mEq/L
- Decreased LOC, Bradyarrhythmias, think floppy, malaise/ muscle weakness,
Who's at greatest risk of F&E imbalances?
- renal failure pt
- endocrine disorder pt.
- <1.5 mEq/L
- causes: chronic alcoholism which is associated with malnutrition. malabsorption, medications(gentamicin, neomycin, amphotericin B, insulin.
- similar S&S to Hypocalcemia/hypokalemia due to magnesium playing an important roll in the transport of Na+ and K+.
- > 2.1 mEq/L
- causes: untreated diabetic ketoacidosis, addisons disease, volume depletion.
- S&S similar to Hypercalcemia and kalemia.
- >4.5 mg/dl
- common cause: renal failure, problems focused on hypocalcemia which is the reciprocal change seen. Hypoparathyroidism lack of PTH causes calcium loss and a phosphate increase.
- S&S will be associated with hypocalcemia.
- <2.6 mEq/dl
- common causes: Hypercalcemia, alcoholism, malabsorption.
- S&S associated with hypercalcemia.
fluids are pulled from the cells and interstitial spaces and into the intravascular space
fluids are forced into cells and interstitial spaces.
used to replace ECF due to illness. expands circulating volume. has same osmolality as plasma
- 0.9% NaCl
- Ringers-Balanced electrolyte solution resembling normal plasma
- Lactated Ringers-Converted into bicarbonate by the liver.
- Dilutes ECF, restores ICF balance-flushes kidneys and excretes electrolytes.
- 0.45% NaCl
- D5-10W-2/3 enters cells, 1/3 stays in ECF
- Rarely used, very dangerous.
- water pulled from cells causing crenation
- 3-5% saline bags for dangerously low sodium levels.