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1. Another name for fluid volume excess
2. Too much fluid in the VASCULAR SPACE
What can cause hypervolemia?
- Heart failure
- Renal Failure
- *things with too much sodium
How does heart failure cause hypervolemia?
- The heart is WEAK
- So cardiac output goes DOWN
- which means kidney perfusion goes DOWN
- Therefore, urinary output goes DOWN
The volume stays in the vascular space
How can kidney failure cause hypervolemia?
- Kidney's aren't working.
- So urinary output is decreased, resulting in the fluid staying in the vascular space.
Name 3 things that are high is sodium
- Effervescent soluble medications - meds that have high amounts of sodium
- Canned/processed foods
- IV fluid with sodium
Hormonal regulation of fluid volume
- ANP (Atrial Natriuretic Peptide)
- Anti-diuretic Hormone
What is aldosterone?
Where is it found?
- Aldosterone is a steroid released by the adrenal glands on the kidneys
- Helps control BP by holding onto salt and losing potassium from the blood.
What does aldosterone do?
- When blood volume gets low (such as from vomiting, hemorrhage, etc.), aldosterone secretion is increased.
- Aldosterone makes you retain sodium and water
- and lose potassium
- therefore, blood volume goes up
What diseases cause too much aldosterone
- Cushings disease
- Conns Syndrome
You retain TOO MUCH SODIUM AND WATER, causing blood volume to go up = fluid volume excess.
- this disease causes you to make to many hormones, one of which is aldosterone
- so you have too much aldosterone (among other hormones)
- another name for Hyperaldosteronism
- a disease in which the adrenal gland(s) make too much aldosterone which leads to hypertension (high blood pressure) and low blood potassium levels.
Disease with too little aldosterone
- you lose too much sodium and water
- Atrial Natriuretic Peptide
- Found in the atria of the heart
- Works the opposite of aldosterone and causes the excretion of sodium and water.
- When there is fluid volume excess, it stretches the right atrium which causes the release of ANP
- Works on kidneys to excrete sodium and water
- Anti-diuretic Hormone
- Makes you retain water
Found in the pituitary gland
What happens with TOO MUCH ADH?
- SIADH (Syndrome of Inappropriate ADH)
- *think too many letters, too much water
- Makes you retain water, so you go into fluid volume excess!
- Urine becomes concentrated
- Blood becomes diluted
What happens with NOT ENOUGH ADH?
- You diurese = losing lots of water
- Will have LARGE amounts of diluted urine
- Diabetes Insipidus! (DI = Diureses) = SHOCK is possible!!
- Urine will be diluted
- Blood will be concentrated
What should make you think there is a potential problem with ADH?
- Any condition that can lead to an increased ICP (Intracranial pressure)
- Ex: Craniotomy, head injury, sinus surgery, etc.
What is another name for ADH (a drug name)
- or Desmopressin Acetate
- Can be utilized as ADH replacement in DI
What 3 main things are effected when fluids are off?
- Urine specific gravity
What s/s will you see with hypervolemia?
- Distended neck veins/peripheral veins (Vessels are full!)
- Peripheral edema/third spacing (Vessels can't hold anymore, so they start leaking)
- Increased CVP
- Lung sounds are wet & crackly
- Bounding pulse, increased HR
- Increased BP (MORE VOLUME, MORE PRESSURE)
- Fast weight gain
what are normal values?
- Central Venous Pressure
- measured in the right atrium
- "More volume, more pressure"
- 2-6 mmHg or 5-10cmH2O (depending on what device is used)
When there is fluid retention, what should you think of first
Think HEART PROBLEMS first
Treatment for hypervolemia
- Low sodium diet/restrict fluids
- I&O's and daily weights
- Bed Rest
- Physical assessment - focus on pertinent s/s
Types of Diuretics
- Potassium sparing
- Furosemide (Lasix)
Will lose potassium
- Thiazide (brand name) or HCTZ
- Another type of diuretic
- Will cause you to lose potassium
Example of Potassium sparing
How does bed rest induce diureses?
- More blood volume to truck =more blood to heart
- This stretches the atrium, thereby releasing ANP
- The release of ANP reduces the production of ADH
Another name for Fluid Volume Deficit
- Big Time Deficit = SHOCK!!
*not enough O2 getting to tissues for metabolism.
Causes of Hypovolemia
- Loss of fluid from anywhere
- Third spacing
- Diseases with polyuria
What is Third Spacing & What can cause it?
- When fluid is in the place that does you no good.
- Can be caused by burns
- Can result in Ascites
- Fluid leaks out into the abdominal space
- If it continues, will push up on diaphragm and cause breathing problems
- Will need to monitor BP as it can cause it to go down
- Measure abdominal girth daily
S/S of hypovolemia
- Weight loss
- Decreased skin turgor
- Dry mucus membranes
- Decreased urine output (Kidneys are being perfused or their trying to hold onto any fluid)
- Decreased BP (less volume, less pressure)
- Increased HR (heart trying to pump what it can)
- Increased RR (think HYPOXIA!!)
- Cool Extremities
- Increased urine specific gravity
Treatment for hypovolemia
- Prevent further fluid loss
- Replace volume: PO fluids for mild, IV fluids for severe
Safety Precautions in treatment for hypovolemia
- They will have a higher risk for falls due to orthostatic hypotension. Watch for changes in VS and LOC
- Make sure to monitor for fluid overload when replacing volume
What is an isotonic solution?
- IV fluid that stays in the vascular space.
- Increases BP
Examples of isotonic solutions
- LR - best for shock, more electrolytes
- D5 NS
Contraindications for isotonic
Don't give to pt's with hypertension, cardiac disease or renal disease
Isotonic can cause fluid volume excess, hypertension, or hypernatremia (IF the solution contains sodium).
What is a hypotonic solution
- Goes into the vascular space and then shifts into the cells to replace cellular fluid
- It rehydrates but DOES NOT cause hypertention
- Wont increase BP
Examples of hypotonic solution
What is hypotonic fluids used for?
A client who has hypertension, renal or cardiac disease and needs fluid replacement because of nausea, vomiting, burns, hemorrhage, etc.
Also used for dilution when a pt had hypernatremia and for cellular dehydration
Alert for hypotonic fluids
- Watch for cellular edema
- Fluids are moving into the cells, which could lead to fluid volume deficit and decreased BP
- Volume expanders that will draw fluid into vascular space from the cell
- Packed with particles
Examples of hypertonic soluctions
- TPN (most common)
- 3% or 5% NS
- D5 NS
*More than 0.9%
When are hypertonic solutions used
- With a client with hyponatremia or a client who has shifted large amounts of volume into a 3rd space
- Also used with severe edema, burns, or ascites
Alert for hypertonic solutions
- Watch for fluid volume excess & pulmonary edema
- Monitor vitals and CVP!
What do Magnesium and Calcium have in common?
they both act like sedatives
*Magnesium is excreted by the kidneys, but can be lost in other ways (such as GI tract) but if they kidneys aren't working, they can't excrete
If you want to get Mg and Ca questions right, what should you think of?
Think muscles first!!
Normal mg value
1.3 - 2.1 mEq/L
Normal Ca value
9.0 - 10.5 mg/dl
Causes of Hypermagnesemia
S/S of hypermagnesemia
- Mg makes you vasodialate
*Because Mg makes you vasodialate, can help with seizures
Treatment for hypermagnesemia
- May require:
- Calcium gluconate (which is antidote for mag. toxicity. works by reversing respiratory depression and arrhythmias)
Signs and Symptoms that are common with hypermagnesemia or hypercalcemia
They are sedatives!!!
- DECREASED DTR's (deep tendon reflexes)
- DECREASED muscle tone
- DECREASED LOC
- DECREASED Pulse
- DECREASED Respiration
What has an inverse relationship with calcium?
- *Calcium goes down, phosphate goes up
- *Calcium goes up, phosphate goes down
Causes of hypercalcemia
- Hyperparathyroidism - too much PTH
- Thiazides - you retain calcium
- Immobilization - you have to bear weight to keep Ca in the bone
How does hyperparathyroidism cause hypercalcemia
- When your serum calcium gets low, parathormone (PTH) kicks in and pulls Ca from the bones and puts it in the blood
- Therefore, serum calcium goes up.
S/S of hypercalcemia
- Bones are brittle
- Kidney stones - which a majority are made of calcium
Treatment for hypercalcemia
- Fluids to prevent kidney stones
- Add protein to diet, as protein has phosphorus. This has inverse relationship with Ca, so will help decrease serum Ca.
What safety precautions should be in place for hypercalcemia?
- Remember: Pt will be SEDATED!!
- Monitor frequently for decreased HR & RR
- Keep Ca Gluconate at bedside to reverse possible RR depression
- Heart monitor for possible arrhythmia's
- Assess for decreased LOC = Fall Risk!!
What must be given with Ca in order for absorption?
What meds will decrease serum Ca
- Prostaglandin Synthesis Inhibitors
- Calcitonin - lowers calcium levels by driving Ca back into the bones. Used to treat osteoporosis
Whats the deal with hypomagnesemia and hypocalcemia
Not enough sedative!
Causes of hypomagnesemia
- Diarrhea - theres lots of Mg in intestines
- Alcoholism - not eating or drinking (we get a majority of Mg from our diet)
Alcohol suppresses ADH & it's hypertonic
S/S of hypomagnesemia or hypocalcemia
- Muscle tone will be tight and rigid
- Client could have seizure
- As airway is smooth muscle, could have stridor/laryngospasm
- Swallowing problems - esophagus is smooth muscle. Risk for aspiration
- Positive Chvostek's
- Positive Trousseau's
- Arrhythmias (heart is muscle)
- Increased DTR's
- Mind changes
What is Chvostek's
- tap the cheek and it twitches
- shows hyperactivity in facial muscles
("C" is for Cheek)
What is Trousseau's
Occurs when you pump up BP cuff and the hand tremors
Treatment for hypomagnesemia
- Give some Mg
- Check kidney function (before and during IV Mg)
- Seizure precautions
- Eat Magnesium
Foods high in magnesium
- summer squash
- pumpkin seeds
Causes of Hypocalcemia
- Radical Neck
*All these = NOT ENOUGH PTH
Treatment for hypocalcemia
- Give Vit D
- Phosphate binders
- calcium acetate
IV Ca - give SLOWLY and make sure pt is on heart monitor.
What is unique about sodium
- Only electrolyte that follows water
- The sodium level in blood is totally dependent on how much water you have in the blood
*Think neuro changes
Hypernatremia is equal to what?
- Too much sodium = not enough water
Causes of hypernatremia
- Hyperventilation - when exhaling, losing H2O
- Heat stroke
S/S of hypernatremia
- *Think neuro changes with either hyper/hypo
- Dry mouth
- Thirsty - your already dehydrated by the time you're thirsty
- swollen tongue
Treatment of hypernatremia
- Restrict sodium
- Dilute client with fluids which will decrease Na
- If theres a problem with Na, there is a fluid problem, so treatment will include:
- Daily weights
- Lab work
Why can tube feeding pt's become dehydrated
- TPN has everything but water.
- Important to watch for dehydration
What is hyponatremia?
- Too much water = not enough sodium
Causes with hyponatremia
- Drinking H2O for fluid replacement (vomiting, sweating) - this only replaces water and dilutes the blood
- Psychogenic polydipsia - mental illness where pt loves to drink water
- D5W (sugar and water)
- SIADH - makes you retain water
S/S of hyponatremia
*Brain hates it when sodium is messed up
Treatment for hyponatremia
Client needs sodium, doesn't need water!
- If having neuro problems, need hypertonic saline: means "packed with particles"
- ex: 3% or 5% NS
What has a inverse relationship with Sodium?
What can cause hyperkalemia?
- Kidney trouble
- Spironolactone - "K-sparing" diuretic which makes you retain Potassium
S/S of hyperkalemia
- Think LIFE THREATENING ARRHYTHMIAS!!
- Begins with muscle twitching
- Then proceeds to muscle weakness
- Then flaccid paralysis
ECG changes with hyperkalemia
- Tall and peaked T waves
- Prolonged PR intervals
- Flat or absent P waves
- Widened QRS
- conduction blocks
Treatment for hyperkalemia
- Dialysis - Kidney's aren't working
- Calcium gluconate - decreases arrhythmias
- Glucose and insulin
- Sodium polystyrene sulfonate
How does glucose and insulin help treat hyperkalemia?
- Insulin carries glucose and potassium into the cell.
- You'll give insulin to avoid hypoglycemia.
- Anytime you give IV insulin, worry about hypoglycemia and hypokalemia
What can cause hypokalemia
- NG suction (there is lots of potassium in stomach)
- Not eating
S/S of hypokalemia
- Muscle cramps
- Muscle weakness
ECG changes with hypokalemia
Treatment for hypokalemia
- Give potassium
- Spironolactone - makes pt retain potassium
- Eat more potassium
Normal potassium levels
3.5 - 5.0
Foods high in potassium
- dark green veggies
Major problem with oral potassium
Upset stomach so give with food
How should IV potassium be given?
- NEVER give by IV push
- always put on pump
- Burns during infusion as it eats up peripheral veins so MONITOR IV SIGHT!!