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Fluid & Electrolyte
Imbalances
N4935
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Alterations in Fluid Volume
Dehydration
Fluid Volume Deficit (Hypovolemia)
Fluid Volume Excess (Hypervolemia)
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Age
Disease
Medications
Who is at Risk for Fluid
Volume Alterations?
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Types of Fluid Loss
Insensible Loss
Skin ~ 400 mL/day
Lungs ~ 500 mL/day
Sensible Loss
Excess perspiration
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How does it happen?
Loss of water only
Dehydration
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Loss of fluids and solutes
Caused by:
Excessive fluid loss
Fluid loss with reduced intake
Third spacing (where it cannot be readily
regulated) Excessive diuretic therapy
Fluid Volume
Deficit/Deficient
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Dry mucous membranes Thirst Decreased skin turgor
Tachycardia Orthostatic hypotension - hypotension Urine output decreased increased
concentration (color & specific gravity) Restless/ anxious/drowsy/confusion Weight loss Increased urine specific gravity Shock/seizure/coma
Fluid Volume DeficitManifestations
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Oral fluids are generally not enough.
Isotonic IV solutions
Treat cause: albumin, blood, surgery
Vasopressors
O2Monitor for over correction &/or
progression of condition
Safety
Management
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Excess water and sodium in theextracellular space.
This can occur in the intravascularspace or in the interstitial space
Who is at risk?
The elderly and anyone with cardiac or renalproblems, IV replacement (overcorrection)
Fluid Volume Excess(Hypervolemia)
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Bounding pulse, increased BP
Neck vein distention
Dyspnea
Crackles, Cough, Frothy sputum
Edema (dependent)Headache, confusion, lethargy
Weight gain (1 liter=2.2 lbs)
Seizure, coma
Fluid ExcessManifestations
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Treat the cause
Restrict Na and fluid intake.
Diuretics
Morphine
O2Bedrest, HOB up
Monitor
Management
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Acid-Base BalanceAcid production, buffering, and excretion interplay to
create balance.
Acids release hydrogen (H+) ions; bases (alkaline
substances) take up H+
ions.Degree of acidity is reported as pH.
pH scale: 1.0 (very acid) to 14.0 (very base)
pH of 7.0 is neutral; normal arterial blood is 7.35 to
7.45.Maintaining pH within this normal range is very
important for optimal cell function.
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Quick Quiz
When a nurse evaluates a patients 24
hour I & O, the fluid intake should be:
a. Slightly more that the output
b. Lower than the urine output
c. Higher than the fluid output
d. Equal to the urine output
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Acid-Base Balance
(contd)Acid production
CO2 +H2O H2CO3 H+ + HCO3
Carbon dioxide + water Carbonic acid
Hydrogen ion + BicarbonateAcid buffering: Buffers are pairs of chemicals that
work together to maintain normal pH of body fluids
HCO3 + H+ H2CO3
Bicarbonate + Hydrogen ion Carbonic acid H2CO3 H
+ + HCO3
Carbonic acid Hydrogen ion + Bicarbonate
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Acid-Base Balance
(contd)Acid excretion systems: lungs and kidneys
Lungs excrete carbonic acid.
Kidneys excrete metabolic acids.
Excretion of carbonic acid
When you exhale, you excrete carbonic acid in the
form of CO2and water.
Excretion of metabolic acids The kidneys excrete all acids except carbonic
acid.
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Quick Quiz!The bodys fluid and electrolyte balance is maintained
partially by hormonal regulation. You will express an
understanding of this mechanism in which of the
following statements?
A. The pituitary secretes aldosterone.
B. The kidneys secrete antidiuretic hormone.
C. The adrenal cortex secretes antidiuretic hormone.D. The pituitary gland secretes antidiuretic hormone.
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Quick Quiz
Which assessment indicates deficient
fluid volume?
a. Negative balance of intake & output
b. Decreased body temperature
c. Increased blood pressure
d. Shortness of breath
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Calcium (Ca++)
Normal serum level = Lewis 8.6-10.2
mg/dL; P & P 8.4 10.5 mg/dL
Ionized Ca++ = 4.5 5.3 mg/dL
99% stored in bones and teeth
50% of Ca in blood is bound to albumin
Has an inverse relationship with PO4(When Ca++ increase, PO4 levels decrease
and visa versa)
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Calcium
Influenced by dietary intake (Dairy
products, legumes, green leafy
vegetables, sardines, salmon, clams,
oysters, rhubarb)
Regulated by
Parathyroid hormone
Calcitonin
Vitamin D
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Calcium
Functions in
Development of bones and teeth
Also requires Vitamin D and Phosphorous
Muscle contractility (skeletal, smooth, & cardiac)
Transmission of nerve impulses
Blood clotting
Cell structure & membrane permeability
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Hypocalcemia Causes
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Hypocalcemia Findings -Reflect excitability of cells
Anxiety, irritability
Muscle twitching
Numbness & tingling in toes, fingers, oraround mouth
Positive Trousseaus and Chvostekssign
TetanyArrhyhythmias/ EKG changes
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Hypocalcemia Management
Give Ca++--oral or IV (slowly) If PO, give 30 min. ac (to increase absorption)
Assess Vit D intakeEncourage dietary intake
Avoid laxatives
Seizure precautions
Injury prevention
Monitor Ca, albumin, and clotting levels
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Hypocalcemia Nursing
ConsiderationsAssess for symptoms
Tracheotomy tray, seizure precautions
Heart monitor
IV site monitoring
Monitor lab values
Watch for overcorrection
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Hypercalcemia Causes
>10.2 mg/dlHyperparathyroidism
Malignancies (lung, breast, multiple myeloma)
Prolonged immobility
Loss of Ca++ from bone into plasma
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Hypercalcemia Manifestations relate to decreased excitability
Muscle weakness, Decreased DTRs
Fracturescan occur spontaneously (aka:pathologic fx)
Confusion, personality changes, depressionLethargy, drowsiness, apathy, coma
Anorexia, vomiting, constipation
Polyuria
Renal calculi (kidney stones cause flank pain inlow back)
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Hypercalcemia
ManagementIncrease fluids to help with excretion
IV NSto replace Na+ which follows Ca++
w/diuresis
Loop diuretics
Weight-bearing physical activitywatch
increased fall risk because of confusion
Meds to promote reabsorption
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Hypercalcemia Nursing
ManagementMonitor cardiac rhythms, VS, & lab
values
Strain urine for calculi
Activity with caution (pathological fx)
Teaching
Safety
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Quick Quiz
Which of the following influences serum
Ca levels?
A. Vitamin K
B. Sodium
C. Potassium
D. Parathyroid hormone
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Quick Quiz
What is the normal calcium serum
level?
A. 7.5-9.0 mg/dL
B. 8.0-9.5 mg/dL
C. 8.6-10.2 mg/dL
D. 9.5-11.0 mg/dL
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Quick Quiz
Which of these is a function of calcium?
A. Contraction ability of muscles
B. Renal balance
C. Regulation of water
D. Transports potassium into the cell
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Quick Quiz
Your patient has low serum calcium.
You observe for?
A. Increase urine outputB. Hypertension
C. Muscle twitching
D. Coma
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Quick Quiz
What manifestation of low serum Ca
would you check for in this patient?
A. Rough, dry skinB. Bradycardia and dysrhythmias
C. Decreased urine output
D. Constipation
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Quick Quiz
Your patient has an elevated serum
Ca++ level. What do you suspect as
the cause?A. Metabolic acidosis
B. Bone tumors
C. HypoparathyroidismD. Hyperphosphatemia
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Quick Quiz
One aspect of the treatment of
hypercalcemia is?
A. Decrease fluid intakeB. Give Ca++ supplements
C. Antacids
D. Weight bearing, walking
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Magnesium Mg ++
Normal serum level 1.5 2.5 mEq/L
Absorbed from food
Tied to Ca++ function
Primarily excreted by kidneys
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Magnesium Functions
Helps with CHO & protein metabolism
Affects cardiac and skeletal musclecontractility
Vasodilation
Regulation similar to Ca++ in GI & renalsystem
Assess Ca++, K+, albumin
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Hypomagnesemia
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Hypomagnesemia
Manifestations (CNS irritation)Confusion
Hyperactive DTRs
Tremors, twitching, tetany
Positive Trousseau and Chvosteks signs
Seizures
DysrhythmiasHTN
H i
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Hypomagnesemia
Management
Slow infusion of MgSO4 (Again, can
cause tissue damage!)
Or PO supplement
Dietary intake (Nuts, leafy greens,
bananas, oranges, peanut butter, chocolate,grains)
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Nursing Management of
HypomagnesemiaReduce environmental stimuli
Seizure precautions
Monitor cardiac and neuro status
Assess DTR every 1 4 hrs
Dysphagia
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Hypermagnesemia
>2.5mEq/LChronic renal failure
Excessive intake antacids & laxatives
Treatment of pre-eclampsia/eclampsia
(to be expected)
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Hypermagnesemia
Flushed & sensation of warmth
Lethargy, drowsiness
Hypoactive DTRs
Facial numbness
EKG changes
Respiratory depression or paralysis
Cardiac arrest
Nausea & vomiting
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Hypermagnesemia
Management
Dialysis if renal failure is the cause
IV fluidsif renal function is normal
Avoid laxatives and antacids with Mg++
IV calcium gluconateDiet therapy-reduce intake of Mg++
Prevent future episodes
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Nursing Management of
HypermagnesemiaEncourage po fluid intake
Monitor cardiac and respiratory status
Monitor I&O, VS, DTR, labs
Safety
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Quick Quiz
Magnesium functions to:
A. Prevent Ca+ absorption
B. Aid in cell metabolism
C. Regulate ECF of Ca++ and K+
D. Inhibit parathyroid function
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Quick Quiz
Which of the following in the history,
physical and review of data would lead
to a diagnosis of hypomagnesemia?A. Increased serum Ca++
B. Intake of antacids with Mg++
C. Excessive diarrhea and vomitingD. Hypoaldosteronism
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Quick Quiz
Where will you see the primary effects
of Mg++ deficit?
A. Cardiac dysrhythmias and muscle tetanyB. Hypoactive reflexes
C. Hypertension
D. Depression
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Quick Quiz
Which of the following patients should
be observed for Mg++ excess?
A. Over hydrationB. Hypoparathyroidism
C. Hyperparathyroidism
D. Chronic renal failure