NUR 242 - Med surg Exam 2 Study Guide.

Med surg exam 2 study guide Chap 11 Fluid compartments Intracellular 60% Contained within the cell body About 25L Veins, arteries, capillaries, heart, etc Extracellular 33% Most important area of homeostasis, area outside of cells Divided into intravascular space and interstitial space Extracellular fluid volume is about 15L In-between the cells Fluid Balance Closely linked to/affected by electrolyte concentrations Fluid intake 2.3-3L a day Fluid loss Minimum urine amount needed to excrete toxic waste products= 400-600 mL/day Insensible water loss-through skin, lungs, stool. Usually 500 to 1L a day This increases during a fever, tachypnea and extreme stress Facts to remember Any fluid imbalances that occur=continuous assessment of UOP Urine output Dehydrated pts, CHF, RF, Fluid volume deficient, and fluid volume overload IV fluids, diuretics Daily weights 1L of water weighs 2.2lb, equal to 1kg Weight change of 1lb= fluid volume change of about 500 mL Fluid volume deficit: Dehydration Fluid intake/retention does not meet bodys fluid needs; results in fluid volume deficit Assessment Thread and increased pulse rate; decreased BP; lethargy; decreased UOP; dry mucous membranes; constipation; thirst Increased H&H (hemoconcentration), BUN, sodium, and urine specific gravity Causes-vomiting, diarrhea, ileostomy, laxatives, burns, fever, diuretics, GI suctioning, and NPO Interview/risk factors Inquire about recent dietary habits Use of OTC diuretics Outdoor activities Weight gain and weight loss Who at risk: hemorrhage, vomiting, diaherra, excessive sweating, NPO, sustained burn wounds, GI suction, Diuretics, uncontrolled diabetes, Poor intake Flat neck and hand veins, increased RR, skin tenting, tongue wrinkles, dehydration, fever, UOP concentrated, Urine specific gravity concentrated (the higher the dryer) BUN and Creatinine BUN and Creatinine are kidney markers and are sensitive to decreased blood flow BUN (10-20) and Creatinine (06-1.2) rise when nitrogenous wastes are found in the blood indicating kidney impairment GFR (65) typically has an inverse relationship (increased BUN and Creatinine with a decreased GFR)- chronic renal failure Elevations can be caused by dehydration Fluid volume overload Assessment Bounding and increase pulse; elevated BP; dyspnea, crackles on lung auscultation; edema; decreased Hematocrit (hemodilution), decreased serum sodium and urine specific gravity (dilute urine). Weight gain is the best indicator Causes- ESRD, CHF, water intoxication, SIADH, corticosteroid therapy, and rapid fluid replacement Drug therapy Diuretics (loop diuretics) Nutrition therapy Fluid restriction ( 1200 ml/day) Salt restriction Monitoring of intake and output Daily Weight!!!! ESRD= End stage renal disease SIADH= syndrome of inappropriate ADH Edema- while standing ankles, feet, while laying down sacrum, back Extreme cases it will be everywhere Electrolyte imbalances: etiology Hyponatremia Due to sodium loss, water gain, or inadequate intake Sodium loss: drugs; diuretics, anticonvulsants, SSRIs, antipsychotics, cancer meds Hypernatremia Dehydration, excessive Na intake (sodium polystyrene, sodium bicarb, renal issue) Hypokalemia Not enough in too much out, depleting drugs, medical conditions Not enough in: inadequate K intake Too much out: GI fluid losses Depleting drugs: diuretics, corticosteroids, insulin, excessive laxative use, albuterol Black licorice-acts like aldosterone Hyperkalemia Too much intake, blood products, drugs, not enough excreted, crush injury supplements Too much intake: increased dietary intake,, salt substitutes, potassium Donated blood Drugs: K sparing diuretics, ACE inhibitors, ARBs, NSAIDs Not enough excreted: renal failure ( low Na, K, protein diet) Crush injury: intracellular K released Hypocalcemia Inadequate intake, malabsorption, calcium loss, others Inadequate intake: calcium and vitamin D (sunlight) Malabsorption: post menopausal women, diseases that affect the small bowel, drugs (anticonvulsants) Calcium loss: loop diuretics Others: renal failure, hypoparathyroidism, low magnesium, multiple blood transfusions, alkalosis, low albumin levels Hypercalcemia Increased resorption from the bone Hyperparathyroidism Cancer Thiazide diuretics Hypomagnesemia Poor intake, poor GIT absorption, excessive GIT loss, excessive urinary losses Poor intake; alcoholics, patients on TPN or enteral feeding Poor absorption: IBD, celiac disease GIT loss: diarrhea, laxative use, NGT drainage Urinary loss: diuretics (loop and thiazide) Hypermagnesemia Excessive intake, impaired excretion Excessive intake: magnesium containing antacids/laxatives Impaired excretion: renal dysfunction Rare Sodium imbalances: affect CNS Hyponatremia Common: headache, irritability, disorientation/confusion, tired, abdominal cramping, muscle twitching/weakness, crave salt Worst case scenario (critical low): psychosis, seizures, ataxia, airway issues Treatment Mild: fluid restriction (safest), oral sodium supplements Critical: hypertonic 3% saline SLOWLY!!! Nursing implications: Monitor neurologic status, seizure/fall precautions, strict I/Os, implement fluid restriction, monitor labs Hypernatremia Common: crave water restlessness or agitation, anorexia, N/V, weakness, lethargy, confusion, Worst case scenario: decreased LOC seizures, coma Treatment: fluids PO/IV, what type (initially isotonic fluid, increase BP, switch then to hypotonic fluid (D5W) (less salt more water!!!) Nursing implications Frequent v/s, monitor neurologic status, seizure/fall precautions, strict i/os, assess skin/mm, oral care, monitor labs Give fluids if dehydration present Potassium imbalances: affect heart/muscles/GI tract Hypokalemia Common Cardiac arrhythmias, leg cramps (hallmark), muscle weakness, decreased GI motility (decreased BS, constipation, n/v), decreased DTRs, muscle weakness, alkalosis Worst case scenario Life threatening cardiac arrhythmias/cardiac arrest Hypokalemia may potentiate dig toxicity*** Treatment Increase dietary intake of potassium, k supplementation, Give IV potassium slowly!!!! 20mEq/hr Nursing implications Frequent V/s, cardiac monitoring, patent IV, monitor labs (recheck after supplementation), NEVER GIVE POTASSIUM IVP OR BOLUS!!!!! Very dangerous Remember suction S= skeletal muscle weakness, U= U WAVE, C= constipation, T= toxic effect of dig, I= irregular pulse, o= orthostatic hypotension, N=numbness Hyperkalemia Common Cardiac arrhythmias, muscle weakness (which may lead to flaccid paralysis), increased GI motility, decreased DTR’s, acidosis Worst case scenario Life threatening cardiac arrhythmias/ cardiac arrest Treatment Potassium restricted diet, if critical/symptomatic will require drug therapy (CBIGKD) which stand for: C= calcium, B= bicarb, I= Insulin (regular, IV push), G= glucose, K= kusulate (sodium poly), D= dialysis Nursing implications Cardiac monitoring, frequent labs, VS, monitor for hypoglycemia if insulin IVP given Calcium imbalances: affect neurological/neuromuscular system (9-10.5) Hypocalcemia (over stimulation ) Common Anxiety, irritability, confusion, paresthesia’s of toes, fingers, face, around mouth, severe muscle cramping, trousseau’s and Chvostek’s sign, increased DTR’s alkalosis Worst case scenario: Seizures, high risk for fractures Treatment Calcium/vitamin d supplements; if acute or symptomatic IV calcium gluconate or IV calcium chloride Nursing implications If at high r/f hypocalcemia, assess carefully for s/s, vs, patent IV, assess for Chvostek’s and trousseau’s signs, monitor labs (esp after multiple transfusions), teach about dietary sources of calcium Hypercalcemia (under stimulation) Common Lethargy, confusion, memory loss, AMS, personality changes ( neuropsychiatric), decreased DTR’s, muscles weakness Worst case scenario Coma Treatment Reduce dietary intake of calcium, IVF, loop diuretics, bisphosphonates Nursing implications Vs, assess neurologic and neuromuscular function frequently, monitor electrolytes, maintain patent IV, strict I/Os, monitor for fractures Hypocalcemia/hypomagnesemia Palmar flexion indicating a positive trousseaus sign in hypocalcemia Facial muscle response indicating a positive Chvostek’s sign in hypocalcemia Magnesium imbalances: affect cardiac/neurological system Hypomagnesemia (not relaxed) Common Altered LOC, confusion, hallucinations, nystagmus, leg and foot cramps, Chvostek’s and trousseau’s signs, hyperactive DTRs, tachycardia, muscles cramps, spasms Worst case scenario Seizures, life threatening cardiac arrhythmias!!! Treatment Change in diet, PO or IV supplementation Nursing implications Assess mental status frequently and report changes, evaluate NM status, seizure precautions, VS, cardiac monitoring, patent IV, check electrolytes Hyper magnesemia (too relaxed) Common Drowsy, lethargic, decreased LOC, vasodilation (will decrease BP), muscle weakness (decreased muscle and nerve activity) and nerve activity, bradycardia, decreased DTR’s, occasional n/v Fluid tonicity Worst case scenario Bradycardia, heart blocks, cardiac arrest Treatment Calcium gluconate/calcium chlorite is antidote Nursing interventions Monitor VS, and cardiac rhythm, monitor electrolytes, maintain patent IV Isotonic 0.9% NS Lactated ringers Useful for fluid resuscitation Hypertonic 3% NS 5% NS D5 or 0.9% nacl D5% lactated ringers TPN Caused for cerebral edema Used for hyponatremia Assess for fluid volume overload D5W- isotonic in bag, hypotonic in the body Normal ABG value pH 7.35-7.45 CO2 35-45 HCO3 22-26 pO2 80-100 Acidosis Hyperkalemia Hypercalcemia Hydrogen ions Overproduction