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DMRN 131. Capstone 2

Electrolytes Potassium (3.5-5), sodium (135-145), chloride (97-107 mEq/L)

Calcium (9-10.5), magnesium (1.5-2.5), phosphorus (2.5-4.5 mg/dL)

Maintenance of Fluid and Electrolytes Balance: Kidneys: RAAS for Na, H2O and K

Pituitary: ADH for H2O

Calcium and phosphorus: PTH, Calcitonin and vitamin D

Blood osmolarity (285 295 mOsm/L) = [Na+] IV fluids: isotonic, hypertonic, hypotonic

Urine specific gravity (1.010-1.030): Dehydration = Concentration = S.G.

Oncotic pressure: albumin (3.5-5 g/dL)

Third-spacing Shift of fluid from intravascular to interstitial or other body space.

E.g. ascites, burns, intestinal obstruction

Anasarca: generalized edema

2

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ALDOSTERONE VASOCONSTRICTION

VASOPRESSIN (ADH)

Na+ & H2O

Diabetes Insipidus SIADH

ADH Low High

Urinary output High Low

Urine Specific Gravity Low High

Plasma Osmolarity High Low

Plasma Sodium High Low

Hematocrit & BUN High Low

Symptoms Polyuria, polydipsia Oliguria, brain edema,weight gain, crackles

Causes Stroke, trauma, surgery Lung cancer

Treatment Vasopressin DemeclocyclineTolvaptan, Conivaptan:anti-ADH drugs

Expected Outcome Decreased diuresis Increased diuresis

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The nurse is caring for a client who had an excision of a malignant pituitarytumor and diabetes insipidus. Which findings should the nurse document thatindicate the client is receiving too much treatment?

A. Hypernatremia and periorbital edema.

B. Muscle spasticity and hypertension.C. Weight gain with low serum sodium.D. Increased urinary output and thirst.

A 10-year-old child with meningitis is suspected of having diabetes insipidus.In evaluating the child's laboratory values, which finding is indicative ofdiabetes insipidus?

A. Decreased urine specific gravity.B. Elevated urine glucose.C. Decreased serum potassium.D. Decreased serum sodium.

C, A, 4

Causes: hemorrhages, fluid loss, burns, diuretics Assessment

Hypotension

Tachycardia: why?

Oliguria + Increased specific gravity (>1.030): Why? Exception: diabetes insipidus (polyuria

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CVP: 5-10cm H2O (2-6mmHg)

PCWP: 6-12 mmHg

CVP PCWP

Type Solution Osmolarity Composition Use

Normal Saline Isotonic (308 mOsm/L) 0.9 g NaCl/100mL H2O

Fluid replacement

Lactated Ringers Isotonic (275 mOsm/L) NS with buffer Fluid replacement

D5W Isotonic in bag,Hypotonic in body

5 g glucose/100mL H2O

Replacement ofwater or glucose

NS Hypotonic (154 mOsm) 0.45 g NaCl/100mL H2O

Replacement ofwater

D5NS Hypertonic (560) 5 g D + 0.9 gNaCl/100 mL H2O

Replaces fluidand dextrose

D5 NS Hypertonic (406) 5 g D + 0.45 gNaCl/100 mL H2O

Same

D5LR Hypertonic (295) 5 g D/100 mL LR Same

3% NaCl Hypertonic 3g NaCl/100 mL H2O Volume expansion

PlasmaExpanders

FFP, Albumin,Hetastarch

Volume expansion

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A man who was severely burned over 90% of his body during an accident onthe job has been brought to the ED. The rescue personnel were unable to

establish IV access during transport to the hospital. Which type of IV devicewould be most appropriate at this time?A. PICC lineB. Central lineC. Intra-osseous catheterD. Subcutaneous infusion

A client with CKD is brought bleeding profusely after a MVA. MD inserts acentral catheter (CVC). To promote rapid volume replacement the nurseshould use:A. D5W and IV pump through a 18 G saline lock deviceB. LR and IV pump through a 18 G needle for veins of the AV shunt armC. LR and tubing with needless connectionD. LR and IV pump through a 20 G butterfly needle

C,c,3

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Causes: heart failure, renal failure, IV fluids, water intoxication

Assessment Tachycardia

Hypertension (bounding pulses)

Distended neck veins

Orthopnea, cough, pink frothy sputum

Moist crackles

Pitting, dependent edema

Elevated CVP and PCWP

Weight gain 1 K = 1 L and 1 g = 1 mL

Interventions Administer diuretics as prescribed

Restrict sodium and fluid intake as prescribed Avoid process food, canned, sauces, dressings, tomato juice, soups, dry fruits , sea

food, dairy, pretzels, pickles, milk and dairy

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C, b

The most appropriate method to rehydrate an infant with moderatedehydration secondary to diarrhea is:a. Replacing milk-based formula with a lactose-free formulab. Oral rehydration therapy with electrolyte solution every 3-4 hours

c. Administering intravenous (IV) fluids of D5 NSd. Offering bananas, rice, applesauce, and toast (BRAT diet) along with

oral fluids

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Hyponatremia Na+ < 135 mEq/L Causes:

Diuretics, hypotonic solutions,water intoxication (enemas, bladder irrigation),SIADH

Assessment Brain edema: confusion, coma, seizures Skeletal muscle weakness Diminished deep tendon reflexes Increased GI motility: hyperactive bowel sounds, cramps, diarrhea Decreasedurine specific gravity (ADH suppression) Pontine myelinolysis: sudden dysphagia, dysarthria, acute paralysis Na+ replacement: NaCl 3%

Hypernatremia Na+ > 145 mEq/L Causes: Diabetes Insipidus, hypertonic solutions, near drowning in salt water

Assessment Altered cerebral function and seizures Diminished to absent deep tendon reflexes Hyperosmolarity: intense thirst, parched mucosa

Fluid volume excess: fluid retention, hypertension, bounding pulses Oliguria and Increased urine specific gravity (ADH activation) Avoid process food, soups, tomato juice, dry fruits, dressings and sauces

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Serum K+

< 3.5 mEq/L Causes: diuretics, glucocorticoids, NG suction, vomits, diarrhea,

Cushing, black licorice (aldosterone action)

Assessment

Skeletal muscle weakness, cramps, shallow respirations

Hyporreflexia

Decreased GI motility: ileus paralyticus

Changes in (ECG): U wave, depressed ST

Nursing Interventions:

Assess renal function before K+ replacement

Monitor cardiac rhythm

IV K+ infusion rate

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Serum K+> 5.0 mEq/L Causes:

Renal failure

K+-sparing diuretics: amiloride, triamterene, spironolactone

ACE inhibitors Addisons

Shift of intracellular potassium to extracellular fluid

Mrs. Dash, Gatorade

Assessment Severe muscle weakness, shallow respirations

Palpitations, arrhythmias

Changes in ECG: tall peaked T waves, flat P

Nursing Interventions: Monitor cardiac rhythm

Sodium polystyrene (Kayexalate)

Dextrose + insulin

Na bicarbonate

Ca gluconate

Dialysis

Foods low in potassium include apples, pears, peach,

grapes, berries (except strawberry), cabbage, lettuce,summer squash, eggs

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A potassium level is reported 6 mEq/L. The laboratory indicates the specimen

is hemolyzed. What intervention should the nurse takeA. Notify immediately the health care providerB. Obtain a prescription for KayexalateC. Draw a new blood sampleD. Encourage the patient to increase fluids intake

The nurse teaches a client about how to increase dietary potassium. The clientsays she knows bananas are high in potassium but does not like the taste. Thenurse determines teaching is effective if the client states which of the following?

A. I should include carrots, broccoli, and yogurt in my dietB. I should eat more rhubarb, tofu and celeryC. Potatoes, spinach, and raisins are high in potassiumD. Eating onions, corn, and oatmeal each day will give me all the potassium I need

A client with ESRD has BUN 48 mg/dL and potassium level of 5.5 mEq/L. TheHCP orders IV D5W with 10 units of regular insulin. The client asks the nurse if

he has become diabetic. What is the best answer the nurse can give this client?A. The renal damage has affected the pancreasB. Dextrose and insulin will restore your caloric needsC. Dextrose and insulin will help to decrease the potassium in your bloodD. Dextrose and insulin are necessary to normalize the BUN

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C, c, c

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What means having palpitations and fainting? Is a client in Synthroid or ESRD with palpitations a priority?

Who can have hyperkalemia? ESRD (CKD)

Mrs. Dash

ACEi

Spironolactone, Amiloride, Triamterene

Rhabdomyolysis, Hemolysis, Old bank blood, Chemotherapy

Fake hyperkalemia: in vitro hemolysis

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Ca++ < 8.5 mg/dL Causes: Hypoparathyroidism (thyroid surgery),

ESRD, pancreatitis, blood transfusions

Assessment Increased bowel sounds (diarrhea)

Cardiac arrhythmias (prolonged QT)

Paresthesis fingers and lips

Muscle irritability, DTR

Trousseau's and Chvosteks signs

Laryngeal spasm and stridor

Seizures

Nursing Interventions

Calcium gluconate available

Seizure precautions Foods rich in Ca: dairy, soy milk, tofu, sardines,

salmon, spinach, broccoli, collard greens, greenbeans, rhubarb, spinach, almonds

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Chvosteck

Trousseau

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Serum calcium > 10.5 mg/dL

Causes: Hyperparathyroidism, metastatic cancer,Multiple Myeloma (M.M.), Pagets disease, Vitamin Dintoxication

Assessment

Polyuria, dehydration

Constipation

Kidney stones

Acute Renal failure

Muscle weakness, shallow respirations

DTR

Heart rate and BP

Nursing Interventions

Hydration

Furosemide Calcitonin

Multiple Myeloma

(Bence-Jones protein)

20

Q-T

EKG?

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Hypomagnesaemia

CausesCauses: malnutrition, alcoholism

AssessmentAssessment:Twitching, paresthesisPositive Trousseau's and Chvosteks signsSeizuresProlonged QTTorsade de Points

Nursing InterventionsNursing InterventionsSeizure precautionsCardiac monitorizationMg supplement, legumes, whole grains,nuts

Hypermagnesemia

CausesCauses: CKD, Mg laxatives or antacids,MgSO4 in eclampsia

AssessmentAssessment:Hyporreflexia: DTR 1+ or 0Respiratory depressionAMS and coma

Nursing InterventionsNursing InterventionsCalcium gluconateDialysisAvoid laxatives and antacids containingmagnesium

Magnesium NV: 1.5 to 2.5 mg/dL

A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. Which of thefollowing symptoms would you NOT expect to see in this patient?

A. Numbness in hands and feet.B. Muscle cramping.C. Hypoactive bowel sounds.