CH 17 Fluid and Electrolyte Imbalances

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1

Electrolytes are _____ (sometimes called salts) that are present in all body fluids.

minerals

2

When dissolved in water or another solvent, electrolytes separate into _____.

ions

3

True or False:

While laboratory tests can accurately reflect the electrolyte concentrations in plasma, it is not possible to directly measure electrolyte concentrations within cells.

true

4

Fluid volume deficits (FVDs) include:

Isotonic FVD

Dehydration

5

Isotonic FVD

Dehydration

Isotonic FVD (Hypovolumia)

6

____ is the loss of water from the body without the loss of electrolytes

Dehydration

7

Dehydration _____ results in increases in Hct, serum electrolytes, and urine specific gravity.

hemoconcentration

8

FVD compensatory mechanisms include sympathetic nervous system responses of increased

include sympathetic nervous system responses of increased thirst, antidiuretic hormone (ADH) release, and aldosterone release.

9

Hypovolemia can lead to _____.

hypovolemic shock

10

Older adults have an increased risk for dehydration due to

multiple physiological factors including a decrease in total body mass, which includes total body water content.

11

Causes of isotonic FVD (hypovolemia):

Abnormal gastrointestinal (GI) losses
Abnormal skin losses
Abnormal renal losses
Third spacing
Hemorrhage
Altered intake

12

Third spacing examples:

peritonitis
intestinal obstruction
ascites
burns

13

Causes of dehydration:

Hyperventilation
Prolonged fever
Diabetic ketoacidosis
Enteral feeding without sufficient water intake

14

FVD Symptoms Vital signs

hypothermia, tachycardia, thready pulse, hypotension, orthostatic hypotension, decreased central venous pressure, tachypnea, hypoxia

15

FVD Symptoms Neuromusculoskeletal

dizziness
syncope
confusion
weakness
fatigue

16

FVD Symptoms GI

thirst
dry mucous membranes
dry furrowed tongue
nausea/vomiting
anorexia
acute weight loss

17

FVD Symptoms Renal

oliguria (decreased production of urine)

18

FVD Symptoms Other clinical findings

diminished capillary refill
cool clammy skin
diaphoresis
sunken eyeballs
flattened neck veins
absence of tears
decreased skin turgor

19

FVD Laboratory Findings Hct

Increased in both hypovolemia and dehydration unless the fluid volume deficit is due to hemorrhage.

20

FVD Laboratory Findings Serum osmolarity

Dehydration - increased hemoconcentration osmolarity (greater than 300 mOsm/kg) -
increased protein, BUN, electrolytes, glucose.

21

FVD Laboratory Findings Urine specific gravity and osmolarity

Dehydration - both increased concentration (urine specific gravity greater than 1.030)

22

FVD Laboratory Findings Serum sodium

Dehydration - increased hemoconcentration

23

FVD Fluid replacement

Administer IV fluids as prescribed (isotonic solutions such as lactated Ringer's
or 0.9% sodium chloride; blood transfusions).

24

FVD I&O's

Monitor I&O. Encourage fluids as tolerated. Alert the provider to a urine output less than 30 mL/hr.

25

_____ is the isotonic retention of water and sodium in abnormally high proportions.

Fluid volume excess (FVE)

26

Fluid volume excesses include:

Overhydration

27

____ is the gain of more water than electrolytes

Overhydration (or hypoosmolar fluid imbalance)

28

Severe hypervolemia can lead to _____.

pulmonary edema
heart failure

29

FVE compensatory mechanisms include:

increased release of natriuretic peptides, resulting in increased excretion of sodium and water by the kidneys, and a decreased release of aldosterone.

30

Causes of hypervolemia:

heart failure
cirrhosis,
kidney failure
hypertonic fluids
burns
age-related changes (heart, kidney)
excessive sodium intake

31

Causes of overhydration:

Water replacement without electrolyte replacement
SIADH
Head injuries
Barbiturates
Anesthetics

32

SIADH (related to overhydration)

Syndrome of inappropriate antidiuretic hormone, which is the excess secretion of ADH

33

FVE Symptoms Vital Signs

tachycardia
bounding pulse
hypertension
tachypnea
increased central venous pressure

34

FVE Symptoms
GI

weight gain
ascites

35

FVE Symptoms Respiratory

dyspnea
orthopnea
crackles

36

FVE Symptoms Other clinical findings

edema
distended neck veins

37

FVE Laboratory Findings Hct

Hypervolemia - decreased Hct
Overhydration - decreased Hct = hemodilution

38

FVE Laboratory Findings Serum osmolarity

Overhydration - osmolarity less than 280 mOsm/kg

39

FVE Laboratory Findings Serum sodium

Hypervolemia - sodium within expected reference range

40

FVE Laboratory Findings Electrolytes, BUN, and creatinine

Overhydration & hypervolemia - decreased electrolytes, BUN, and creatinine

41

FVE Laboratory Findings ABG's

Respiratory alkalosis - decreased PaCO2 (less than 35 mm Hg), increased pH (greater than 7.45)

42

FVE Diagnostic Procedure Chest x-ray

may indicate pulmonary congestion

43

FVE Nursing Care Implement prescribed restrictions for fluid and sodium intake

Provide fluids in small glass to promote the perception of a full glass of fluid.
Set 1- to 2-hr short-term goals for the fluid restriction to promote client control and understanding.

44

_____ is essential for maintenance of acid-base and fluid balance, active and passive transport mechanisms, and irritability and conduction of nerve and muscle tissue.

Sodium

45

Sodium (Na+) is the major _____ found in ECF and is present in most body fluids or secretions.

electrolyte

46

Expected serum sodium levels are between _____.

136 and 145 mEq/L

47

_____ is a net gain of water or loss of sodium-rich fluids.

Hyponatremia

48

Hyponatremia delays and slows the _____ of membranes.

depolarization

49

In hyponatremia _____ moves from the ECF into the ICF, which causes cells to swell (cerebral edema).

water

50

Serious complications can result from untreated acute hyponatremia:

coma
seizures
respiratory arrest

51

Causes of hyponatremia:

Deficient ECF volume
Abnormal GI losses
Renal losses
Skin losses
Excessive oral water intake
SIADH
Edematous states - CHF, cirrhosis
Excessive hypotonic IV fluids
Inadequate sodium intake (NPO status)
Age-related risk factors

52

Hyponatremia Symptoms Vital Signs

hypothermia
tachycardia
rapid thready pulse
hypotension
orthostatic hypotension

53

Hyponatremia Symptoms Neuromusculoskeletal

headache, confusion, lethargy
muscle weakness with possible respiratory
compromise
fatigue, decreased deep tendon reflexes (DTRs)
seizures, coma

54

Hyponatremia Symptoms GI

increased motility, hyperactive bowel sounds
abdominal cramping, anorexia
nausea, vomiting

55

Hyponatremia Laboratory Findings Serum sodium

Decreased - less than 136 mEq/L

56

Hyponatremia Laboratory Findings Serum osmolarity

Decreased - less than 280 mOsm/kg

57

Hyponatremia Nursing Care Acute hyponatremia:

Administer hypertonic oral and IV fluids as prescribed.
Encourage foods and fluids high in sodium (cheese, milk, condiments)

58

Hyponatremia Nursing Care Restoration of normal ECF volume:

Administer isotonic IV therapy (0.9% sodium chloride, lactated Ringer's).

59

Hypernatremia electrolyte imbalance can cause

neurological, endocrine, and cardiac disturbances.

60

Hypernatremia is a serum sodium level greater than _____.

145 mEq/L

61

Increased sodium causes _____ of the serum. This causes a shift of

hypertonicity

out of the cells, making the cells dehydrated.

62

Causes of Hypernatremia:

Water deprivation (NPO)
Heat stroke
Excessive sodium intake
Bicarbonate intake
Excessive sodium retention - kidney failure, Cushing's syndrome, aldosteronism, some
medications (glucocorticosteroids)
Fluid losses
Age-related changes
Compensatory mechanisms - increased thirst and increased production of ADH

63

Hypernatremia Symptoms Vital Signs

hyperthermia
tachycardia
orthostatic hypotension

64

Hypernatremia Symptoms Neuromusculoskeletal

restlessness, disorientation, irritability
muscle twitching, muscle weakness,
seizures, decreased level of consciousness, reduced to absent DTRs

65

Hypernatremia Symptoms GI

thirst, dry mucous membranes
dry and swollen tongue that is red in color
increased motility, hyperactive bowel sounds
abdominal cramping, nausea

66

Hypernatremia Symptoms Other clinical findings

edema
warm flushed skin
oliguria

67

Hypernatremia Laboratory Findings Serum sodium

Increased - greater than 145 mEq/L

68

Hypernatremia Laboratory Findings Serum osmolarity

Increased - greater than 300 mOsm/kg

69

Hypernatremia Nursing Care Fluid loss - based on serum osmolarity

Administer hypotonic IV fluids (0.225% sodium chloride)

70

Hypernatremia Nursing Care

Encourage water intake and discourage sodium intake.
Administer diuretics (loop diuretics).

71

_____ has a reciprocal action with sodium and plays a vital role in cell metabolism; transmission of nerve impulses; functioning of cardiac,
lung, and muscle tissues; and acid-base balance.

Potassium

72

Potassium (K+) is the major cation in _____.

ICF

73

serum potassium levels are _____.

3.5 to 5 mEq/L

74

_____ is a serum potassium level below 3.5 mEq/L and is the result of an increased loss of potassium from the body or movement of potassium into the cells.

Hypokalemia

75

Causes of hypokalemia:

Abnormal GI losses
Renal losses - excessive use of potassium-excreting diuretics (furosemide), corticosteroids
Skin losses - diaphoresis, wound losses
Hyperaldosteronism
Insufficient potassium
Inadequate dietary intake (rare)
Prolonged administration of non-electrolyte-containing IV sols such as 5% dextrose in water
ICF - metabolic alkalosis, after correction of acidosis (treatment of diabetic ketoacidosis), during periods of tissue repair (burns, trauma, starvation), total parenteral nutrition

76

Hypokalemia Symptoms

Vital Signs

hyperthermia
weak irregular pulse
hypotension
respiratory distress

77

Hypokalemia Symptoms

Neuromusculoskeletal

ascending bilateral muscle weakness with respiratory collapse and paralysis
muscle cramping
decreased muscle tone hypoactive reflexes
paresthesias
mental confusion

78

Hypokalemia Symptoms

ECG

premature ventricular contractions (PVCs)
bradycardia
blocks
ventricular tachycardia
flattening T waves
ST depression

79

Hypokalemia Symptoms

GI

decreased motility
hypoactive bowel sounds
abdominal distention
constipation
ileus, nausea
vomiting, anorexia

80

Hypokalemia Symptoms

Other clinical findings

polyuria (excretion of dilute urine)

81

Hypokalemia Laboratory Findings

Serum potassium

Decreased - Less than 3.5 mEq/L

82

Hypokalemia Laboratory Findings

ABG's

Metabolic alkalosis - pH greater than 7.45

83

Hypokalemia Diagnostic Procedures

Electrocardiogram (ECG)

shows findings of dysrhythmias, such as PVCs, ventricular tachycardia, flattening T waves, and ST depression.

84

Hypokalemia Nursing Care

Replace potassium

Provide dietary education and encourage foods high in potassium (avocados, dried fruit, cantaloupe, bananas, potatoes, spinach).
Provide oral potassium supplementation.

85

Hypokalemia Nursing Care

IV potassium supplementation

Potassium is a tissue irritant.

86

Hypokalemia increases the risk for _____ toxicity

digoxin

87

_____ is a serum potassium level greater than 5.0 mEq/L and is the result of an increased intake of potassium, movement of potassium out of the
cells, or inadequate renal excretion

Hyperkalemia

88

Hyperkalemia is uncommon in clients who have adequate _____ function and is potentially life-threatening due to the risk of cardiac arrhythmias and cardiac arrest.

renal

89

Causes of hyperkalemia:

Increased total body potassium
ECF shift
Hypertonic states - uncontrolled DM
Decreased excretion of K+
Older adult clients

90

Hyperkalemia Symptoms

Vital Signs

slow, irregular pulse; hypotension

91

Hyperkalemia Symptoms

Neuromusculoskeletal

irritability, confusion
weakness with ascending flaccid paralysis
paresthesias
lack of reflexes

92

Hyperkalemia Symptoms

ECG

ventricular fibrillation
peaked T waves
widened QRS
cardiac arrest

93

Hyperkalemia Symptoms

GI

increased motility
diarrhea
abdominal cramps
hyperactive bowel sounds

94

Hyperkalemia Symptoms

Other clinical findings

oliguria

95

Hyperkalemia Laboratory Findings

Serum potassium

Increased - Greater than 5 mEq/L

96

Hyperkalemia Laboratory Findings

ABG's

Metabolic acidosis - pH less than 7.35

97

Hyperkalemia Nursing Care

Decrease potassium intake

Stop infusion of IV potassium.
Withhold oral potassium.
Provide a potassium-restricted diet.
If potassium levels are extremely high, dialysis may be required.

98

Hyperkalemia Nursing Care

Promote movement of K+
from ECF to ICF:

Administer IV fluids with dextrose and regular insulin.

99

Hyperkalemia Nursing Care

Medications to increase K+ excretion:

Administer loop diuretics, such as furosemide, if kidney function is adequate. Loop diuretics increase excretion of K+ from the renal system.

100

Hyperkalemia Nursing Care

Sodium polystyrene sulfonate (Kayexalate)

is given orally or as an enema. Increases
the excretion of K+ from the GI system.

101

_____ balance is essential for proper functioning of the cardiovascular, neuromuscular, and endocrine systems, as well as blood clotting and bone and teeth formation.

Calcium

102

The expected total calcium level is _____.

9 to 10.5 mg/dL

103

__ is a serum calcium level less than 9 mg/dL.

Hypocalcemia

104

Hypocalcemia Symptoms

Increased calcium output:

Chronic diarrhea
Steatorrhea as with pancreatitis (binding of calcium to undigested fat)

105

Hypocalcemia Symptoms

Inadequate calcium intake or absorption:

Malabsorption syndromes, such as Crohn's disease
Vitamin D deficiency (alcohol use disorder, kidney failure)

106

Hypocalcemia Symptoms

Calcium shift from extracellular fluid into bone or to an inactive form:

Repeated blood transfusion
Post-thyroidectomy
Hypoparathyroidism

107

Hypocalcemia Symptoms

Muscle twitches/tetany:

Numbness and tingling (extremities, circumoral)
Frequent, painful muscle spasms at rest that can progress to tetany
Hyperactive DTRs
Positive Chvostek's sign (tapping on the facial nerve triggering facial twitching)
Positive Trousseau's sign

108

Hypocalcemia Symptoms

Cardiovascular:

Decreased myocardial contractility
(decreased heart rate and hypotension)

109

Hypocalcemia Symptoms

Central nervous system:

seizures due to overstimulation of the CNS

110

Hypocalcemia Diagnostic Procedures:

ECG

Prolonged QT interval and ST segments

111

Hypocalcemia Nursing Care:

Administer oral or IV calcium supplements. (Carefully monitor respiratory and cardiovascular status.)
Initiate seizure precautions.
Keep emergency equipment on standby.
Encourage foods high in calcium, including dairy products and dark green vegetables.

112

_____ is a serum calcium level greater than 10.5 mg/dL.

Hypercalcemia

113

Hypercalcemia

Risk Factors:

Decreased Calcium output, Thiazide diuretics
Increased calcium intake and absorption
Calcium shift from bone to extracellular fluid
Hyperparathyroidism
Bone cancer
Paget's disease
Chronic immobility

114

Hypercalcemia Symptoms:

Neuromuscular

Decreased reflexes
Bone pain
Flank pain if renal calculi develop
Cardiovascular
Dysrhythmias

115

Hypercalcemia Symptoms:

GI

anorexia
nausea
vomiting
constipation

116

Hypercalcemia Symptoms:

Central nervous system

Weakness, lethargy
Confusion, decreased LOC

117

Hypercalcemia Diagnostic Procedures:

ECG

shortened QT interval and ST segment

118

Hypercalcemia Nursing Care:

Increase client activity level.
Limit dietary calcium.
Encourage fluids to promote urinary excretion.
Encourage fiber to promote bowel elimination.
Implement safety precautions if client confused.
Monitor for pathologic fractures.
Encourage acid-ash fluids such as prune or cranberry juice to decrease the risk for renal calcium stone formation.

119

Most of the body's _____ is found in the bones and in smaller amounts within
body cells. A very small amount is found in ECF.

magnesium

120

The expected magnesium level is _____.

1.3 to 2.1 mEq/L

121

Hypomagnesemia is a serum magnesium level less than _____.

1.3 mEq/L

122

Hypomagnesemia Risk Factors:

Increased magnesium output

GI losses
Thiazide or loop diuretics

123

Hypomagnesemia Risk Factors:

Inadequate magnesium intake or absorption:

Malnutrition
Alcohol use disorder
Laxative use

124

Hypomagnesemia Symptoms:

Neuromuscular

increased nerve impulse transmission (hyperactive DTRs, paresthesias, muscle
tetany)
positive Chvostek's and Trousseau's signs

125

Hypomagnesemia Symptoms:

GI

hypoactive bowel sounds
constipation
abdominal distention
paralytic ileus

126

Hypomagnesemia Symptoms:

Cardiovascular

dysrhythmias
tachycardia
hypertension

127

Hypomagnesemia Nursing Care

Discontinue magnesium-losing medications.
Administer oral or IV magnesium sulfate following safety protocols. IV route is used because IM can cause pain and tissue damage. Oral magnesium can cause diarrhea and increase magnesium depletion.
Encourage foods high in magnesium, whole grains and dark green vegetables.
Implement seizure precautions.

128

_____ is a serum magnesium level greater than 2.1 mEq/L.

Hypermagnesemia

129

Hypercalcemia Risk Factors:

Decreased magnesium output

Kidney failure
Adrenal insufficiency

130

Hypermagnesemia Risk Factors:

Increased magnesium intake and absorption

Laxatives or antacids containing magnesium

131

Hypermagnesemia Symptoms:

Neuromuscular

Diminished DTRs
Muscle paralysis
Shallow respirations, decreased respiratory rate

132

Hypermagnesemia Symptoms:

Central nervous system

Lethargy

133

Hypermagnesemia Nursing Care:

Perform frequent focused assessments (vital signs, level of consciousness, reflexes).
Notify the provider of changes or absent reflexes

134

_____ include hypovolemia-isotonic (loss of water and electrolytes from the ECF) and dehydration-osmolar (loss of water with no loss of electrolytes).

Fluid volume deficits (FVDs)

135

Hypovolemic Shock

Nursing Actions

Administer oxygen.
Provide fluid replacement with the following: Colloids (whole blood, packed RBCs, plasma, synthetic plasma expanders)
Crystalloids (Ringer's lactate, normal saline)

136

FVE Care After Discharge

Encourage client to weigh himself daily. Notify provider if there is a 1- to 2-lb gain in 24 hr, or a
3-lb gain in a week.


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