NUR 453 Role Transition Exam 1 Study Guide. Latest 2021.Unit 1 - Fluid and Electrolytes
Major intracellular electrolyte – K
Major extracellular
... [Show More] electrolyte – Na
Maintaining Fluid and Electrolyte Balance
● RAAS – senses hypotension
o Vasoconstriction
o Aldosterone – Na retention
o ADH – H2O retention
▪ Elevated w/ stroke
tumor and TBI
o Increase blood flow to vital
organs
Serum Values
- Na: 135 to 145 milliequivalents per liter (meq/L).
- K: 3.5 to 5.0 mEq/L
- Cl: 95 to 105 mEq/L
- Mg: 1.5 to 2.5 mEq/L
- PO4: 2.8 to 4.5 mg/dl
- Ca: 8.5 to 10.5 mg/dl
Maintaining Fluid and Electrolyte Balance
- Kidneys
- Play a major role in controlling all types of balance in fluid and electrolytes
- Adrenal glands
- How do they help regulate water balance?
- Through secreting aldosterone – reabsorb sodium / regulates amount of sodium reabsorbed by the kidneys.
- Antidiuretic hormone (ADH)
- How does it help regulate water balance?
- hold on to water – increase in adh – sodium level goes down
-
Solutions
● Isotonic – fluid remains intravascular
o ONLY fluid that can be used for bolus
o NS, Lactated Ringers
o equal to plasma, NS and lactated ringers .. Give to replace volume in vascular space and low blood volume
● Hypotonic – fluid shifts intracellular → pts with dehydration
o Can cause cell rupture
o 1/2 NS, D5W
o lower tonicity than plasma – d5w, 0.45NS, cant bolus with it bc it’ll cause increase cerebral pressure / cerebral edema. Cause
cell to burse .. Give to pts who are dehydrated.
● Hypertonic – fluid shift intravascular → pts w/ fluid overload or ICP
o Dehydrates cells/cell shrinkage
o Creates osmotic diuresis – DKA, hyperglycemia
o 3% NS, combination fluids (ex: D5 ½ NS)
o d51/2, manitol, give when you want to dehydrate the cells and dump into vascular space to be exreted. Give to those with
increased ICP
o
● Colloid
o Plasma expanders
o Pull fluid from interstitial compartment into vascular compartment
o Increases vascular volume rapidly
Excess Fluid
● Edema – fluid in interstitial spaces
o Fracture, inflammatory response
● 3
rd spacing – fluid shift from vascular space into area of abdominal organs/pockets
o Ascites, pleural effusion, pericardial effusion
● Anasarca – generalized edema from head to toe resulting from cardiac, renal or liver failure
Fluid Volume Excess
● Cardiovascular – High BP, bounding pulses, JVD, increase CVP, distended neck and hand veins, dysrhythmias
● Respiratory – SOB & tachypnea, moist crackles, pulmonary edema/pink frothy sputum
● Neuromuscular – low Na → AMS (headache, paresthesia, H/A)
● GI – diarrhea, ascites, hepatomegaly
● Renal - dilute and copious urine (polyuria) if kidneys functioning properly
● Integumentary – edema – dependent and pitting edema, pale, cool
● Treatment/Nursing Implications:
o Best indicator of fluid status and changes is weight
o Semi-fowler to help with breathing
o Diuretics → increase in urine output
▪ Restrict fluid intake/low Na diet
o Must listen to breath sounds before and after for clarity vs. “wet”
o Elderly are highest risk for fluid overload
o If age, religion, ethnicity descriptors are given in a test always points you in a direction to the answer – take it into
account
Fluid Volume Deficit
● Cardiovascular – tachycardia, hypotension, weak thready pulse, decreased CVP, orthostatic hypotension (80/40 do not have
pt ambulate), flat neck veins in dependent position, dysrhythmias
● Respiratory – tachypnea
● Neuromuscular – hypernatremia, AMS, muscle weakness
● Renal – decreased urine output
● Integumentary – dry mucous membranes, poor skin turgor, high BUN
● GI – constipation, decreased motility, thirst, decreased body weight
● Treatment/Nursing Implications:
o Replace fluid loss (ex: hypovolemic shock)
▪ Isotonic – first → maximum 150 ml/hr
▪ Hypotonic - second
▪ Hypertonic – if pt has had hypotonic dehydration
Electrolyte Imbalances
● Sodium
o Indicator of fluid status and neurotransmission
o Hyponatremia causes:
▪ Increased sodium excretion - Diuretic use, diaphoresis, diarrhea, wound drainage
▪ Inadequate sodium intake - Low sodium diet taken to extreme
▪ Dilution of serum sodium - Overhydration, SIADH, renal failure
▪ Nursing Interventions:
● Provide foods high in Na Diuretics
● Provide foods high in sodium
● Give IV NS, or osmotic diuretics-WHY? To get rid of water only
● Monitor VS
● Too much ADH? Which meds to give? – vasopressor receptor antagonist – blocking vasopressor
● If the client is taking lithium, monitor lithium level because hyponatremia can cause diminished
lithium excretion, resulting in toxicity.
o Hypernatremia causes:
▪ Decrease sodium excretion - DI, Cushing’s, ESRD
▪ Increase sodium intake [Show Less]