Fluid and Electrolytes

You find yourself in a room filled with fluid...you have to escape again!

start

When you look at lab results, what fluid compartment is represented by these results?

Intracellular Space

Interstitial Space

Intravascular Space

That one was not correct, that is okay, let us take a second to review the 3 compartments

Labs are drawn from the vascular space and represent values from that.

Which direction does water flow?

From the most amount of water to the lowest amount of water

From the least amount of water to the most amount of water

Water will move from the most amount of water to the least amount of water

When you have intravenous (IV) fluids, they contain substances. An example is 0.9% sodium chloride. 0.9% is sodium chloride, the rest of it is water.1 - 0.9 = 99.1% water

Which of the two has more water?0.9% sodium chloride0.45% sodium chloride

0.45% has more water.1 - 0.9 = 99.1% water1 - 0.45 = 99.55% water

When we administer fluids to a patient, the concentration of the fluids we administer will promote fluid shifts depending upon the tonicity of the fluid and the patient status.

Which of the following fluids would be an example of a hypotonic solution?

0.9% sodium chloride

5% dextrose in 0.9% sodium chloride

0.45% sodium chloride

5% albumin

The nurse is caring for a client that is receiving albumin through an IV infusion. The nurse know's this fluid type will cause what type of fluid shift?

Intravascular space -> Intracellular space

Intravascular space -> Interstitial space

Intracellular space -> Interstitial space

Interstitial space -> Intravascular space

The nurse is caring for a client that is receiving packed red blood cells. The nurse anticipates which lab value to change after this is administered?

Platelets

Hemoglobin

Not quite, let us review the 4 types of blood products!

Packed Red Blood Cells (PRBCs) are used for blood loss and will correspond with an increase in hemoglobin / hematocrit

Platelets are used for low platelet levels

Fresh Frozen Plasma (FFP) are used to restore clotting factors

Cryoprecipitate is also used to restore clotting factors

The nurse is caring for a client that is receiving blood. Which statement below indicates that the nurse made an error when starting the blood?

A consent was obtained prior to the infusion being started

Signs of an allergic reaction were assessed prior to the infusion being started

A type and crossmatch was performed prior to the infusion being started

Let's review what is needed for blood administration real fast before continuing

What is required before a unit of packed red blood cells are transfused?- a consent- a type and crossmatch (in an emergency they can use O negative blood, but the question did not say it was an emergency)

What is required once an infusion has started?- observe for signs of an allergic reaction such as fever, chills, altered blood pressure, respiratory difficulty, or other allergic signs- vital signs checked at start, 15 minutes after start, and then every hour after that

If you suspect a transfusion reaction has occurred, stopping the transfusion of blood is a priority.

The nurse is caring for a client that has dehydration. What vital sign or lab abnormality supports that diagnosis?

Hyponatremia

Increased blood pressure

Elevated creatinine

Decreased serum osmolality

Dehydration represents a loss of overall body fluid without a change in electrolytes

Serum osmolality = the particles in a given weight of fluid. If you have less fluid, then you have more particles, therefore serum osmolality would increase with dehydration

With dehydration there generally is a decreased blood volume leading to hypotension, tachycardia, orthostatic hypotension, decreased urine output, flat neck veins, and a weak pulse

Third-spacing or when fluid builds up in the interstitial space also causes a type of dehydration. The fluid is not where it is supposed to be. This changes the type of fluid that you would administer to the patient.

The nurse is caring for a client that has a diagnosis of fluid volume excess. What treatment would the nurse expect to administer?

Begin administration of 0.45% sodium chloride

Administer Furosemide intravenously

Limit the client's fluid intake to 3 liters a day

Administer albumin intravenously

Fluid volume excess has multiple causes: heart failure, renal failure, cirrhosis, excess fluids, or medications that cause sodium and water retention.

Do you know what some symptoms of fluid volume excess are? Think of them. They will appear in 15 seconds..

Symptoms include weight gain of more than 0.5 kg a day, hypertension, bounding pulse, distended neck veins, dyspnea, crackles, and orthopnea

Medications that may be used to treat fluid volume excess are: diuretics like furosemide, spironolactone, bumetanide, or hydrochlorothiazide.Client's may also be placed on a fluid restriction. 2 liters of intake or less would be an expected fluid restriction.

Oh oh!

It is time to switch from fluids over to electrolytes, feel free to take a brief mental break before continuing!If you need a break to create some output…

The nurse is caring for a client with hypokalemia. Which medication in the client's history could explain this result?

Polyethylene glycol (Miralax)

Pantoprazole (Protonix)

Furosemide (Lasix)

Oxycodone (Oxycontin)

Hypokalemia or a low potassium can be caused by diuretics, such as furosemide

Other causes for hypokalemia include: metabolic alkalosis, chronic kidney disease, folic acid deficiency, gastrointestinal losses, and a decreased intake of potassium

The signs and symptoms you will see include: cardiac arrythmias, constipation, fatigue. More severe ones include paralytic ileus, respiratory paralysis, tetany, hypotension, rhabdomyolysis, or more life threatening arrythmias

You are caring for a client scheduled to receive potassium chloride via an intravenous infusion. The nurse knows what to be true regarding this infusion?

Potassium chloride is administered as an intravenous push medication with a syringe

Oral formulations of potassium have a higher degree of bioavailability

The patient may report burning at the site

The concentration is 1 mEq per 1 mL

Administering potassium is one of the treatments for hypokalemia and the intravenous route has certain traits a nurse needs to know

Intravenous potassium should only be done through a slow infusion

With a peripheral IV the safest concentration is 10 mEq / 100 mL. With a central access device concentrations can go up to 40 mEq / 100 mL, but never 1 mEq / 1 mL.

The patient may report burning at the IV site while it is infusing. In those cases the nurse may need to contact the provider to get a slower rate.

Pharm Review: IV administration has higher bioavailability than oral administration

The nurse is preparing to provide treatment to a client that has hyperkalemia. The nurse has 4 treatments lined up, and 3 of them are correct. Which treatment listed would the nure need to contact the provider about getting changed?

Respuesta correcta

Respuesta incorrecta

Respuesta incorrecta

Respuesta incorrecta

Dextrose

Sodium polystyrene sulfonate

Calcium gluconate

Furosemide

Hyperkalemia can be caused by acute renal failure, dehydration, diabetes, burns, acidosis, or a blood transfusion

Your patient may present with nausea, vomiting, muscle aches, weakness, dysrhythmias (synonymous with arrythmias). More severe symptoms include paralysis, heart failure, and death

Sodium polystyrene sulfonate (Kayexalate): this helps the potassium get pooped out

Treatments include:

Calcium gludonate to stabilize the electrical activity of the heart (does not reduce the potassium level)

Loop diuretics like furosemide or bumetanide to excrete potassium through the urine

Intravenous insulin can help push potassium from the intravascular space to the intracellular space. However, insulin also will lower dextrose. It is common to administer insulin and dextrose when treating hyperkalemia. Dextrose by itself would not impact the potassium level.

The nurse is caring for a client with hyponatremia. The nurse is administering 3% sodium chloride. What symptom specific to 3% sodium chloride administration would indicate the treatment needs to stop?

Altered mental status

Constipation

Nausea

Respiratory changes

Hyponatremia can be caused by vomiting, diarrhea, excess water intake, excess alcohol, thiazide diuretics (and other diuretics), heart disease, and liver disease

Sodium is an important electrolyte for fluid movement. When sodium levels change, fluids shift from the intracellular space to the interstitial space or the intravascular space.

Symptoms can be mild with nausea and general feeling of being unwell. Nausea by itself would not indicate stopping the infusion. The severe symptoms all relate to issues of fluid shifts in cerebral cells. Cerebral edema, lethargy, confusion, irritability, seizures, coma, or altered mental status in general.

When you administer 3% sodium chloride, you are giving a hypertonic solution. The intravascular space will be concentrated with sodium. The body will draw fluid into the intravascular space from the intracellular space. The cerebral cells may shrink if this is too fast and it will show as signs of altered mental status.

In general, fluid replacement for hyponatremia would be 0.9% sodium chloride to allow the sodium to correct slowly to prevent rapid changes in the cerebral cells

True or False: Hypernatremia has symptoms similar to hyponatremia, and the causes of it in general are things that cause dehyration

False

True

Hypernatremia is caused by things that cause dehydration primarily. The signs and symptoms are similar to hyponatremia.

The treatment for hypernatremia requires restoring the fluid status. What causes cerebral edema? Lowering the sodium too quickly. Sodium should not change quickly. This is why you use hypotonic IV fluids instead of just free water when restoring dehydration in the setting of hypernatremia.

Hypotonic solutions or 0.45% sodium chloride are only used if there is not an indication of shock. If a patient is on tube feeding you may see the provider increase the amount of water being flushed routinely to help lower sodium. Either way, if the patient has hypernatremia and hypovolemic shock, then isotonic fluids only.

The nursing student is performing a set of vital signs manually. Which vital sign may elicit a response that informs the student that the client could have a calcium issue?

Heart Rate

Blood Pressure

Oral temperature

Respiratory Rate

Trousseau's sign occurs when you have a blood pressure cuff inflated for over 3 minutes. The patient will have a carpopedal spasm. A picture below:

One of you is probably thinking "I don't keep the cuff on for 3 minutes". Let this be an invitation to take a manual blood pressure to see if you can beat the 3 minute clock...but wait until after you've escaped first.

The nurse is caring for a client that presents with hypercalcemia. What in the client's medical history could explain an elevated level of calcium?

Diabetes

Congestive heart failure

Asthma

Heartburn

high calcium levels can be caused by renal failure, cancer, vitamin D toxicity, hyperparathyroidism, and overconsumption of calcium.

An over the counter medication called Tums contains calcium carbonate and is a common treatment for heartburn

Someone presenting with hypercalcemia may experience: constipation, abdominal pain, nausea, vomiting. Severe symptoms can include confusion, renal failure, arrythmias, coma, and death.

Hypercalcemia is treated with IV fluids, loop diuretics, or hemodialysis in severe cases. Another treatment is phosphorus containing compounds like potassium phosphate or sodium phosphate. Phosphorus and Calcium have an inverse relationship. If you replace phosphorus, it will lower the calcium

The nurse is caring for a client with hypomagnesemia. What food items could the nurse recommend as magnesium-rich foods?

canned soup

carrots

peanut butter

meat

Hypomagnesemia is caused by a decreased intake of magnesium. It occurs along with hypokalemia and hypocalcemia, or it has specific causes like type 2 diabetes, diarrhea, pancreatitis, Crohn’s disease or celiac disease.

Treatment includes oral or intravenous magnesium. One fun fact, oral magnesium is used for constipation as well. Dietary sources of calcium are also part of the treatment. Due to the occurrence of altered potassium or calcium levels when magnesium is altered, treating those is a priority.

The symptoms can include: decreased appetite, fatigue, nausea, weakness. Severe symptoms can include msucle cramps, numbness and tingling, seizures, tetany, and personality changes.

Foods high in magnesium include: nuts and peanut butter, egg yolk, milk, whole grain cereals, bananas, citrus fruits, dark green vegetables, legumes, seafood, chocolate.

Here is a visual of the table from the lecture

Another table from the lecture

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https://westerncarolina.instructure.com/courses/26663/pages/sleep-and-rest-case-study?module_item_id=2077052

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