6/30/2015

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+]

Urine specific gravity (1.010-1.030):

Oncotic pressure: albumin

Third-spacing

IV fluids: isotonic, hypertonic, hypotonic

Dehydration = Concentration = S.G.

(3.5-5 g/dL)

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

E.g. ascites, burns, intestinal obstruction
Anasarca: generalized edema

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ALDOSTERONE

VASOCONSTRICTION

Na+ & H2O

VASOPRESSIN (ADH)

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

Symptoms
Causes
Treatment
Expected Outcome

High

Low

Polyuria, polydipsia

Oliguria, brain edema,

weight gain, crackles

Stroke, trauma, surgery

Lung cancer

Vasopressin
Decreased diuresis

Demeclocycline

Tolvaptan, Conivaptan:anti-ADH drugs

Increased diuresis

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The nurse is caring for a client who had an excision of a malignant pituitary
tumor and diabetes insipidus. Which findings should the nurse document that
indicate 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 of
diabetes 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 <1.010)

Decreased skin turgor: where?

Loss of weight: 1 K = 1 L and 1 g = 1 mL

Dry skin and Mucous membranes

Thirst
Decreased CVP and PCWP
Flat neck veins

Increased hematocrit and BUN

Interventions
Oral rehydration preferred
IV hydration severe cases: Isotonic fluids: NS, LR
Volume expanders: plasma, albumin, hetastarch (Hespan)

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CVP

PCWP

PCWP: 6-12 mmHg

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

Type Solution
Normal Saline

Osmolarity
Isotonic (308 mOsm/L)

Composition

Use

0.9 g NaCl/100
mL H2O

Fluid replacement

Lactated Ringers Isotonic (275 mOsm/L)

NS with buffer

Fluid replacement

D5W

Isotonic in bag,
Hypotonic in body

5 g glucose/100
mL H2O

Replacement of
water or glucose

NS

Hypotonic

0.45 g NaCl/100
mL H2O

Replacement of
water

D5NS

Hypertonic

(560)

5 g D + 0.9 g
NaCl/100 mL H2O

Replaces fluid
and dextrose

D5 NS

Hypertonic

(406)

5 g D + 0.45 g
NaCl/100 mL H2O

Same

D5LR

Hypertonic

(295)

5 g D/100 mL LR

Same

3% NaCl

Hypertonic

3g NaCl/100 mL H2O

Volume expansion

Plasma
Expanders

FFP, Albumin,
Hetastarch

(154 mOsm)

Volume expansion

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A man who was severely burned over 90% of his body during an accident on
the 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 device
would be most appropriate at this time?

A.
B.
C.
D.

PICC line
Central line
Intra-osseous catheter
Subcutaneous infusion

A client with CKD is brought bleeding profusely after a MVA. MD inserts a

central catheter (CVC). To promote rapid volume replacement the nurse
should use:
A. D5W and IV pump through a 18 G saline lock device
B. LR and IV pump through a 18 G needle for veins of the AV shunt arm
C. LR and tubing with needless connection
D. 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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The most appropriate method to rehydrate an infant with moderate

dehydration secondary to diarrhea is:
a. Replacing milk-based formula with a lactose-free formula
b. Oral rehydration therapy with electrolyte solution every 3-4 hours
c. Administering intravenous (IV) fluids of D5 NS
d. Offering bananas, rice, applesauce, and toast (BRAT diet) along with
oral fluids

C, b

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Hyponatremia

Hypernatremia

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
Decreased urine specific gravity (ADH suppression)
Pontine myelinolysis: sudden dysphagia, dysarthria, acute paralysis
Na+ replacement: NaCl 3%

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 <10 mEq/h
Take oral potassium supplements with food/juice
Assess for digital toxicity (drug interactions*)
Dietary K+: bananas, melons, cantaloupe, apricot,
orange, raisins and dry fruits, strawberry, tomato,
avocado, potatoes and sweet potato with peel,
spinach and leafy vegetables, fish, meats, milk, nuts

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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.
B.
C.
D.

A.
B.
C.
D.

A.
B.
C.
D.

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

is hemolyzed. What intervention should the nurse take
Notify immediately the health care provider
Obtain a prescription for Kayexalate
Draw a new blood sample
Encourage the patient to increase fluids intake

The nurse teaches a client about how to increase dietary potassium. The client
says she knows bananas are high in potassium but does not like the taste. The
nurse determines teaching is effective if the client states which of the following?
I should include carrots, broccoli, and yogurt in my diet
I should eat more rhubarb, tofu and celery
Potatoes, spinach, and raisins are high in potassium
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. The
HCP 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?
The renal damage has affected the pancreas
Dextrose and insulin will restore your caloric needs
Dextrose and insulin will help to decrease the potassium in your blood
Dextrose and insulin are necessary to normalize the BUN
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

Chvosteck

Nursing Interventions
Calcium gluconate available
Seizure precautions
Foods rich in Ca: dairy, soy milk, tofu, sardines,
salmon, spinach, broccoli, collard greens, green
beans, rhubarb, spinach, almonds

Trousseau
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Serum calcium > 10.5 mg/dL

Causes: Hyperparathyroidism, metastatic cancer,

Multiple Myeloma (M.M.), Pagets disease, Vitamin D

intoxication

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)

Q-T

EKG?

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Magnesium

NV: 1.5 to 2.5 mg/dL

Hypomagnesaemia

Hypermagnesemia

Causes: malnutrition, alcoholism

Causes

Causes CKD, Mg laxatives or antacids,

Causes:
MgSO4 in eclampsia

Assessment
Assessment:
Twitching, paresthesis
Positive Trousseau's and Chvosteks signs
Seizures
Prolonged QT
Torsade de Points
Nursing Interventions
Seizure precautions
Cardiac monitorization
Mg supplement, legumes, whole grains,
nuts

Assessment
Assessment:
Hyporreflexia: DTR 1+ or 0
Respiratory depression
AMS and coma
Nursing Interventions
Calcium gluconate
Dialysis
Avoid laxatives and antacids containing
magnesium

A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. Which of the
following symptoms would you NOT expect to see in this patient?
A. Numbness in hands and feet.
B. Muscle cramping.
C. Hypoactive bowel sounds. <
D. Positive Chvostek's sign.
A client with malnutrition is being treated for hypomagnesemia. During assessment the
nurse would expect to find:
A. Hyporreflexia
B. Hypoventilation
C. Positive Trousseaus sign<
D. Negative Chevosteks sign

The nurse discovers that an elderly client with no history of cardiac or renal
disease has an elevated serum magnesium level. To further investigate the
cause of this electrolyte imbalance, what information is more important to
obtain from the client?
A.
B.
C.
D.

Ingestion of shellfish of fish oil capsules daily

Length and frequency of the clients tobacco use
Genetically inherited disorders of family members
Frequency of laxative use for chronic constipation

<

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6/30/2015

The nurse discovers that an elderly client with no history of cardiac or renal
disease has an elevated serum magnesium level. To further investigate the
cause of this electrolyte imbalance, what information is more important to
obtain from the client?
A.
B.
C.
D.

Ingestion of shellfish of fish oil capsules daily

Length and frequency of the clients tobacco use
Genetically inherited disorders of family members
Frequency of laxative use for chronic constipation

<

TORSADE DE POINTS
HYPOMAGNESEMIA

Hypochloremia:

Cl- < 95 mEq/L

Metabolic alkalosis

P < 2.5 mg/dL

Hypercalcemia
Food rich in P:

Hyperchloremia:

> 108 mEq/L

Metabolic acidosis

Hypophosphatemia

Meats, poultry, fish, milk,

whole grains, nuts

Cl-

Hyperphosphatemia
P > 4.5 mg/dL
Hypocalcemia
P binders:

Calcium carbonate, aluminum

hydroxide, sevelamer

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Allen Test

If circulation return:
positive

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pH: concentration of Hydrogen (H+)

Acids:

Bases:

Acids and bases are in BALANCE

Release hydrogen ions (H+)

CO2 is acid
Accept hydrogen ions (H+)
HCO3 is alkaline

Lungs change CO2 in minutes

Kidneys need time to change the HCO3

Normal Values:

Potassium changes with changes of pH:

pH:
7.35 7.45. (the middle is: 7.4)
pCO2:
35 45 mmHg
HCO3: 22 26 mEq/L

Acidosis: hyperkalemia
Alkalosis: hypokalemia

Normal Range
7.357.47.45
acidosis

alkalosis
27

H+
H+

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Look at pH:
Acidosis if less than 7.35 (less than 7.4 if compensated )
Alkalosis if more than 7.45 (more than 7.4 if compensated)
Find the primary cause:
Metabolic: if the cause is HCO3 (HCO3: alkalosis, HCO3: acidosis)
Respiratory: if the cause is CO2 (CO2: acidosis, CO2: alkalosis)
Find the compensation:
Change in CO2 for metabolic problems
Change in HCO3 for respiratory problems
Decide if the compensation is incomplete (partial) or complete (total):
Incomplete: pH does not reach normal range
Complete: pH reach the normal range:
Apply the 7.4 rule

Normal Range

7.35 7.47.45
acidosis
alkalosis
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REMEMBER:
pH:
7.35 7.45. (middle: 7.4)
pCO2:
35 45 mmHg
HCO3: 22 26 mEq/L

CO2 = RESPIRATORY
HCO3 = METABOLIC

Acidosis = Too much CO2

Too little HCO3

Alkalosis = Too little CO2

Too much HCO3

pH: 7.15
p CO2: 20
pHCO3 : 18
pH: 7.15
p CO2: 58
pHCO3 :30
pH: 7.50
p CO2: 48
pHCO3 : 31

COMPENSATED?

pH: 7.50
p CO2: 29
pHCO3 : 24

Kussmaul's respiration

Seen in any metabolic acidosis:

DKA, Renal
Failure, etc.
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pH

CO2

ROME
Respiratory Opposite
Metabolic Equal

METABOLIC

pH: 7.15
p CO2: 20
pHCO3 : 18

pH and CO2 same

direction

RESPIRATORY

pH: 7.15
p CO2: 58
pHCO3 :30

pH and CO2 opposed

A client with CRF is admitted in ED. His blood gases are: pH 7.32, pCO2: 30 mmHg,
HCO3: 18 mEq/L. What finding should the nurse expect?
a. Bradycardia
b. Hypotension
c. Tachypnea
d. Diaphoresis
A client has pink sputum. How can the BNP determination help to determine what is
the cause of this finding?
a. BNP is elevated if the cause of pink sputum is a respiratory failure
b. BNP is low if the cause of the pink sputum is heart failure
c. BNP is high if the cause of the pink sputum is pulmonary embolism
d. BNP is low is the cause of the pink sputum is a pulmonary disease
What could be used to improve a respiratory alkalosis?
a.
Paper bag
b.
Cupped hands
c.
Rebreather mask
d.
All of the above
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A, c, d, d,

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....pH = 7.33, CO2 = 66, HCO3 = 35

COMPENSATED RESPIRATORY ACIDOSIS

METABOLIC ALKALOSIS
METABOLIC ACIDOSIS

PARTLY COMPENSATED RESPIRATORY ACIDOSIS

7

....pH = 6.68, CO2 = 85, HCO3 = 10

pH: 7.61, CO2: 48, HCO3: 30

COMBINED ACIDOSIS

pH: 7.32, CO2: 24, HCO3: 12

METABOLIC AND RESPIRATORY ACIDOSIS

....pH = 7.35, CO2 = 42, HCO3 = 23
COMBINED ALKALOSIS
NORMAL
COMBINED ACIDOSIS

PARTLY COMPENSATED METABOLIC ACIDOSIS

9

....pH = 7.21, CO2 = 60, HCO3 = 24

RESPIRATORY ACIDOSIS

COMPENSATED METABOLIC ALKALOSIS

COMPENSATED RESPIRATORY ACIDOSIS

COMPENSATED RESPIRATORY ALKALOSIS

10

pH: 7.48, CO2: 31, HCO3: 20

COMBINED ALKALOSIS

COMPENSATED RESPIRATORY ALKALOSIS

pH: 7.31, CO2: 50, HCO3: 28

pH: 7.49, CO2: 33, HCO3: 25

pH: 7.46, CO2: 46, HCO3: 37
pH: 7.50, CO2: 49, HCO3: 33
pH: 7.48, CO2: 48, HCO3: 28
pH: 7.35, CO2: 28, HCO3: 20
pH: 7.49, CO2: 49, HCO3: 31

....pH = 7.48, CO2 = 19, HCO3 = 14

NORMAL

RESPIRATORY ACIDOSIS
COMPENSATED METABOLIC ACIDOSIS

PARTLY COMPENSATED RESPIRATORY ALKALOSIS

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