Unit 1, part 2 study guide

Electrolyte imbalances - hyper, hypo and treatments

Fluid balance: hypovolemia: 1. contributing factors: vomiting, diarrhea, fever, sweating, blood loss, third space fluid shifts 2. signs/symptoms: weight loss, decreased skin turgor, concentrated urine, decrease BP, increase pulse 3. labs show: increase hemoglobin/hematocrit, increase serum, increase urine osmolatity/specific gravity, decrease urine sodium, increase BUN and creatinine. 4. treatment: isotonic solutions common (especially hypotensive patients), hypotonic used (.45% sodium chloride) once patient is normotensive hypervolemia: 1. contributing factors: renal failure, heart failure, cirrhosis, severe stress, 2. weight gain, edema, distended jugular veins, crackles, elevated CVP, shortness of air, increase respiratory rate, increase BP, bounding pulse and cough 3. labs show: decrease hemoglobin/hematocrit, decrease serum and urine osmolality, decrease urine sodium and specific gravity 4. treatment: diuretics, hemo-dialysis, dietary restriction of sodium Sodium hyponatermia (below 135 mEq/L): 1. contributing factors: loss of fluids, diuretics, loss of GI fluids, gain of water, renal disease, hyperglycemia, heart failure 2. signs/symptoms: h/a, lethargy, dizziness, cramps, weakness, increase pulse, decrease BP, edema, CNS changes and excitability, muscle twitching, seizures 3. labs show: decrease serum and urine sodium, decrease urine specific gravity 4. treatment: sodium replacement, water restriction, possible hypertonic solutions hypernatermia (above 145 mEq/L): 1. contributing factors: hypertonic tube feedings, diabetes, heat stroke, diarrhea, burns, diaphoresis 2. signs/symptoms: thirst, increase body temp, dry tongue, pulmonary edema, hyperreflexia, twitching, increase pulse, increase BP 3. labs show: increase serum sodium, decrease urine sodium, increase urine specific gravity and osmolaity, decrease CVP 4. treatment: hypotonic solutions, gradual reduction important during treatment Potassium hypokalemia (less than 3.5 mEq/L) 1. contributing factors: diarrhea, vomiting, corticosteroid administration, diuretics 2. signs/symptoms: fatigue, anorexia, n/v, cramps, ventricular asystole or fibrillation, EKG changes 3. treatment: intravenous potassium, should only be administered after urine flow has been established hyperkalemia (greater than 5.0 mEq/L) 1. contributing factors: renal failure, metabolic acidosis, addisons disease, burns 2. signs/symptoms: tachycardia/bradycardia, flaccid paralysis, EKG changes: possible death if given too much. 3. treatment: reduction in dietary potassium. if dangerously high administration of calcium gluconate. Note: caclium gluconate does not reduce the serum potassium level in the system, but it reverses the adverse cardiac effects.

Calcium

hypocalcemia (less than 8.5 mg/dl) 1. contributing factors: hypoparathyroidism, pancreatitis, alkalosis, peritonitis, decreased parathyroid hormone, diuretic phase of renal failure 2. signs/symptoms: numbness, tingling of fingers and toes, tetany, CNS excitability, 3. treatment: life threatening and requires prompt treatment, administration of calcium must be down slowly, too rapid can cause cardiac arrest, usually diluted in D5W and administered slowly. hypercalcemia (greater than 10.5) 1. contributing factors: hyperparathyroidism, oligruic phase of renal failure, acidosis, corticosteroid therapy, digoxin toxicity. 2. signs/symptoms: reduction in CNS excitability, muscle weakness, incoordination, anorexia, consipation, cardiac standstill 3. treatment: administering fluids to dilute concentrations and promote excretion by kidneys, restricting dietary calcium, administration of IV phosphate, IV lasix (promotes calcium excretion during dieresis.) Magnesium hypomagnesemia (less than 1.8 mg/dl) 1. contributing factors: chronic alcoholism, hyperparathyroidism, hyperaldosteronism, diuretic phase of renal failure, malabsorptive disorders, parenteral nutrition, diarrhea, 2. signs/symptoms: neuromuscular irritability, insomnia, mood changes, increased tendon reflexes, increase BP, some EKG changes 3. treatment: diet (dark leafy vegs, nuts, seeds, legumes, whole grains), magnesium salts, IV mag (bolus of mag can result in heart block or asystole) hypermagnesemia (greater than 2.7 mg/dl) 1. contributing factors: oliguric phase of renal failure, magnesium administration, adrenal insufficiency, DKA, hypothroidism 2. signs/symptoms: flushing, hypotension, drowsiness, hypoactive reflexes, depressed respirations, cardiac arrest, coma 3. IV calcium gluconate is antidote

IVF, hypotonic/isotonic/hypertonic and common uses

Isotonic: same osmolality of ECF and thus remains in ECF space. 1. given to expand ECF volume, no effects on cellular dynamics 2. caution in CHF and HTN patients 3. examples a. normal saline: replaces NaCl, only solution that is administered with blood products b. Ringers sol: replaces K, Na, Cl, Ca. Does not contain lactate which is harmful to those unable to metabolize lactic acid c. Lactate ringers: similar to blood serum and plasma, need additional K d. D5W: unlike those above, does provide free water once metabolism occurs (becomes hypotonic), promotes renal elimination of solutes, treats hypernatremia, does not provide electrolytes, one liter: 170 calories Hypotonic: osmolality is lower than serum plasma 1. given to reverse dehydration, water is pulled out of vessels and into cells, causes cells to swell 2. provides free water for cells and for excretion, used to treat hypernatremia 3. excessive use can lead to cellular edema and damage, intravascular fluid to deplete, decreased B/P 4. contraindicated in acute brain injuries: cerebral cells are very sensitive to free water and will rapidly absorb 5. examples:

a. .45 NaCl ( NS) and .225% NaCl ( NS): provides free water and some NaCl, assist with renal function, replaces normal daily fluid loss but considered electrolyte replacements ( moves into cells, and remains in extracellular fluid b. D5W: isotonic in bad, becomes hypotonic after metabolism c. D5 1/4NS and D5 NS, considered hypertonic in bag, become hypotonic after metabolism Hypertonic: higher osmolality than normal plasma which causes water to be pulled from cells into vessels, increases vascular volume and decreases cell water 1. used in extreme edema 2. once fluid is pulled into vascular space, diruetics may be given for renal excretion of excess 3. examples: a. 3% NS b. fluids with D10 or greater: TPN

Colloids vs Crystalloids, function, indication, precautions

Crystalloids: are able to pass through semi-permeable membranes, flow from vascular to interstitial space and cells (Isotonic, Hypotonic, Hypertonic) Colloids: high molecular weight, do not cross capillary semipermeable membranes, remain in intravascular space for several days (Albumin, dextran, hespan, plasma protein fraction) 1. can be isotonic or hypertonic 2. contraindicated in anemic or dehydrated patients, caution in cardiac or pulmonary patients 3. examples: Albumin, Intralipids 10%, Intralipids 20%, 10% Dextran IN 5% or NS, 8% Amino acids 4. more likely to cause circulatory overload compared to crystalloid solutions, can cause febrile reactions

PPN/TPN- use and precautions

Parenteral Nutrition: supply body with nutrients intravenously when oral intake is not possible or not adequate. PPN: 1. can go through a peripheral line 2. usual length of therapy is 5 - 7 days, usually needs lipids to hang with TPN: 1. goes through central line 2. dextrose concentration of greater than 10% (usually 20 - 25%) TNA: 1. 3 in 1 solution, dextrose, amino acids, lipids are all together Intralipids 1. sometimes mixed, is isotonic if not mixed 2. usually given 1 - 3 times/ week 3. up to 30% of calories can come from fat emulsion Clinical indications: 10% deficit in weight, inability to take oral food, hypercatabolic illness Complications: pneumothroax, air embolism, clotted catheter line, catheter displacement and contamination, sepsis, hyperglycemia, fluid overload, rebound hypoglycemia

Venous access devices/ PICC lines/Central lines/Port a caths

1. peripheral: flushed every shift, changed every 3 - 4 days, need 20 G for blood 2. Midline: often a PICC that is not able to reach upper vena cava

3. Central: a. non-tunnelled: 16 G distal lumen for blood or viscous fluids b. PICC: no BP on same side, mid to long term: 3 - 12 months c. tunnelled central catheter: threaded under skin to subclavian vein or internal jugular, advanced to right atrium, used for long term therapy (chemo, TPN) d. implanted ports/ portacaths: metal chamber adhered to chest wall, Huber needle needed to access

Blood Transfusion handout, basics of administering blood products (verification, orders, time, possible reactions)