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NCLEX Fluids & Electrolytes (Hurst)

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define
hypervolemia

AKA fluid volume excess


too much fluid in the vascular space &
cardiovascular system (chambers of the
heart)

list the
causes of
hypervolemia

1. HF (heart is weak, decreased CO, kidney


perfusion, & UO--volume stays in the
vascular space)
2. renal failure (kidneys aren't working)
3. meds (i.e. alka seltzer, fleet enema, IVF c
Na [all have a lot of salt])

List the 3
hormones
that help
regulate fluid
volume

1. aldosterone
2. atrial naturetic peptide (ANP)
3. anti-diuretic hormone (ADH)

What is
aldosterone?
and where is
it found in
the body?

Aldosterone is a naturally occuring


steroid/mineralcortocoid found in the adrenal
glands.

What is the
NL action of
the body
when fluid
volume gets
low?

when blood volume gets low (i.e.


vomiting/blood loss) --> ALDOSTERONE
secretion increases, causing the body to
retain Na+ & H2O --> blood volume goes up
(b/c fluid is retained in the vascular space)

What does
aldosterone
cause the
body to do?

retain sodium & water

List 2
diseases that
result from
too much
aldosterone

1. cushing's disease (too much of all steroids)


2. Conn's syndrome (hyperaldosteronemia)

List one
disease that
results from
too little
aldosterone.

Addision's disease (fluid volume deficit)

What is ANP
and where in
the body is it
found?

ANP = atrial naturetic peptide and it is


released when fluid volume increases causing
the atria to stretch.q

What is the
affect of ANP
on the body?

ANP causes the excretion of Na+ & H2O. It


works on the kidneys to decrease blood/fluid
volume

What is ADH
and where is
it in the
body?

ADH = anti-diuretic hormone is found in the


pituitary gland.

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What does ADH


cause the body
to do?

Retain water

What is SIADH
and what
causes it?

SIADH = syndrome of inappropriate ADH


secretion is when the body has too much
ADH. It causes the body to retain water,
r/i fluid volume excess. Blood is dilute
(Na+ & HCT low) and urine is
concentrated (SG high).
TIP: too many letters = too much water

Concentrated
makes the #'s go
_______.

Up
Lab values such as HCT, urine SG, and
serum Na+.

Dilute makes
#'s go
________.

Down
Lab values such as HCT, urine SG, and
serum Na+.

What is DI and
what causes it?

DI = diabetes insipidus is when the body


does not have enough ADH. It causes the
body to diuresis/lose large amounts of
water (thru urine), r/i fluid volume deficit.
Urine is dilute (SG low) and blood is
concentrated (HCT & Na+ is high)
TIP: D = diuresis

What are key


words that
make you think
of risk or
potential for an
ADH problem?

craniotomy, head injury, sinus surgery,


transphenodial hypophysectomy or any
condition that could lead to increased ICP.

What are the


drug names
used to treat
ADH? (2)

1. vasopressin (pitressin)
2. Desmopressin Acetate (DDAVP)

Distened neck
vein/peripheral
veins mean the
vessels are:

full with fluid


s/s of fluid volume excess or HF

What does
peripheral
edema and
third spacing
mean (in
relation to fluid
volume status)?

the vessels can't hold anymore fluid so


they start to leak into the tissues

What are NL
CVP values?
And where is
CVP measured?

CVP 2-6 mmHg


CVP is measured in the right atria (via
central line)

More
_________,
means more
___________.

Volume, pressure

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What do the lungs sound like with


FVE?
And pt feels ______.

Lungs are wet


(crackles in
bases), & SOB

Describe pulse quality & rate with


FVE.

Pulses are full,


bouning, and the
rate increases.

If fluid is not moving foward thru


the heart, it's going to go
____________ into the ______,
which could result in pulmonary
edema or HF.

backwards, lungs

With FVE, BP __________. Why?

Increases b/c of
increased fluid r/i
increased pressure
(resistance-afterload).

With FVE, does the weight increase


or decrease?

WT increased d/t
increased fluid
(acute gain/loss is
fluid, >+-2lbs)

What are the s/s of FVE? (8)

1. distended
neck/peripheral
veins
2. peripheral
edema & third
spacing
3. CVP increased
4. Lungs are wet
5. polyuria
(kidneys
diuresising to dec
fluid)
6. increased pulse
(full & bounding)
7. BP increases
8. WT increases

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With FVE, what do the kidneys try to


do to help?

diuresis to
decrease fluid

Describe the 6
treatments/interventions used for
FVE.

1. Low Na+ diet &


restrict fluids
2. I&Os, & daily
weights
3. diuretics (loop
{Lasix, Bumex),
HCTZ, K+ sparing
(aldactone)
4. bed rest
5. focused physical
assessment
6. Give IVFs
slowly to the old or
young

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What are 3 diuretics


that cause the body to
lose potassium &
require close
monitoring of
electrolytes?

Lasix, Bumex, & HCTZ

How does bed rest


induce diuresis?

it causes the release of ANP and


decreased production of ADH.

What is
hypovolemia?

Fluid volume deficit


Big time deficit = SHOCK

What are the 3 main


causes of
hypovolemia?

1. A loss of fluids from anywhere


(thoracentesis, paracentesis,
vomiting, diarrhea, hemorrhage)
2. Third spacing
3. diseases with polyuria (think
shock first!, then worry about renal
failure)

What is third
spacing, and what
causes it?

third spacing is when fluids go into


the tissues or body cavities. It is
often caused by Burns (fluid goes
into interstitial tissues), or ascities
(fluid goes into peritoneal space)

What 2 main
assessments are done
with ascities?

1. measure abd girth QD


2. watch for s/s of difficulty
breathing

What are the s/s of


fluid volume deficit?
(11)

1. WT decreases
2. descreased skin turgor
3. dry mucous membranes
4. decreased UO (kidneys either
aren't being perfused, or they are
trying to hold onto fluid)
5. decreased BP (less volume, less
pressure)
6. Pulse increases, and quality is
weak & thready (heart trying to
pump what little fluid is left)
7. Respirations increase (body
perceives decreased blood volume as
hypoxia)
8. decreased CVP
9. peripheral veins/neck veins
vasoconstrict (very tiny)
10. cool extremities (d/t
vasoconstriction to shunt blood to
core organs)
11. concentrated urine (if pt has
UO)

What does the pt with


FVD have cool
extremities?

Because of peripheral
vasoconstriction to shunt blood to
the core/vital organs

With FVD, why do


respirations
increase?

the body perceives decreased blood


volume as hypoxia

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What is the
treatment for
hypovolemia
(FVD)? (3)

1. Prevent further losses


2. replace loses (mild deficit = PO fluids;
severe deficit = IVF)
3. Safety precautions (fall d/t changes in
VS & mental status)

What sequence
would you use
to assess the
client with
orthostatic
hypotension:
1. assess the VS
with pt sitting
2. assess VS
with pt lying
3. assess VS
with pt
standing
4. record BP &
Pulse with the
position noted
5. have pt lie
down for at
least 3 min

5, 2, 1, 3, 4

What do
isotonic IVF do
to the body?
And when are
they used?

Go into the vascular space & stays there


(and builds up)
Isotonic IVFs are used when the pt has
lost fluid thru N/V, burns, sweating,
trauma, or hemorrhage
TIP: Isotonic solutions "stay where I put it"

List 4 examples
of isotonic IV
solutions.

1. Normal Saline
2. Lactated ringers (best shock solution)
3. D5W
4. D5 1/4 NS

What types of
pt's should not
receive isotonic
IV solutions?

pts with HTN, cardiac or renal diseases.

What do
hypotonic
solutions do to
the body? And
when are they
used?

Go into the vascular space, then shift out


into the cells to replace cellular fluid
(hydrating fluids--they rehydrate, but do
not cause HTN).
Hypertonic IVFs are used on pt's with
HTN, renal or cardiac disease who need
replacement from N/V, burns, trauma,
sweating, hemorrhage. Also used when pt
has hypernatremia and for cellular
dehydration.
TIP: hypOtonic solutions "go Out of the
vessel"

List 3 examples
of hypotonic
solutions.

1. 1/2 NS
2. 0.33% NS
3. D2.5W

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What does the RN need


to watch for when
administering
hypotonic IVFs?

Watch for cellular edema b/c fluid


is moving out of vascular space
into the cell which could lead to
FVD and decrease BP.

What do hypertonic
solutions do to the
body? And when are
they sued?

Hypertonic solutions are "packed


with particles". They are volume
expanders that will draw fluid
into the vascular space from the
cell.
Hypertonic solutions are used for
pt's with hyponatremia or those
who have third spacing, severe
edema, burns, or ascities.
TIP: hypErtonic solutions "Enter
the vessel"

List 8 examples of
hypertonic solutions

1. D10W
2. 3%NS
3. 5% NS
4. D5LR
5. D5.5 NS
6. D5 NS
7. TPN
8. Albumin

What does the RN need


to watch for with
hypertonic IVFs?

Watch for fluid volume excess.


Monitor in ICU setting wtih
frequent monitoring of BP, P, &
CVP

What 2 electrolytes
(when in excess) have
sedative effects?

magnesium & calcium

Magnesium is excreted
by the __________
and can be lost through
the GI tract too.

kidneys

List the causes of


hypermagnesiumemia
(2).

1. Renal Failure
2. antacids (they have lots of Mg)

When someone has


problems with Mg &
Ca++, what is the first
thing the RN should
think of?

Muscles

What are the s/s of


hypermagnesiumemia?
(9)

1. flushing
2. warmth
3. sedated/change in LOC
4. DTRs decreased, muscle tone
decreased
5. arrhythmias
6. decreased LOC
7. decreased pulse
8. decreased respirations
9. decreased BP (d/t mag makes
you vasodilate)

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What are the


treatments/interventions
for
hypermagnesiumemia
(4)?

1. ventilator (d/t dec RR)


2. dialysis (d/t renal failure)
3. Calcium gluconate (antidote
for Mg toxicity)
4. Safety precautions (d/t
sedation)

If calcium is low,
phosphorous is
_______.

high

If Phosphorous is low,
calcium is _______.

high

What are the NL Mg lab


values?

1.2-2.1

What are the NL Ca++


lab values?

9.0-10.5

List the causes of


hypercalcemia.

1. hyperparathyroidism (too
much PTH)
2. Thiazides/HCTZ (retain
Ca++)
3. Immobilization (must bear wt
to keep bone)

How does
hyperparathyroidism
cause hypercalcemia?

When serum Ca++ gets low,


parathyroid hormone (PTH)
kicks in and pulls Ca from the
bone and puts it in the blood,
therefore the serum Ca level
goes up.

What are the s/s of


hypercalcemia? (7)

1. brittle bones
2. kidney stones
3. decreased DTRs & muscle
tone
4. arrhythmias
5. decreased LOC, sedative
effects
6. decreased Pulse
7. decreased RR

What is the
treatment/interventions
for hypercalcemia?

What type of
relationship do calcium
& phosphorous have?

1. Move, ambulation
2. fluids (to prevent kidney
stones)
3. Phospho Soda & fleet enemas
4. steroids
5. add foods rich in
phosphorous (anything with
protein)
6. safety precautions (d/t
sedative effects)
7. must have vitamin d to use
calcium
8. Calcitonin (tx for
osteoporosis) decreases serum
calcium
inverse

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What are the causes of


hypomagnesemia?

1. diarrhea (lots of Mg in
intenstines)
2. alcoholism (alcohol
suppresses ADH & causes
diuresis)

What are the s/s of


hypomagnesemia AND
hypocalcemia (9)?

THINK NOT ENOUGH


SEDATIVE EFFECTS
1. rigid/tight muscle tone
2. potential for seizures
3. stridor/laryngospasm
(airway is smooth muscle)
4. Positive Chvostek's sign (tap
cheek & assess for twitch)
5. Positive Trousseau's (hand
tremors when BP cuff is pumped
up)
6. arrhythmias
7. DTRs are hyperreflexive
8. LOC changes (depressed or
hallucinations)
9. swallowing problems
(esophagus is smooth muscle;
at risk for aspiration)

List the
treatments/interventions
for hypomagnesemia. (4)

1. give Mg
2. check kidney function (before
& during IV Mg)
3. seizure precautions
4. eat Mg

Which foods are high in


Mg?

spinach, mustard greens,


summer squash, broccoli,
halibut, turnip greens, pumpkin
seeds, peppermint, cucumber,
green beans, celery, kale,
sunflower seeds, sesame seeds,
and flax seeds

A client receiving MgSo4


IV has a drop in UO.
What should the RN do?
1. call the PCP
2. decrease the infusion
3. stop the infusion
4. reassess in 15 min

3, stop the infusion


The pt is retaining Mg, should
be worrying about the kidneys.

What are the causes of


hypocalcemia? (3)

THINK NOT ENOUGH


SEDATIVE EFFECTS
1. hypoparathyroidism
2. radical neck surgery
3. thyroidectomy (not enough
PTH)

What is the
treatment/interventions
for hypocalcemia?

1. vitamin d (to help use Ca++


correctly
2. phosphate binders (to
decrease phos--renagel,
phosLo, os-cal)
3. IV Ca++ (give SLOWLY)

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When giving IV Ca++, what


should the nurse make sure is
always done?

Pt should be on a heart
monitor

The UCP is preparing to walk


a patient. Which pt should
the nurse intervene on?
1. the pt with a hx of grandmal seizures
2. the pt that is 8hrs post
heart cath

2, the pt that is 8 hrs post


heart cath. Worried about
bleeding.

What should you do if your pt


reports flushing and sweating
when you start IV Mg?

Stop the infusion (these


are s/s of
hypermagnesemia).

Serum sodium level is totally


dependent upon how much
_______ you have in your
body.

Water

What are Nl serum sodium


levels?

135-145

List the main causes of


hypernatremia (4).

RESULTS FROM NOT


ENOUGH WATER-DEHYDRATION
1. hyperventilation (Water
loss)
2. Heat stroke
3. DI
4. N/V/D

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What are the s/s of


hypernatremia (5)?

1. dry mouth
2. thirsty
3. swollen tongue
4. neuro changes

What are the


treatments/interventions for
hypernatremia (5)?

1. restrict Na+
2. IVFs (hemodilute)
3. daily weights
4. I&Os
5. labs

Tube feeding pt's tend to get


________.

dehydrated

List the main causes of


hyponatremia

DILUTION, RESULTS
FROM TOO MUCH
WATER (NOT ENOUGH
nA+)
1. drinking water for fluid
replacement (only replaces
water, and dilutes the
blood)
2. psychogenic polydipsia
(loves to drink water)
3. D5W (sugar water)
4. SIADH (retaining H2O)

Hyponatremia =
__________

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Hemodilution

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What are the s/s of


hyponatremia? (3)

1. HA
2. Seizure
3. Coma
4. Neuro changes
**brain doesn't like it when Na+ is
messed up

What is the
treatment for
hyponatremia? (2)

1. Replace sodium** (pt doesn't need


water! they are already hemodiluted)
2. if pt having neuro probs, needs
hypertonic saline (3% or 5% NS
given slowly)
**watch for FVE...Na+ pulls water
into vascular space

Potassium is
excreted by the
_________.

Kidneys

If the kidneys aren't


working well,
__________ will go
up.

Potassium

List the causes of


hyperkalemia. (2)

1. Kidney probs
2. aldactone (K+ sparing diureticmakes body retain K+)

What are the s/s of


hyperkalemia?

1. Starts with muscle twitching


2. proceeds to muscle weakness
3. then flaccid paralysis
4. life threatening arrhythmias

What are the EKG


changes seen with
hyperkalemia? (6)

1. bradycardia
2. tall, peaked T waves
3. prolonged PR intervals
4. Flat or absent P waves
5. widened QRS complex
6. v-fib

What are the EKG


changes seen with
hypokalemia? (5)

1. prominent U waves (U need more


K+)
2. PVCs
3. depressed ST segment
4. inverted T waves
5. v-tach

What are the


treatments for
hyperkalemia? (4)

1. dialysis
2. calcium gluconate (decreases
arrhythmias)
3. glucose & insulin (insulin carries
K+ & glucose into cell--worry about
hypoglycemia & hypokalemia)
4. Kayexalate (exchanges K+ for
Na+ - watch for hypernatremia &
dehydration)

Sodium & Potassium


have an _________
relationship.

inverse

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What are the causes of hypokalemia?


(4)

1. vomiting
2. NG suctioning (lots of K+ in stomach)
3. Diuretics
4. not eating

List the s/s of hyperkalemia. (3)

1. muscle cramps
2. weakness
3. life-threatening arrhythmias

What are the treatments for


hypokalemia?

1. Give K+
2. aldactone (makes body retain K+)
3. Eat more potassium

What are K+ rich foods?

bananas, squash, white beans, prune juice, cantaloupe, pears, halibut, tuna, raisins,
mango, broccoli, potatoes, cabbage, cauliflower, oranges, spinach

What is the major problems with PO


K+?

GI upset...give with food.

What must be assessed before and


during IV K+ administration?

urine output

IV K+ should never be given _______.

IV push. K+ must be DILUTED!

Giving K+ through a PIV may cause


_________ during the infusion.

burning