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Fluid & Electrolytes
NUR101
| Question | Answer |
|---|---|
| Body fluids are distributed between what two compartments | Intracellular (ICF) and extracellular (ECF) |
| Total amount of water in the body depends on | Age, sex, amount of body fat |
| How long can an individual last without water? | 3 days |
| What is the most important factor in determining fluid intake? | Thirst |
| How much water should the average, healthy adult consume per day | 1500-2000ml |
| What types of body fluid can be measured | urine, feces, wound drainage, emesis, NG tube drainage |
| Body fluid that cannot be measured is called | insensible fluid loss |
| Insensible fluid loss comes from | respiration and perspiration |
| Functions of water in the body include | Temperature control, transporting electrolytes and waste products, lubricating joints, protects brain and spinal column, aids in digestion, helps maintain hydrogen balance in the body |
| Most of the fluid in the body is found where? | intracellular compartment |
| What are the three spaces within the extracellular compartment | Interstitial, intravascular, and transcellular |
| Movement of fluid (passive transport) in the body is controlled by | osmosis, diffusion, filtration |
| Osmosis is | fluid moves from a lower concentration to a higher concentration |
| Diffusion is | solutes move from a higher concentration to a lower concentration |
| Filtration | movement occurs due to hydrostatic pressure |
| "Third spacing" can result in | decreased BP, compression of nerve endings, cellular death |
| What is third spacing | fluid moves into the interstitial space or fluid is forced into the peritoneal cavity |
| What is hypovolemia | equal loss of body fluid and electrolytes ie: hemorrhage |
| What is dehydration | loss of body fluid only |
| The MOST accurate indicator of fluid status is | Weight |
| Fluid loss risk factors | strenuous exercise, anything the impairs intake or absorption of fluid, high elevation, intake of caffeine or alcohol, increased metabolism |
| signs and symptoms of fluid volume deficit | dry, cracked tongue, increased pulse and respirations, decreased BP, increased Hgb, Hct, Na and BUN, fever, flushed skin, decreased urine output, decreased LOC |
| What is the minimal normal urine output per hour | 30 mL/hr |
| Risk factors for hypervolemia | heart, kidney, liver impairment, use of hypertonic IV fluids, burns, use of corticosteroids, severe stress, hyperaldosteronism |
| signs and symptoms of hypervolemia | Increased BP, full, bounding pulse, adventitious breath sounds, JVD, SOB, weight gain, decreased Hgb, Hct, Na, BUN |
| Electrolytes are chemical substances that when mixed in water release | positively and negatively charged particles |
| cations are | positively charged |
| cations include | potassium, sodium, calcium and magnesium |
| anions are | negatively charged |
| anions include | bicarbonate, chloride, sulfate and hydrogen phosphate |
| When measuring electrolytes, from what compartment are we obtaining the fluid from to measure them | extracellular compartment |
| What is the most abundant electrolyte in the body | sodium |
| What is the most abundant cation in the intracelluar fluid | potassium |
| What is the most abundant cation in the extracellular fluid | sodium |
| Normal range of sodium is | 135-145 mEq/L |
| The primary source of sodium is | table salt |
| what follows sodium | water |
| What does sodium do for the body | Maintains neuromuscular irritability necessary for function of skeletal & heart muscles |
| Causes of hyponatremia | decreased sodium intake, excessive loss of sodium, excessive retention of water, excessive intake of water, |
| Signs and symptoms of hyponatremia | confusion, stupor, lethargy, anorexia, orthostatic hypotension, stomach cramps, limp muscles |
| Nursing interventions for hyponatremia | encourage high Na foods, teach signs and symptoms of hyponatremia, isotonic fluids, irrigate with NS not water (NG) |
| Causes of hypernatremia | excessive intake of sodium (IV or oral), decreased excretion of sodium, severe dehydration |
| Signs and symptoms of hypernatremia | flushed skin, low grade fever, increased BP, fluid retention, agitation, confusion, thirst |
| nursing interventions for hypernatremia | teach about foods high in sodium, administer fluids (IV or oral), daily weigths, assess skin, treat underlying cause |
| Chloride normal level | 98-106 mEq/L |
| Chief anion on intravascular and interstitial fluids | Chloride |
| Most common cause of hypochloremia | prolonged vomiting or nasogastric suctioning |
| What function does potassium have in the body? | transmission of nerve impulses & muscle contraction-including skeletal, smooth and cardiac muscles |
| Normal range for potassium | 3.5-5mEq/L |
| Kidneys prefer which electrolyte? potassium or sodium | sodium |
| Causes of hypokalemia | vomiting, prolonged NG suction, potassium depleting diuretics, severe diarrhea |
| signs and symptoms of hypokalemia | muscle weakness, dysrythmias, leg cramps, shallow respirations, polyuria |
| nursing interventions for hypokalemia | I and O, teach patient how to prevent, increase dietary potassium, administer potassium IV or oral, monitor closely |
| At what rate should IV potassium be given | Cannot be infused faster than 10-20 mEq/hr |
| What should the nurse do if given an order for IV push potassium? | Refuse to give it and obtain a new order |
| Major Cause of hyperkalemia | Renal disease, |
| Other causes of hyperkalemia | burns, crushing injuries, severe dyhydration, potassium sparing diuretics, use of salt substitutes, rapid infusion of stored blood, chemotherapy |
| Signs and symptoms of hyperkalemia | decreased/no urine output, muscle weakness (paralysis), respiratory distress, decreased cardiac contractility, ECG changes, areflexia |
| Nursing interventions for hyperkalemia | Monitor cardiac status, administer kayexalate or insulin as ordered, decrease potassium intake, administer loop diuretics as ordered |
| Both a severe deficit or excess potassium will result in what? | life threatening cardiac dysrhythmias |
| How many mg of Calcium is needed per day for the average adult? | 1200mg |
| Where is most of calcium concentrated in the body? | 99% of calcium is in bones and teeth |
| The normal total calcium range is | 9-10.5 mg/dL |
| Calcium is important for | bone and teeth formation, blood clotting, nerve transmission, muscle contraction and strength and thickness of cell walls |
| Risks for hypocalcemia | renal disease, alcoholism, severe diarrhea, pancreatitis, parathyroid or vit D deficiency, anticonvulsant medications |
| signs and symptoms of hypocalcemia | cramps, alteration in cardiac rhythm, tingling, spasms |
| Describe Trousseau's Sign | BP cuff inflated past the SBP for 3 minutes, Causes flexion of the wrist and adduction of the thumb |
| Describe Chvostek's Sign | tapping the facial nerve just anterior to the ear causes facial/lip twitching or spasm |
| What 2 electrolyte imbalances can a positive Trouseau's and Chvostek's Sign be seen | hypocalcemia and hypomagnesemia |
| nursing interventions for hypocalcemia | encourage calcium rich foods, monitor cardiac, administer calcium supplements, I & O, encourage weight bearing activity |
| How does weight bearing activities help with hypocalcemia | helps to keep calcium in the bone where it cannot be excreted |
| Risk for hypercalcemia | malignancies, immobilzation, lack of weight bearing exercises, hyperparathyroidism, renal disease, Vit D overdose |
| signs and symptoms of hypercalcemia | constipation, joint aches, depression, kidney stones, decreased deep tendon reflexes, confusion, slurred speech |
| nursing interventions for hypercalcemia | Monitor calcium levels, cardiac rate and rhythm, vital signs, decrease calcium intake, increase activity, administer calcitonin if ordered |
| What is the second most abundant cation in the intracellular fluid | magnesium |
| What wo electrolytes are favored by the kidneys over potassium | sodium and magnesium |
| What other electrolyte is usually low if magnesium is low? | potassium |
| What causes hypomagnesemia | starvation, alcoholism, hyperparathyroidism, vomiting, ketoacidosis |
| signs and symptoms of hypomagnesemia | spasticity, tremors, cramps, hyperactive reflexes, cardiac dysrhythmias, ataxia, mental status changes, parasthesias |
| nursing interventions for hypomagnesemia | monitor neuromuscular status, monitor dysphagia, I & O, administer magnesium supplements, monitor vital signs and respiratory status |
| Causes of hypermagnesemia | impaired renal function, excess administration of magnesium, ketoacidosis |
| What happens to the body with hypermagnesemia | severely restricts nerve and muscle activity |
| signs and symptoms of hypermagnesemia | decreased BP, decreased deep tendon activity, depressed cns activity, respirations, and skeletal muscle activity. coma or cardiac arrest if prolonged |
| nursing interventions for hypermagnesemia | administer IV calcium and diuretics as ordered, stop/slow iV magnesium, decrease foods high in magnesium, monitor I & O |
| phosphorus as what type of relationship with calcium | inverse relationship |
| What is the normal range of phosphorus | 2.5-4.5 mg/dL |
| causes of hypophosphotemia include | impaired dietary intake, impaired kidney function, ketoacidosis, decreased potassium or magnesium levels, vomiting, diarrhea, hyperventilation |
| signs and symptoms of hypophosphotemia | muscle weakness, bone pain, respiratory failure |
| Causes of hyperphophotemia | renal failure, intake of large amounts of Vit D or phosphorus, large break down of tissue, fluid volume depletion |
| signs and symptoms of hyperphosphotemia | tingling around mouth, fingers, toes; increased deep tendon reflexes, tetany, twitching, seizures; decreased cardiac output |
| nursing interventions for hypophosphotemia | monitor I & O, especially respirations, decrease calcium rich foods |
| nursing interventions for hyperphosphotemia | Monitor I & O, monitor vital signs, monitor for seizures, encourage foods low in ohosphorus, administer phosphorus lowering medications (Phoslo) as ordered |
Created by:
Ms. A LPNI
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