class 1 (1).pdf
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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+] IV fluids: isotonic, hypertonic, hypotonic
Urine specific gravity (1.010-1.030): Dehydration = Concentration = S.G.
Oncotic pressure: albumin (3.5-5 g/dL)
Third-spacing 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
VASOPRESSIN (ADH)
Na+ & H2O
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 High Low
Symptoms Polyuria, polydipsia Oliguria, brain edema,weight gain, crackles
Causes Stroke, trauma, surgery Lung cancer
Treatment Vasopressin DemeclocyclineTolvaptan, Conivaptan:anti-ADH drugs
Expected Outcome Decreased diuresis Increased diuresis
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The nurse is caring for a client who had an excision of a malignant pituitarytumor and diabetes insipidus. Which findings should the nurse document thatindicate 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 ofdiabetes 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
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CVP: 5-10cm H2O (2-6mmHg)
PCWP: 6-12 mmHg
CVP PCWP
Type Solution Osmolarity Composition Use
Normal Saline Isotonic (308 mOsm/L) 0.9 g NaCl/100mL H2O
Fluid replacement
Lactated Ringers Isotonic (275 mOsm/L) NS with buffer Fluid replacement
D5W Isotonic in bag,Hypotonic in body
5 g glucose/100mL H2O
Replacement ofwater or glucose
NS Hypotonic (154 mOsm) 0.45 g NaCl/100mL H2O
Replacement ofwater
D5NS Hypertonic (560) 5 g D + 0.9 gNaCl/100 mL H2O
Replaces fluidand dextrose
D5 NS Hypertonic (406) 5 g D + 0.45 gNaCl/100 mL H2O
Same
D5LR Hypertonic (295) 5 g D/100 mL LR Same
3% NaCl Hypertonic 3g NaCl/100 mL H2O Volume expansion
PlasmaExpanders
FFP, Albumin,Hetastarch
Volume expansion
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A man who was severely burned over 90% of his body during an accident onthe 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 devicewould be most appropriate at this time?A. PICC lineB. Central lineC. Intra-osseous catheterD. Subcutaneous infusion
A client with CKD is brought bleeding profusely after a MVA. MD inserts acentral catheter (CVC). To promote rapid volume replacement the nurseshould use:A. D5W and IV pump through a 18 G saline lock deviceB. LR and IV pump through a 18 G needle for veins of the AV shunt armC. LR and tubing with needless connectionD. 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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C, b
The most appropriate method to rehydrate an infant with moderatedehydration secondary to diarrhea is:a. Replacing milk-based formula with a lactose-free formulab. Oral rehydration therapy with electrolyte solution every 3-4 hours
c. Administering intravenous (IV) fluids of D5 NSd. Offering bananas, rice, applesauce, and toast (BRAT diet) along with
oral fluids
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Hyponatremia 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 Decreasedurine specific gravity (ADH suppression) Pontine myelinolysis: sudden dysphagia, dysarthria, acute paralysis Na+ replacement: NaCl 3%
Hypernatremia 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
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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 potassium level is reported 6 mEq/L. The laboratory indicates the specimen
is hemolyzed. What intervention should the nurse takeA. Notify immediately the health care providerB. Obtain a prescription for KayexalateC. Draw a new blood sampleD. Encourage the patient to increase fluids intake
The nurse teaches a client about how to increase dietary potassium. The clientsays she knows bananas are high in potassium but does not like the taste. Thenurse determines teaching is effective if the client states which of the following?
A. I should include carrots, broccoli, and yogurt in my dietB. I should eat more rhubarb, tofu and celeryC. Potatoes, spinach, and raisins are high in potassiumD. 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. TheHCP 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?A. The renal damage has affected the pancreasB. Dextrose and insulin will restore your caloric needsC. Dextrose and insulin will help to decrease the potassium in your bloodD. Dextrose and insulin are necessary to normalize the BUN
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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
Nursing Interventions
Calcium gluconate available
Seizure precautions Foods rich in Ca: dairy, soy milk, tofu, sardines,
salmon, spinach, broccoli, collard greens, greenbeans, rhubarb, spinach, almonds
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Chvosteck
Trousseau
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Serum calcium > 10.5 mg/dL
Causes: Hyperparathyroidism, metastatic cancer,Multiple Myeloma (M.M.), Pagets disease, Vitamin Dintoxication
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)
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Q-T
EKG?
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Hypomagnesaemia
CausesCauses: malnutrition, alcoholism
AssessmentAssessment:Twitching, paresthesisPositive Trousseau's and Chvosteks signsSeizuresProlonged QTTorsade de Points
Nursing InterventionsNursing InterventionsSeizure precautionsCardiac monitorizationMg supplement, legumes, whole grains,nuts
Hypermagnesemia
CausesCauses: CKD, Mg laxatives or antacids,MgSO4 in eclampsia
AssessmentAssessment:Hyporreflexia: DTR 1+ or 0Respiratory depressionAMS and coma
Nursing InterventionsNursing InterventionsCalcium gluconateDialysisAvoid laxatives and antacids containingmagnesium
Magnesium NV: 1.5 to 2.5 mg/dL
A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. Which of thefollowing symptoms would you NOT expect to see in this patient?
A. Numbness in hands and feet.B. Muscle cramping.C. Hypoactive bowel sounds.