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Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Medical Surgical Nursing  NURS 127 Megan Rohm, MNc, BSN,

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Presentation on theme: "Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Medical Surgical Nursing  NURS 127 Megan Rohm, MNc, BSN,"— Presentation transcript:

1 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Medical Surgical Nursing  NURS 127 Megan Rohm, MNc, BSN, RN-BC  Today:  Introduce ourselves  Introduce the course -Syllabus Fluids and ElectrolytesFluids and Electrolytes

2 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Medical Surgical Nursing  NURS 127  Unit One Topics:  Fluids and Electrolytes  Immune System

3 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Unit 1 Fluid and Electrolytes MeganRohm, BSN,RN Acknowledgements to Elsevier

4 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Unit 1 Fluid and Electrolytes Objectives: 1) Explain how water balance and electrolyte balance are interdependent 2) List, describe and compare the body fluid compartments 3) Discuss active and passive transport processes and give examples of each 4) Discuss the role of specific electrolytes in maintaining homeostasis 5) Describe the cause and effect of deficits and excesses of sodium, potassium, chloride, calcium, magnesium, & phosphorus 6) Discuss the role of the nursing process in maintaining fluid and electrolyte balances. 7) Discuss how the very young, very old, and obese patient are at risk for fluid volume deficit.

5 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Homeostasis  State of equilibrium in body  Naturally maintained by adaptive responses  Body fluids and electrolytes are maintained within narrow limits

6 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Water Content of the Body  60% of body weight in adult  45% to 55% in older adult  70% to 80% in infants  Varies with gender, body mass, and age

7 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Balance

8 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Compartments  Intracellular fluid (ICF) _______ ______ ______ cell membrane  Extracellular fluid (ECF)  Interstitial = tissue ______________________ capillary membrane  Intravascular (plasma)

9 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Compartments of the Body

10 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Extracellular Fluid (ECF)  One third of body fluid  3 major components 1)Interstitial fluid 2)Intravascular 3)Transcellular fluid over or across the cellsover or across the cells

11 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Interstitial Component  Fluid btwn cells  Surrounds cells  Transport medium for nutrients, gases, waste products and other substances btwn blood and body cells  Also acts as a back up fluid reservoir

12 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

13 Fluid Regulation  How does movement from space to space occur?  Diffusion  Osmosis  Filtration  Active transport

14 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Regulation  Diffusion  Movement of solutes from an area of higher concentration to an area of lower concentration in a solution and or across a permeable membrane  This movement occurs until near equal state

15 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Regulation  Osmosis  Now with water.

16 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

17 Osmosis VS. Diffusion  Osmosis  Low to high  Water potential  Diffusion High to lowHigh to low Movement of particlesMovement of particles

18 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Regulation  Filtration  Water pushing against the confining walls of a space

19 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Electrolytes  Substances whose molecules dissociate into ions (charged particles) when placed into water  Cations: positively charged  Anions: negatively charged

20 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Electrolyte Composition  ICF  Prevalent cation is K +  Prevalent anion is PO 4 3   ECF  Prevalent cation is Na +  Prevalent anion is Cl 

21 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Regulation of Electrolytes  Active transport  Allows molecules to move against concentration and osmotic pressure to areas of higher concentration

22 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Active Transport: Sodium–Potassium Pump Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 17-5

23 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Movement in Capillaries  Amount and direction of movement determined by  Capillary hydrostatic pressure  Plasma oncotic pressure  Interstitial hydrostatic pressure  Interstitial oncotic pressure

24 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Exchange Between Capillary and Tissue Fig. 17-8

25 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Osmolality  Concentration of body fluids- affects movement of fluid by osmosis.  Reflects hydration status  Measured by serum and urine  Solutes measured-mainly urea, glucose, & sodium

26 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Osmolality  Serum value mOsm/kg  Urine value mOsm/kg  Increases in serum level  Free water loss  Elevated Na  Hyperglycemia  Uremia

27 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Volume Shifts  Normally fluid shifts btwn intracellular and extracellular compartments to maintain equilibrium btwn spaces  Fluid not lost from body, but not available for use in either compartment- considered third-space fluid shift (third- spacing)  Enters interstitial compartment

28 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 28 Causes of Third-Spacing  Burns  Peritonitis  Bowel obstruction  Massive bleeding into joint or cavity  Liver or renal failure  Lowered plasma proteins  Increased capillary permeability

29 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 29 Assessment of Third-Spacing  More difficult – fluid sequestered in deeper structures  Signs/Symptoms  Decreased urine output with adequate intake  Increased HR  Decreased BP  Increased weight  Pitting edema, ascites

30 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

31 31 Phases of Third-Spacing 1. Loss phase  Lasts hours  Symptoms of FVD 2. Reabsorption phase  Fluid gradually reabsorbed after problem subsides  FVO possible  Monitor VS, I&O, Wt, and breath sounds

32 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 32 Treatment  Treat underlying cause if possible  Close observation of VS  Monitor I & O more frequently  Daily weights  Measure abdominal girth in ascites  Measure extremities if necessary  Monitor lab values  albumin level important

33 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 33 Treatment Goals  Stabilized I & O  Stabilized weight  VS within normal range  Resolution of third-spacing

34 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Extracellular Fluid Volume Imbalances  ECF volume deficit (hypovolemia)  Abnormal loss of normal body fluids (diarrhea, fistula drainage, hemorrhage), inadequate intake, or plasma-to-interstitial fluid shift  Treatment: replace water and electrolytes with balanced IV solutions

35 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 35 Fluid Volume Deficit  Hypovolemia  Abnormally low volume of body fluid in intravascular and/or interstitial compartments  Causes  Vomiting  Diarrhea  Fever  Excess sweating  Burns  Diabetes insipidus  Inadequate intake  Hemorrhage  Overuse of diuretics  Third spacing

36 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 36 Fluid volume deficit  What happens  Output > Intake  Water extracted from ECF ECF hypertonic (water moves out of cell  cell dehydration) + osmotic pressure increased (stimulates thirst preceptor in hypothalamus)ECF hypertonic (water moves out of cell  cell dehydration) + osmotic pressure increased (stimulates thirst preceptor in hypothalamus) ICF hypotonic with decreased osmotic pressure  posterior pituitary secretes more ADHICF hypotonic with decreased osmotic pressure  posterior pituitary secretes more ADH Decreased ECF volume  adrenal glands secrete AldosteroneDecreased ECF volume  adrenal glands secrete Aldosterone

37 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

38 38 Signs and Symptoms  Acute weight loss  Decreased skin turgor  Oliguria  Concentrated urine  Weak, rapid pulse  Capillary filling time elongated  Decreased BP  Increased pulse  Sensations of thirst, weakness, dizziness, muscle cramps

39 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 39 Labs  Increased HCT  Increased BUN  Increased serum osmolality  Increased urine osmolality  Increased specific gravity  Decreased urine volume, dark color

40 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 40 Significant Points  Dehydration – one of most common disturbances in infants and children  Additional S/S  Sunken eyeballs  Depressed fontanels  Significant wt loss

41 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 41 Significant Points  Older Adult  Vein filling better indicator than skin turgor  Have additional health problems  Take various medications  May ↓ intake to prevent incontinence

42 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses  Hypovolemia  Deficient fluid volume  Decreased cardiac output  Potential complication: hypovolemic shock

43 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 43 Interventions  Major goal prevent or correct abnormal fluid volume status before ARF occurs  Encourage fluids  IV fluids  Isotonic solutions (0.9% NS or LR) until BP back to normal, then hypotonic (0.45% NS)  Monitor I & O, urine specific gravity, DAILY WEIGHTS

44 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 44 Interventions  Monitor skin turgor  Monitor VS and mental status  Goal:  Normal skin turgor, increased UOP with normal specific gravity, normal VS, clear sensorium, good oral intake of fluids, labs WNL

45 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Regulation of Water Balance  Antidieuretic Hormone (ADH) Hold on to waterHold on to water  Aldosterone Increases Na+ retentionIncreases Na+ retention

46 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

47

48

49 Where is a lot of this happening in the body?

50 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Renal Regulation  regulating fluid and electrolyte balance  Adjusting urine volume Selective reabsorption of water and electrolytesSelective reabsorption of water and electrolytes Renal tubules are sites of action of ADH and aldosteroneRenal tubules are sites of action of ADH and aldosterone

51 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Effects of Stress on F&E Balance Fig

52 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Gastrointestinal Regulation  Oral intake accounts for most water  Small amounts of water are eliminated by gastrointestinal tract in feces  Diarrhea and vomiting can lead to significant fluid and electrolyte loss

53 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Extracellular Fluid Volume Imbalances  Fluid volume excess (hypervolemia)  Excessive intake of fluids, abnormal retention of fluids (CHF), or interstitial-to-plasma fluid shift  Treatment: remove fluid without changing electrolyte composition or osmolality of ECF

54 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Causes  Excessive isotonic or hypotonic IV fluids  Heart failure  Renal failure- urinary  Liver failure, cirrhosis  Long-term use corticosteroids

55 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Signs/Symptoms  Headache, confusion, lethargy  Edema  Distended neck veins  Bounding pulse,  Polyuria  Dyspnea, crackles, pulmonary edema  Wt. Gain  Seizures, coma

56 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses  Hypervolemia  Excess fluid volume  Ineffective airway clearance  Risk for impaired skin integrity  Disturbed body image  Potential complications: pulmonary edema, ascites

57 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  I&O  Monitor cardiovascular changes  Assess respiratory status and monitor changes  Daily weights  Skin assessment

58 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Neurologic function  LOC  PERLA  Voluntary movement of extremities  Muscle strength  Reflexes

59 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Electrolyte Imbalances  Refer to charts available on Angel

60 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Electrolyte Disorders Signs and Symptoms ElectrolyteExcessDeficit Sodium (Na) HypernatremiaThirst CNS deterioration Increased interstitial fluid Hyponatremia CNS deterioration Potassium (K) Hyperkalemia Ventricular fibrillation ECG changes CNS changes HypokalemiaBradycardia ECG changes CNS changes

61 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Electrolyte Disorders Signs and Symptoms ElectrolyteExcessDeficit Calcium (Ca) HypercalcemiaThirst CNS deterioration Increased interstitial fluid HypocalcemiaTetany Chvostek’s, Trousseau’s signs Muscle twitching CNS changes ECG changes Magnesium (Mg) Hypermagnesemia Loss of deep tendon reflexes (DTRs) Depression of CNS Depression of neuromuscular function Hypomagnesemia Hyperactive DTRs CNS changes

62 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Sodium  Normal mEq/L  Plays a major role in  ECF volume and concentration  Generation and transmission of nerve impulses  Acid–base balance

63 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Differential Assessment of ECF Volume

64 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypernatremia  Elevated serum sodium occurring with water loss or sodium gain  Causes hyperosmolality leading to cellular dehydration  Primary protection is thirst from hypothalamus

65 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 65 Signs/Symptoms  Early: Generalized muscle weakness, faintness, muscle fatigue, HA  Moderate: Confusion, thirst  Late: Edema, restlessness, thirst, hyperreflexia, muscle twitching, irritability, seizures, possible coma  Severe: Permanent brain damage, hypertension, tachycardia, N & V

66 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses  Risk for injury  Potential complication: seizures and coma leading to irreversible brain damage

67 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Treat underlying cause  Free water to replace ECF volume  If oral fluids cannot be ingested, IV solution of 5% dextrose in water or hypotonic saline (gradual)  Diuretics

68 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hyponatremia  Results from excess loss of Na containing fluids or from water excess:  GI losses, diuretic therapy, severe renal dysfunction, severe diaphoreses, narcotic use  Manifestations, S/S  Confusion, nausea, vomiting, seizures, decreased BP, headache, muscle twitching, cramps

69 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses  Risk for injury  Potential complication: severe neurologic changes

70 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Caused by water excess  Fluid restriction is needed  Severe symptoms (seizures)  Give small amount of IV hypertonic saline solution (3% NaCl)  Abnormal fluid loss  Fluid replacement with sodium- containing solution

71 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Potassium  Normal mEq/L  Major ICF cation  Necessary for  Transmission and conduction of nerve and muscle impulses  Maintenance of cardiac rhythms  Acid–base balance

72 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Potassium  Sources  Fruits and vegetables (bananas and oranges)  Salt substitutes  Potassium medications (PO, IV)  Stored blood

73 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hyperkalemia  High serum potassium caused by  Massive intake of K  Impaired renal excretion  Shift from ICF to ECF  Common in massive cell destruction  Burn, crush injury, or tumor lysis

74 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hyperkalemia  Manifestations, S/S  Weak or paralyzed skeletal muscles  ECG changes; Ventricular fibrillation or cardiac standstill  Abdominal cramping or diarrhea

75 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

76 Nursing Management Nursing Diagnoses  Risk for injury  Potential complication: dysrhythmias

77 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Eliminate oral and parenteral K intake  Increase elimination of K (diuretics, dialysis, Kayexalate)

78 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Force K from ECF to ICF by IV insulin or sodium bicarbonate  Reverse membrane effects of elevated ECF potassium by administering calcium gluconate IV

79 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypokalemia  Low serum potassium caused by  Abnormal losses of K + via the kidneys or gastrointestinal tract  Magnesium deficiency  Metabolic alkalosis

80 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypokalemia  Manifestations  Most serious are cardiac  Skeletal muscle weakness  Weakness of respiratory muscles  Decreased gastrointestinal motility

81 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

82 Nursing Management Nursing Diagnoses  Risk for injury  Potential complication: dysrhythmias

83 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  KCl supplements orally or IV  Slowly  K is an irritant  Should not exceed 40 mEq/hr  To prevent hyperkalemia and cardiac arrest

84 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Hypertonic glucose solution  Monitor  I&Os  VS, cardiac rhythm  Muscle strength  Bowel sounds

85 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Calcium  Normal mEq/L  Obtained from ingested foods  More than 99% combined with phosphorus and concentrated in skeletal system the other 1% is in ECF and soft tissuesthe other 1% is in ECF and soft tissues

86 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Calcium  Bones are readily available store  Blocks sodium transport and stabilizes cell membrane

87 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Calcium  Functions  Transmission of nerve impulses  Myocardial contractions  Blood clotting  Formation of teeth and bone  Muscle contractions

88 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Calcium  Balance controlled by  Parathyroid hormone  Calcitonin  Vitamin D

89 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypercalcemia  High serum calcium levels caused by  Hyperparathyroidism (two thirds of cases)  Malignancy  Vitamin D overdose  Prolonged immobilization

90 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypercalcemia  Manifestations, S/S  Decreased memory  Confusion, fatigue, coma  Anorexia, constipation  Muscle weakness, loss of muscle tone  Polyuria & predisposes to renal calculi

91 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses  Risk for injury  Potential complication: dysrhythmias  death

92 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Excretion of Ca with loop diuretic  Hydration with isotonic saline infusion  Synthetic calcitonin  Mobilization

93 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypocalcemia  Low serum Ca levels caused by  Decreased production of PTH  Acute pancreatitis  Multiple blood transfusions  Alkalosis  Decreased intake

94 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypocalcemia  Manifestations  Positive Trousseau’s or Chvostek’s sign  Laryngeal stridor  Dysphagia  Tingling around the mouth or in the extremities

95 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tests for Hypocalcemia Fig

96 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses  Risk for injury  Potential complication: fracture or respiratory arrest

97 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Treat cause  Oral or IV calcium supplements  Not IM to avoid local reactions  Treat pain and anxiety to prevent hyperventilation-induced respiratory alkalosis

98 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Phosphate  Primary anion in ICF  Essential to function of muscle, red blood cells, and nervous system  Deposited with calcium for bone and tooth structure

99 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Phosphate  Involved in acid–base buffering system, ATP production, and cellular uptake of glucose  Maintenance requires adequate renal functioning  Essential to muscle, RBCs, and nervous system function

100 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hyperphosphatemia  High serum PO 4 3  caused by  Acute or chronic renal failure  Chemotherapy  Excessive ingestion of phosphate or vitamin D

101 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hyperphosphatemia  Manifestations  Calcified deposition in soft tissue such as joints, arteries, skin, kidneys, and corneas  Neuromuscular irritability and tetany

102 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hyperphosphatemia  Management  Identify and treat underlying cause  Restrict foods and fluids containing PO 4 3   Adequate hydration and correction of hypocalcemic conditions

103 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypophosphatemia  Low serum PO 4 3  caused by  Malnourishment/malabsorption  Alcohol withdrawal  Use of phosphate-binding antacids  During parenteral nutrition with inadequate replacement

104 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypophosphatemia  Manifestations  CNS depression  Confusion  Muscle weakness and pain  Dysrhythmias  Cardiomyopathy

105 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypophosphatemia  Management  Oral supplementation  Ingestion of foods high in PO 4 3   IV administration of sodium or potassium phosphate

106 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Magnesium  50% to 60% contained in bone  Coenzyme in metabolism of protein and carbohydrates  Factors that regulate calcium balance appear to influence magnesium balance

107 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Magnesium  Acts directly on myoneural junction  Important for normal cardiac function

108 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypermagnesemia  High serum Mg caused by  Increased intake or ingestion of products containing magnesium when renal insufficiency or failure is present

109 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypermagnesemia  Manifestations  Lethargy or drowsiness  Nausea/vomiting  Impaired reflexes  Respiratory and cardiac arrest

110 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypermagnesemia  Management  Prevention  Emergency treatment IV CaCl or calcium gluconateIV CaCl or calcium gluconate  Fluids to promote urinary excretion

111 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypomagnesemia  Low serum Mg caused by  Prolonged fasting or starvation  Chronic alcoholism  Fluid loss from gastrointestinal tract  Prolonged parenteral nutrition without supplementation  Diuretics

112 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypomagnesemia  Manifestations  Confusion  Hyperactive deep tendon reflexes  Tremors  Seizures  Cardiac dysrhythmias

113 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypomagnesemia  Management  Oral supplements  Increase dietary intake  Parenteral IV or IM magnesium when severe

114 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. IV Fluid Replacement  Purposes 1.Maintenance When oral intake is not adequateWhen oral intake is not adequate 2.Replacement When losses have occurredWhen losses have occurred

115 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. IV Fluid Reference

116 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

117 IV Fluids  Hypotonic  More water than electrolytes Pure water lyses RBCsPure water lyses RBCs  Water moves from ECF to ICF by osmosis  Usually maintenance fluids

118 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. IV Fluids  Isotonic  Expands only ECF  No net loss or gain from ICF

119 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. IV Fluids  Hypertonic  Initially expands and raises the osmolality of ECF when it shifts fluids from ICF & ECF into vascular component - expands blood volume  Require frequent monitoring of Blood pressureBlood pressure Lung soundsLung sounds Serum sodium levelsSerum sodium levels

120 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Normal Saline (NS)  Isotonic  No calories  30% stays in intravascular space

121 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Normal Saline (NS)  Expands IV volume  Preferred fluid for immediate response  Risk for fluid overload higher  Does not change ICF volume  Blood products  Compatible with most medications

122 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Lactated Ringer’s  Isotonic  More similar to plasma than NS  Has less NaCl  Has K, Ca, PO 4 3 , lactate (metabolized to HCO 3  )  Expands ECF

123 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Plasma Expanders  Stay in vascular space and increase osmotic pressure  Colloids (protein solutions)  Packed RBCs  Albumin  Plasma


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